Every summer my grandmother would ask my childhood self what my favourite colour is. By the time winter rolled around, she would have knitted me a sweater to bundle me in my favourite colour. Old family photographs have my brother and myself posing in the same sweaters, all knitted by my grandmother, worn when we were the same approximate size and cuteness. These sweaters, like inheritance, will be passed down. Their knit and yarn would ensure they last, weaving my grandmother and all of us who wear these sweaters in a warm and scratchy togetherness. Now, grown and away from home, a writer (and knitter) in London, I have an orange sweater too big for me. When I wear it, it holds me. My grandmother knitted it for my mother when she was in college. This sweater is older than me. It was forgotten and tucked away, until I found it and since then have never let it far from reach. In my enclothed cognition, this orange sweater lends me solace - a product of my grandmother’s love, a veteran of my mother’s youth, and big and comforting as both their hugs. It is through knitting that I have known the most lasting, tangible, labours of love. Social media can yield a cornucopia of mental health challenges but fortunately for me, some algorithmic luck led me to knitting (searches for Tom Daley, an Olympic diver who openly knitted in stadiums to cope with pressure, may or may not have been involved). Knitting is a gateway to a state of calm. The rhythmic movements of the needles, the necessary focus to count stitches, elicit a ‘relaxation response’ that lowers heart rate and alleviates stress. Still, it wasn’t the mental health benefits of knitting, nor the desire to be the best-sweatered woman in every room, or even the militant urge to fight fast fashion, that made me take it up. I started knitting to give back the knitted love that I had received. My first knitting project was a scarf with pockets at its ends for my grandmother. Its colour was purple - unlike my childhood self, her favourite colour had been consistent. Why pockets? It may be hard to imagine how wearing gloves can be difficult, but if you are old with stiff joints and arthritis-ridden fingers, or know someone who is, it isn’t. During winters, it is now my grandmother who wraps her favourite-coloured scarf around her neck and slips her hands into the pockets to keep them warm. Even though knitting is something one does on their own, it is seldom done in isolation. One either knits for someone or with someone. While my grandmother had complexly detailed knitting books and magazines to learn from, and I had many YouTube videos to pause and replay and then play again at 0.5x speed, we both also had friends - knitting friends - to solve problems, share ideas, and keep busy company. Beginning knitting would have been a lot less encouraging, and much harder, if I could not have knocked at my housemate Andrea’s room, holding up my knitting, asking her to figure out the mistake I had just made, or my friend Mari who fired up the Zoom whiteboard to explain the pattern I was about to knit. The more I owned knitting as a part of my personality, the more knitters I attracted, or the more I converted the ones around me. Knitting breeds community. Because those who knit are so involved in knitting - visiting yarn stores, discussing patterns, fixing each other’s mistakes - they are surrounded with opportunities for passionate communication - salves in disguise for individual loneliness. And one mostly ends up knitting for others anyway (for there are so many socks and sweaters and hats one can wear). Knitting for charities improves one’s sense of self, making one feel purposeful. While knitting for those around us strengthens ties with warm yarns. Writer Ann Patchett used her knitting needles as a crutch to give up smoking. Whenever her fingers yearned for the slender cylindricity of a cigarette, she would pick up her needles, knitting row after row, until the urge to smoke passed. Instagrammer Mia (@anxiousgirlknits) would knit before eating to allay her mealtime anxiety. Among women suffering from eating disorders, knitting has proven to quell rumination and help progress in therapy. Stitchlinks’ Betsan Corkhill found therapeutic knitting made people feel happier and shifted focus away from chronic pain. She suggests the repetitive poking and wrapping of yarn, the growing river of wool in one’s lap, induces serotonin production that calms, lifts mood, and dulls pain. She also argues that knitting actually requires a lot of brain capacity, creating neural pathways that help maintain brain health. Older people who engage in crafts like knitting show lesser signs of mild cognitive impairment, linked with reduced risks of dementia and Alzheimer’s disease. For me, knitting saves me from myself. Dermatillomania, or skin picking, is a physical manifestation of anxiety. The slightest rise in my heartbeat would often coincide with my digging my nails into the skin around my fingers, peeling, plucking, with sometimes even pain or blood failing to put an end to it. If the tips of my fingers are ever smooth, unhurt, or unbandaged, there is a strong chance that I have a knitting project going on. I started knitting as an adult while I have been picking my skin since childhood. The nature of dermatillomania is such that I may never learn to manage it and continue picking my skin well into old age. But I hope I can carry on knitting in my old age too. The last time I stayed with my grandmother, I saw her lifting one foot with both her hands, propping it onto her knee with silent pained breaths, to slip on a sock. My grandmother is old now. Arthritis in various joints makes it feel more real. She no longer knits. But when I carry my knitting to her, unsure about what mistake I have made but sure that I have made it, she takes the needles into her hands, slips the yarn through her fingers (both of which were aching just now), and seamlessly knits it into the fabric with a shocking dexterity. As if she had never stopped, nor the years gone by. I watch in wonder. And when she looks up at me, I am my grandmother’s little granddaughter again, telling her what my favourite colour is.

I am 63 years old. I have had bipolar since I was 21. I have experienced one prolonged manic episode, many profound depressive episodes, and one prolonged mixed affective state. I have previously written two articles on this platform; one about diagnostic overshadowing and the other about mixed affective states. The Bipolar Mood Scale on the Bipolar UK website illustrates the range of symptoms that can be experienced by a person with bipolar. When I have been at my lowest points, I have been almost completely paralysed by depression and have felt constantly suicidal. At times when my mood has been high, I have found it almost impossible to sit still for any length of time and I have experienced constant racing thoughts. It was during my manic episode when I was aged 25 that I first became acutely aware that society can potentially cause harm to marginalised groups of people. The values of the world often flow in the opposite direction to many spiritual values. Whilst in the grip of the mania, I wrote a short passage titled "A Message of Hope". I can only accurately remember the first line: ‘Thinking and knowing. Trusting what I know. The well are ill and the ill are well.’ All these years later, I still hold by this, but perhaps not in such stark terms. In this article, I share some of my experiences of living with bipolar disorder. I look at the way in which I see the world, how I have managed to survive, and how, despite all the challenges, I am living a rich and meaningful life. We live in a world which seems to value fame, wealth, and power, often above the more spiritual values of kindness, gentleness, and faithfulness. Accumulating wealth appears to be desirable. Acquiring possessions seems to be encouraged. Worldly recognition is highly rated. It can be very challenging to find your way in this world if you are vulnerable and "unwell". Vulnerability is generally not seen as a strength, although I think it should be. I have struggled greatly through my life; having had no career to speak of, low social status, and little money. I have a serious mental health condition, which does not seem compatible with living a successful and fulfilling life. Throughout a lot of my life, I have felt marginalised and alienated from those around me. I have felt misunderstood. When I ran into my first episode of severe depression at the age of 21, I quickly came into contact with psychiatrists. I was "ill" and I was hospitalised. The psychiatrists were very kind, caring, and respectful. They wanted me to be "well" and functioning. But the sickness was definitely located within me. I was expected to change so that I could better fit into the social world. I was given drugs and ECT (Electroconvulsive Therapy). I know that I brought shame to my family. I also felt a huge burden of personal failure and shame, which I carried for many years. Nobody told me that we live in a world with upside-down values. I had not lived up to my family’s expectations of me nor to society’s expectations of me. I didn’t fit in. More positively, over the past 42 years, I have enjoyed some long periods of mood stability when I have managed to sustain work which has aligned with my values. I have worked in a legal aid law firm, as a mental health advocate and as a befriender in my local community. By walking alongside other people who are marginalised, I have found deep meaning in my life. Perhaps I could be a person of value? Perhaps I am a person of value? I see a psychiatrist from time to time when I am struggling with my mood. I have found that some mental health professionals have been empowering and validating of me, whilst others have not. When meeting with a psychiatrist, the power imbalance meets me head-on. I feel as though I am the problematic person in the room. Rightly or wrongly, I immediately feel judged. It has been my experience that the psychiatrist makes a diagnosis or formulation, which has at times been imposed on me without consultation, and has on some occasions been wrong. They might prescribe drugs for my mental health condition without having given me much information about the drug. My own personal life story, or narrative, has at times been trampled all over by psychiatrists. My true voice has often struggled to be heard. Mental health professionals hold the medical records and make most of the entries to these records. How much room is there for a person’s voice to be heard? How much space is there for a person’s own narrative? So, if we live in a world with upside-down values, how do we raise up the marginalised? How do we properly listen to stories of oppression in families and other social systems? How can we flip the psychiatrist-patient power balance so that it is the person seeking assistance who calls the shots and makes their own informed decisions? The huge power imbalance is so engrained in the essence of psychiatry and society that it has become almost invisible. It represents the status quo. The task of raising up people marginalised by way of mental health conditions is a challenge for psychiatry, psychology, and theology to address. I am a member of a large bipolar peer support group. We keep connected through WhatsApp groups and weekly Zoom meetings. The support which we all give each other is so precious. We are equal members facing similar challenges. A constant undercurrent to the group is the knowledge that any one of us may slip into mania or depression at any time. We help each other to recognise early warning signs of any mood slippage and encourage one another to seek appropriate help quickly if this happens. We listen to each other. We believe each other. We see each other as valuable human beings. We hold onto the positives of others, especially when they are unable to see those positives themselves. I am very fortunate to have a GP who listens to me. Occasionally I see a forward-thinking Consultant Psychiatrist who is empowering and validating of me. My current situation has been hard-won after some shockingly poor psychiatric treatment which left me feeling emotionally traumatised and completely defeated. I was utterly powerless in the face of an immovable psychiatric system. Nobody was listening to me. The effect of the poor treatment has been to focus my mind so that I now have a very clear idea of what good care and treatment look like, at least for myself. I do believe in psychiatry as a valid medical discipline. Throughout my life, I have been helped enormously both by medication and psychotherapy. These two approaches need not be mutually exclusive, but rather they can work together very beneficially. However, I believe that psychiatry needs to undergo a paradigm shift in attitudes and practice to make it fit for purpose. It seems to me that a lot of small changes could add up to something much bigger. Some of the better mental health trusts are bringing in changes, but we need to go further in terms of equalising power relations between mental health professionals and people with mental health conditions. We all need to be valued, validated, empowered, and properly listened to. We need to be given the space to be heard. True collaborative working has to be the way forward. I would suggest that people need to be accepted and valued just as they are. We are all made up of a complex combination of strengths, abilities, challenges and vulnerabilities. It has been through being fully accepted at a deep level that I have found a path to healing.

As a researcher in perinatal psychiatry, and having grown up in India, I have had the privilege of understanding pregnancy and birthing traditions that exist not only in my country but across the world. A conversation in December with two leading perinatal psychiatrists in the UK inspired me (don’t mind the pun) to embark on a virtual journey all over the world (all the while sitting at my desk in London), with conversations among colleagues, friends, and professionals within the field along with my trusted friend Google Scholar. This has given me the opportunity to understand and appreciate the wide repertoire of pregnancy and birth traditions that exist in different cultures globally. Today, in this article I will share with you a snippet of what I learnt. (Disclaimer: Most of my sources for this article are first-hand, other than those which have been sourced from other digital platforms which are hyperlinked.) What are some of the prominent pregnancy and birthing traditions within India that I have witnessed? As diverse as it is in terms of language and culture, India also has various traditions surrounding pregnancy and birth. Here I will shine a light on the ones I have seen in my family while growing up. The first that comes to mind is the one I first heard about from my mother. For a woman’s first pregnancy, in her last trimester, she moves into her parents’ home and continues to stay there for the first three months after the baby is born. The idea behind this tradition is that the woman’s mother, having experienced taking care of a baby before, will provide an extra set of helping hands from an experienced perspective. The expectant mum is fed home-cooked meals throughout her pregnancy, and after birth, special recipes like Katlu are prepared to aid lactation and for overall maternal health benefits. Moving away from my Kutchi culture and into the state of West Bengal, there is a ritual known as the Cha-Shasti. In Bengali culture, Shasti is the Goddess responsible for the child’s long life and well-being and is therefore worshipped during this time. Before birth, a feast is arranged for friends and family by the parents-to-be, and a mud lamp is kept lit through the night, as this is believed to increase visibility for the Goddess Shasthi. What are some of the traditions witnessed in other South East Asian countries? Inspired by the conversation with my mother about katlu, I decided to look at whether different countries around South Asia have pregnancy-specific food traditions. And the results were nothing short of interesting. This 2017 paper synthesized the evidence about food-related traditions in Asian counties. Interestingly, different cultures encourage the consumption of “hot” or “cold” food right from pregnancy until the postpartum period, for different reasons. For example, the Malays avoid “cold” vegetables such as spinach, and encourage the consumption of “hot” food like anchovies, mutton, and hot drinks like coffee. I then had the opportunity to learn about the Chinese tradition of Zuò yuè zi from a colleague. With the literal translation being “sitting the month”, this refers to the practice of ‘confinement’, wherein newly postnatal mums are recommended to stay indoors for the first month, to heal from the birth, and for feeding the newborn baby. When the baby turns a month old, there’s also a tradition to have a celebratory party to present the new baby to close friends and family and to receive good wishes and blessings. Zuò yuè zi has its roots in the eastern Han dynasty, from around 200BC, as an important postpartum practice based on traditional Chinese medicine, and it has been passed down through generations until the present day. During this month, the emphasis is laid on keeping the new mother warm, ensuring that she gets enough rest, and eats plenty of nutritious food. She’s meant to stay indoors to avoid wind/cold/wet conditions, pathogens, or (in modern days) pollution. Keeping warm is important: she is recommended to avoid direct exposure to cool breezes (and, again, in modern days) air-conditioning or fans), and to stay covered by wearing sleeves and long pants, even in hot temperatures. Interestingly, one of the most prominent traditions was that new mothers weren’t allowed to wash their hair for a whole month to avoid getting cold. Today, however, there are some modern adaptations to this rule as some women have raised concerns about it. For example, mothers may choose to use warmer water than the ideal water temperature, try to limit shower time, dress warmly and blow dry their hair right away before stepping out of the heated bathroom. New mothers also must have nutritious foods prepared to replenish nutrients and produce milk to feed the baby. Although the practice varies regionally depending on dietary habits and climates, there are some basic rules. Similar to Malay culture, the dietary habits also include cold vs hot foods. However, in China, women avoid “cold”, or raw foods like watermelon, and cucumber as they are believed to create an imbalance of qi, resulting in soreness and poor circulation. The women are encouraged to only drink warm or hot liquids, such as tea, warm water, and soup. What cultural traditions are seen in European countries? Italy has brought to us numerous aspects of the culture we know and love every day: art, food, and music, being some of the most famous. The next stop in my journey, after India and China, was Italy, where I had the chance to understand Italian pregnancy and birthing traditions from one of my colleagues in the perinatal section of the SPI lab. She told me about Fiocco Della Nascita, a tradition wherein a large ribbon is placed at the front door of the home where a baby is born. Pink ribbons are used to announce the birth of a girl, while blue ribbons are used to announce the birth of a boy. Usually, under the Fiocco (ribbon), the baby’s name is printed. I also learnt from her about the tradition to name a baby after their grandparents. But perhaps the tradition I was most intrigued by was the belief about pregnancy 'cravings'. In Italian culture, it is believed that if the expectant mum doesn’t eat the food that she is craving, the baby will be born with a birthmark of the colour of the food the mum was craving (for all of you who have brown birthmarks, perhaps it is likely that your mum was quite the lover of chocolate and all things alike!). After Italy, I next went on to learn about some traditions in Switzerland. My colleague here at Inspire the Mind told me about how a Swiss baby’s first fashion statement is an amber beaded necklace, believed to protect the child against any pain, such as teething. Many grandparents will gift their children’s new infant this necklace to help radiate calm and peaceful energies. The amber, or fossilised resin from prehistoric trees, can date back to 50 million years ago. Swiss parents are also very big believers in home remedies and often use herbal teas, such as fennel for indigestion, sage tea for sore throats and black tea to clean eyes affected by impurities. My colleague even said that her parents often left a chopped onion in her bedroom at night to combat her colds when she was a baby. Today, I’ve only covered some of the traditions I learnt about to write this article. I’ve found myself reflecting on how different, yet how similar some traditions across different countries can be. Some are in stark contrast to one another, like the hot and cold food practices. But others are so similar in the ideology behind the tradition, like the focus of ensuring the mother is eating nutritious food in Indian and Chinese culture. This journey I’ve embarked on has only made me more appreciative of pregnancy and childbirth, and how important these cultural traditions are. They have stood the test of time, having been passed down from generation to generation, and that shows how truly significant they are.

The 1st to the 7th of May is observed as Maternal Mental Health Awareness Week. Today, the 3rd of May is observed as World Maternal Mental Health Awareness Day (WMMHDay). It is a day when we raise public awareness of mental health problems that can occur in pregnant women and mothers, and emphasise the importance of taking care of mental health during pregnancy and the postpartum period. It is celebrated on the first Wednesday in May, just before Mother's Day, and throughout May. This global campaign started in 2016 under the slogan Maternal Mental Health Matters. I am very passionate about this topic, in my role as Associate Professor at the Department of Psychology, Catholic University of Croatia, and the lead of the NGO, Centre for Reproductive Mental Health. Mental difficulties can happen to anyone Current research shows that one in five women have mental health problems during pregnancy or up to 12 months after giving birth. The following disorders occur most often: Depression during pregnancy and after childbirth, described here as "peripartum depression”, is present in 12-18% of women. Some forms of anxiety disorder, such as fear of childbirth in 15% of primiparous women or generalized anxiety disorder in 4% of women. One in four women experiences a traumatic childbirth, while 3% of women experience posttraumatic stress disorder (PTSD) after childbirth. Although pregnancy is a favourable period for women who have previously struggled with bulimia nervosa, it is a sensitive time for the development of binge eating disorder, which is present in about 5% of pregnant women. Obsessive-compulsive disorder (OCD) may occur in about 4% of mothers. Postpartum psychosis may occur in 1 to 2 births per 1,000 in the general population, but it is much more common in women with a diagnosis of bipolar or schizoaffective disorders, or in women with a family history of postpartum psychosis; it requires urgent psychiatric treatment. Why do we need World Maternal Mental Health Day? Unfortunately, the awareness of the public, pregnant women, mothers themselves, their close ones, and health professionals about these problems is still too weak. Women do not recognise the symptoms; if they are aware of them, they are afraid to seek help because of the stigmatisation. They think that others will consider them to be bad mothers, or they feel shame and guilt. Also, some women fear taking medication or even losing parental rights. However, there are other obstacles, namely that, unfortunately, the necessary professional help is not equally available everywhere. Peripartum mental disorders affect maternal well-being and quality of life, the child's development, partners who themselves can suffer from peripartum depression, and the family's overall functioning. All of these impose significant costs on the family and society. For example, estimates in the United Kingdom are that the total lifetime costs of peripartum depression are £75,728 per woman with the condition. However, only one-third of that is due to adverse outcomes in mothers, while two-thirds are related to adverse outcomes in children. That is the reason why it is so important to seek help! There are effective treatments for peripartum disorders As the public usually thinks that peripartum depression is related only to childbirth and the early postpartum period and that it will pass by itself, research with long-term follow-up of women shows that this is not quite so. One study followed about 100 women with peripartum depression for two years and showed that it takes an average of 49 weeks for full recovery, which is almost a year. Of these, about 30% of women recover in the first six months, 60% in 12 months, and 90% in 24 months from the onset of depression. Therefore, it is crucial to seek help as early as possible. What is worrying is that out of 10 women with peripartum depression, only four seek help. The additional problem is that not all European countries have clinical guidelines for peripartum depression management. Only 11 European countries have such policies, although less than half were rated as of adequate quality by a systematic study. However, experts are currently working on developing evidence-based clinical guidelines for peripartum depression within the framework of the international COST Action Riseup-PPD project dedicated to peripartum depression. Regarding the treatment for peripartum depression, antidepressants are used for severe depression, and concerning psychotherapies, cognitive-behavioural therapy proved the most effective. In addition, there are other effective treatments, such as repetitive transcranial magnetic stimulation (rTMS), although caution is warranted during pregnancy. Therefore, effective treatment exists, but we should encourage women in need to use them. What can we do? Get involved! We must never leave the responsibility of seeking help only to women with perinatal mental health difficulties. Indeed, self-blame, which is one of the symptoms of depression, is precisely one of the reasons why women do not seek help, which is paradoxical. It would be like someone with a broken leg not going to the emergency room because they blame themselves for falling! Therefore, the role of the family and friends is important, which should be sensitive to the woman's needs, offer their emotional support, help with household chores, and honestly ask the mother, "How are you?" with compassion, genuine care, and without judgment. Also, as a society, we must ensure the necessary steps: carry out psychoeducation about psychological difficulties during pregnancy and after childbirth for mothers and families as well as for health workers, implement effective preventive programs, conduct screening for mental health problems within the health system, and provide available professional help. The responsibility for positive change lies in our hands! What can we do? Sign the petition to include this day in the official UN calendar! Share World Maternal Mental Health Day infographic. Use #maternalMHmatters on social media. Follow the WMMHday Twitter account and like the Maternal Mental Health Day Facebook page. Ask a pregnant woman or mother around you, "How are you?" and give her a hand to let her know that she is not alone.

As a devotee to the art of music and a past, present, and (most likely) future feeler of pain, the idea that I can take something that I love to combat something that I certainly don’t is intriguing to me. Other than being used for my stubbed toe or a pinched nerve, it can perhaps be better utilised for those who suffer from more serious chronic pain conditions such as rheumatoid arthritis or fibromyalgia. The possibility to reduce the pain from these diseases with the aid of art, instead of a list of medications and possibly tedious daily exercises is incredible. And as an honorary research assistant working in the IOPPN at King’s College London, my ears perk up when I learn about any opportunity for a new psychological intervention to help the management of an illness or disease. The search for new pathways, to add to the list of established and valid therapeutic treatments that are widely available, is important to me, as it can lead to the discovery of alternative methods for patients who are unable to find relief with existing therapeutic methods. Providing more options for therapies would grant a wider array of patients to be appropriately cared for depending on what they respond to. Something to “Handel” your pain As per the International Association for the Study of Pain (or IASP), chronic pain can be defined as pain that lasts beyond the usual period of healing, which is usually anything longer than three months. Chronic pain can occur from an illness, injury, or even neurological conditions, and it can manifest in many forms, from dull to sharp pain. It is an intricate condition and can severely impact not only a person’s physical but also emotional wellbeing. It is a significant issue in the public health sector, affecting around 20% of the world population; but, despite its prevalence, it is often undertreated and misunderstood. Pain management is a huge challenge, not only to those who are experiencing it but to healthcare providers as well. In the UK alone, 46% of the general population have reported chronic pain with 5.6% reporting severe chronic pain. And while there are pain-management programs in place that offer these intensive multidisciplinary approaches that can improve patients' physical performance as well as their psychological wellbeing, the provision of these programs is scarce throughout the UK and are largely unavailable to those who need them. While no cure currently exists for chronic pain, many types of treatment are available that can help manage the condition and improve quality of life. The treatments can range from typical medications (duloxetine, venlafaxine, etc.), to physical therapy, and, of course, surgery (microvascular decompression, glycerol rhizotomy, etc.). But these types of treatments may not work for everyone, can lead to unwanted side effects, or can be tiresome. Recent research has investigated alternative methods for easing chronic pain, one of these being music therapy. “Accordion” to the research… Research has largely supported the idea that music can be used as a powerful tool for reducing pain perception and improving patient outcomes. In 2015, a study analysed the effects of music on a group of 37 participants with fibromyalgia, having 21 of them listen to music for 25 minutes each day for a total of 14 days. They found that in those 14 days, the 21 participants in the intervention group reported significantly lower pain severity on days 1, 7, and 14. In another study (2007) surveying 318 participants with chronic pain, researchers also found listening to music is beneficial for those who suffer from long-term pain. Additionally, this study found it benefits the overall quality of life of the participants as well. Those participants who listen to music more frequently and perceive it as personally important end up enjoying their lives more, having more energy, feeling less depressed and in need of medical treatment less often. As chronic pain can be debilitating and make it difficult to accomplish even the simplest of tasks, it can also have a significant impact on mood and quality of life. This can often lead to depression and social isolation. But because music is able to provide such relief to those with chronic pain, it is also able to subsequently aid in improving the mood and quality of life of those who use this as therapy. And just for good measure… Chronic pain is not only a physical issue. It is just as much of a mental and emotional battle as it is a physical one. It can be a great source of anxiety and stress, which then exacerbates the experience of pain. This causes a never-ending back-and-forth of issues, with anxiety and stress causing more pain, and then more pain causing more anxiety and stress, repeating until you are in a spiral of both physical and mental anguish. Fortunately, music therapy has got that covered for you too. Music has a calming effect on the body, which can allow you to regulate your heart rate, breathing, and blood pressure (essentially, whatever you need to relax), and reduce those levels of stress and anxiety. It can also serve as a distraction, directing attention away from that awful pain to something that is more enjoyable, like a pleasant song. A 2010 study sought to evaluate the effectiveness of music therapy interventions on pain as well as anxiety control for 100 participants that were undergoing bone marrow biopsy and aspiration. Once again, results not only showed that participants who listened to music had lower pain levels than those who didn’t, but significantly lower levels of anxiety to boot. These findings show that not only those with chronic pain, but those undergoing surgical procedures can benefit from music therapy as well. By reducing anxiety levels in addition to pain perception, music therapy has shown time and time again that it is a viable method for helping patients feel more comfortable and at ease during procedures, potentially reducing the need for pesky pain medications. Not Always Music to Our Ears Just like anything else, music therapy is not a "one size fits all" method for treating chronic pain. It serves as more of a tailored treatment that can be really effective for some, and not as much for others. Music therapy also tends to work best when in tandem with other treatments and it’s not really meant to be used as a standalone. Also, music therapy is not widely available as it should be at the moment, and in many healthcare settings, depending on where you live, may not be covered by your insurance either. This makes it quite difficult to receive, even if you are hell-bent on having that specific method of therapy, it just may unfortunately not be an option for you. Still, some patients might not respond to music therapy, even though it has been shown to be effective for many patients. It may be that music therapy does not help the situation, or that the pain is not responding well to the intervention, it could be as simple as that. Pain, Pain, Go Away Music therapy is a promising, low-cost, and non-invasive intervention for those experiencing chronic pain. Of course, like with anything, it does still have its drawbacks that need to be considered when assessing each individual’s situation. Despite this though, its ability to help not only physical pain but also emotional wellbeing should not be understated. While more research is needed to fully comprehend the exact mechanisms behind the effects of music therapy on pain, the existing evidence conveys in no uncertain terms that it can be a viable alternative treatment that can benefit many patients suffering from chronic pain. As famous musician Frank Zappa once quipped "Music is the best!". And as short and succinct as that quote is, he’s right; when it comes to dealing with chronic pain, I think he was onto something. Use the beautiful art of music to manage your pain, it may make life even just a teensy bit more enjoyable. After all, as the saying goes… "Without music, life would B-flat!"

This new study says there’s a difficult but effective way. In moments of heightened anxiety and stress, my intrusive thoughts take over. I’ll be making coffee in the morning and a voice in my head will, randomly, tell me all my friends from last night are talking about me behind my back. And I’ll spiral into questioning whether everything I’ve ever said is stupid, and cannot stop myself from thinking about it obsessively. — — — As a science journalist who writes about health and the mind, “thoughts” are a concept I am enthralled by, so this mechanism also becomes something to research and study rather than just experience. Today, I want to ask: How does one control such insidious, unwanted thoughts? Usually, when trying to avoid unwanted thoughts, you reject the thought and try to replace it with something else — “think about how much fun you had last night, think about how much you laughed!” Yet, science shows that even just thinking about that bad thought in the first place has already reinforced and strengthened said thought in your mind, allowing for it to garner enough energy to keep coming back in an endless loop. Now, science shows that there might be a much more efficient way to proactively avoid these thought associations in the first place, according to a new study published July 14th, 2022, in the journal PLOS Computational Biology. “I really think of this study as the first building block in trying to understand the question of how people regulate their thoughts and make sure, to an extent, that they don’t look into thoughts that might be very distressing,” Isaac Fradkin, a computational psychiatry researcher at The Hebrew University of Jerusalem and lead author of this study, told me when I interviewed him for this article. — — — Thoughts, as you can imagine, are very obscure to science because they’re very abstract. “The basis of knowledge is somewhat limited in this regard,” says Fradkin, albeit the extensive research in the field. “And part of the problem has to do with the fact that most of the instances in which we are sort of aware of trying to control a thought are instances in which this thought has actually already invaded our consciousness.” So, Fradkin and his team looked into how 80 English-speaking people played a word-association game. The participants saw one common word on the screen and had to type out an associated word. Some words would be repeated several times, randomly, across the experiment. For example, they saw the cue ‘table’, not one time, but six times, sprinkled among other words. One group of participants was told not to ever repeat the associations — or they wouldn’t get the experiment money — so they had to swiftly come up with alternative associations when the words repeated themselves. “So you see the cue ‘table’, you write ‘chair’ in the first instance, and then a few trials after that you see ‘table’ again, and your task is not to write ‘chair’ again,” says Fradkin. “And then the question is, how do you do that? Do you first sort of think of the chair in your mind and then have to suppress it somehow, or ignore it, or replace another association? Or can you actually reduce the probability that the association will come to mind in the first place?” To answer this question, the researchers therefore calculated how long it took participants to effectively generate new word associations and came up with a mathematical formula made of a set of equations that tries to approximate, according to reaction time, when people were using “reactive control” and when people were using “proactive control”. To understand reactive and proactive control, it might be helpful to consider yourself driving a car, waiting at a red light to turn left, says Fradkin. Imagine that you suddenly see a traffic light turning green, and only after that do you realize that this light is only relevant for cars continuing straight. Thus, you ignore this traffic light only after it has already captured your attention. This is an example of reactive control over attention. Now, consider the many pedestrian traffic lights at the junction which you completely ignore even if they suddenly turn green. These lights will likely not capture your attention at all. You can filter them out before they grab your attention. This is an example of proactive control over attention, Fradkin notes. The same distinction can be made for thoughts: reactive control over thoughts means that you try to stop thinking a certain thought after it has already reached consciousness. Proactive control means you can filter this thought from reaching consciousness altogether, or at least — reduce the probability that it will come to mind, says Fradkin. “The basic intuition behind using reaction times here is that if indeed you use ‘reactive thought control’, it is a process that usually takes time,” says Fradkin. “Conversely, if you can use what we call proactive control, you might be able to sort of think of an alternative new association, without consuming any extra time for the rejection part.” The results showed that, mostly, people tend to carry out “reactive control”. Like I often do with my morning coffee and the haunts of my friends loathing me. One of the reasons this happens, Fradkin notes, might specifically be because of the self-reinforcing nature of memories: if you thought of the association table-chair once, it naturally makes it more probable that you will think of it again. Yet, the mathematical model shows that, in some cases, people can actually partially preempt this process. Specifically, according to the parameters, the participants weren’t avoiding unwanted associations altogether, but they were actively decreasing the probability of the associations happening again and again. “The people who were allowed to repeat associations showed a very strong rehearsal strengthening effect, and people in the ‘suppress group’ were able to weaken this effect, to some extent,” says Fradkin. “This is something that I think is very optimistic because it suggests that, to some extent, we are able to somewhat unconsciously block some associations.” This finding is, in fact, in agreement with the prior work of Todd Braver, a professor of psychological & brain sciences at Washington University in St. Louis who participated in coining that very “dual mechanism of control framework” — proactive and reactive control. With a computational approach like that of Fradkin's, “it is possible to parse out the behavioral data in a way to richer evidence for one strategy versus another,” says Braver, who was not involved in the study. “This was kind of a very first step, but it opens the door to a lot more research to see how much of the experimental conditions constrain or encourage participants to do one thing or another adopt one strategy or another,” says Braver. Especially whether this differs according to the thinker. In fact, his own research has already shown that people with more advanced working memory tend to be more flexible in their ability to switch between proactive and reactive control of thoughts. Fradkin too has already found some preliminary evidence that how people perform this task is actually related to how they experience themselves, in terms of how they think about their ability to control their intuitive and wanted thoughts in their daily lives — if they think they’re good they’re more likely to be good. The content of the thoughts also matters in the differentiation between these two methods of control, according to Thomas Hills, the co-director of the Global Research Priority in Behaviour, Brain & Society at The University of Warwick. “Negative and positive thoughts are different breeds of thought, and emotional thoughts are also likely to be different from unemotional thoughts,” says Hills. “We know that emotional things tend to be remembered better than unemotional things. They are also likely to be more intrusive, especially negative thoughts.” This is almost certainly by evolutionary design, Hill explains, because if something is likely to harm you, even if it’s only currently a figment of your imagination, you are better prepared to avoid it. “This research is important because, above all, it tells us something about being human. Thoughts pop into our minds. Some of them are unwanted. Part of being human is learning how to deal with unwanted thoughts,” says Hills. “This research also shows that unwanted thoughts don’t just go away because we want them to. It takes effort. It takes an act of will not to accept all that comes into our heads.” The next steps in work like this are focusing on more free-form thoughts, like what kinds of things come to mind in various situations and why are these more or less challenging to deal with under varying circumstances, says Hills. In fact, this is just a little glimpse into the world of thoughts, Fradkin notes. There is so much more research to carry out, moving forward, with greater samples of participants, especially in order to better understand how to help people in clinical settings for psychiatric populations, according to Fradkin. Carrying out these experiments while simultaneously tracking what’s going on inside the brain, through the advances of neuroscience, as well as trying this out in more natural settings, could also help create a clearer picture. “Even though our thoughts are mostly associated, we don’t think in these individual words — we think in much more complex ways,” says Fradkin. “So now the question here is how we can use this basic framework and model to try and study something more realistic of how people actually experience their daily thoughts?”

I am a freelance science journalist and I have previously written for The Guardian, BBC, National Geographic, Gizmodo, Wired, and more. I am passionate about all things science, health, and the mind, and I was particularly interested in this topic because , given my job, it is important to me to explore how we talk about our minds and why that’s important. I wanted to learn how to better communicate the science surrounding mental health, without watering it down to be something it is not. Talking about mental health is, thankfully, no longer taboo for many slices of the population in the Western world — “my therapist said” is a staple of the conversation during drinks with friends, and social media will consistently suggest a variety of content asking to regularly “check in with your inner child” or coping mechanisms and attachment styles. For a large swath of people who weren’t privy to these conversations beforehand, this norm-shift represents a welcome breath of fresh air. For some scholars, however, the ubiquity of this conversation about mental health could be doing more harm than good to our mental health. I’ve long wondered what people from different cultures, or from different moments in history, experience and understand of their own mental health. If there’s different ways of calling a mental condition, does it change what people feel from it? If there’s no way of calling it at all, is that better or worse? This is especially true when I travel, and I’m confronted with completely different ways of describing feelings and emotions in various languages. Many romantic languages use metaphors and similes in their everyday life, and those help people feel things more when, say, they’re reading a poem: is it the same for talking about mental health? On a person to person level, this newfound openness in talking about the status of our mental health has given many people a freedom to express themselves they previously didn’t have, reducing stigma and breaking down barriers. For many, having greater access to information about mental health conditions, and getting accustomed to the very labels and names professionally attributed to classes of symptoms, has helped people make sense of what they are going through and find some resolution — that feeling of if it has a name it’s not all in my head, it’s real, and something can probably be done about it. Not to mention, atop of clarity, classification and diagnosis, even if not professional, can provide community and help people find others who might be feeling the same way. These are just three of the reasons why this new age of mental health awareness has fundamentally changed the lives of many, but even just because we’re well past the season of having to convince ourselves that mental health is important, which is great, because if you’re spending all your time just trying to convince people something is important, you’re losing time where you could be doing something about it right now. Yet, so much talking about subject matters which initially only belonged in the realms of neuroscience, psychiatry and psychology has the potential to become fundamentally unscientific, and conceivably harmful. That is especially true for our newfound tendency to give and receive diagnosis according to what we briefly skimmed over in our phones while on our toilets this morning. “I feel like it’s been useful in some respects, but that there’s been some collateral damage or side effects,” Lucy Foulkes, a psychologist at University College London and author of Losing Our Minds: The Challenge of Defining Mental Illness, told me when I interviewed her for this article. Foulkes notes that if promotion of the idea that mental health problems are common, and that they are things that should have names, doesn’t come with the necessary kind of depth of information, people will start interpreting common experiences and emotions as psychiatric disorders when they aren’t. “When actually they’re just sort of part of daily living, and that’s not to dismiss them, but my worry is more that the people frame them as being medical problems and that is unhelpful.” It’s unhelpful for people who perhaps don’t have these disorders, because they might end up overpathologizing themselves and feeling even more of a mental burden for this new condition they’ve self-diagnosed with. “If you’re not aware of the concept of anxiety disorders, then you’re not going to label yourself as having one, or interpret your experiences through that framework. So, the language that we have is really, really important for understanding our psychological experiences, definitely. And the current cultural trend is to interpret pretty much anything negative as a mental health problem or a mental disorder.” Not to mention, it’s also unhelpful for the people that do have disorders, because it devalues the real, vivid impact of their condition. It also skews who gets to have access to therapy, treatment, or medication. On a long term level, some scholars believe that throwing around all of this diagnostic psychological terminology and calling it ours can, in turn, cause changes in society. This is known as the Looping Effect, and it was coined by Canadian philosopher Ian Hacking: “classificatory practices induce reactions in the members of the human kind by enabling new intentional ways of being and acting,” this research paper describes. “There’s these psychological descriptions circulating in common parlance and people take them up, and these descriptions and classifications can provoke changes in our understanding of ourselves,” Jeff Sugarman, a psychologist of selfhood at Simon Fraser University, told me when I interviewed him for this article. Then, in turn, people start to react to their new understandings of themselves and they develop more behaviors to fit in with these descriptions, once again making changes to the descriptions, notes Sugarman, and it becomes a recurrent cycle. This phenomenon is also heavily rooted in the politics of society too. Neoliberalism has reshaped what it is to be a healthy person, or what success means or what happiness means, according to Sugarman, and these too have become parts of the psychological descriptions by which we understand ourselves. For Kai Ruggeri, a professor of Health Policy and Management at Columbia University, this wishy-washiness of mental health discourse now also opens two more, major, negative possibilities. One, that the concept of mental health becomes co-opted by big corporations undermining and instrumentalizing it in order to ultimately take it away from, say, their employees. “When you have this watering down where it’s like, ‘take a wellness break, walk around, get 15 minutes of fresh air.’ Those are nice things nobody’s saying they’re not, but they’re not core mental health. They’re not addressing your reason for living,” Ruggeri told me when I interviewed him for this article. Ruggeri notes that this big-biz shorthand for mental health is, ultimately, not addressing the bigger questions: do you have good positive interactions with people? Do you have the ability to achieve the things you need to achieve in a day? “Organizations can pat themselves on the back and say, look, we, you know, we did it,” Ruggeri says. “But all those other things are just superficial things.” Two, that long term national policy is harmed in the meantime, since policymakers miss out on recognizing the fundamental elements of mental health and therefore opportunities for good policy on it. Much of the responsibility moving forward now is in the hands of educators in providing depth to the conversation. “It’s not necessarily anyone’s fault because someone often might just be learning it from someone else using it in a term,” says Foulkes. “I think the issue is that the lack of depth like that we’ve promoted the idea that there is such a thing as [a specific mental disorder] but not necessarily fully promoted information about what it really is.” In fact, the debate on whether how we talk about mental health changes the way we experience mental health has been around for as long as the notion of mind and self have existed. The scientific jury is still out on how to label mental illnesses and the pros and cons of doing it in the first place — this is especially true because, with the advancements of science, many of the descriptions of the diagnosis stretch, bend and morph over time in order to encapsulate new information scholars come across through research. According to Foulkes, that’s exactly where one of the solutions to this paradigm lies — being open and transparent, and educating the general public, that a lot of this is much deeper and messier than it seems, even for the experts. “Things are messy, and we need to talk about the fact that [mental health] is on a spectrum and the fact that no one can quite agree when disorder begins, and that some people disagree about whether you should ever use the term ‘disorder.’ I actually think it’s useful to be honest about that,” says Foulkes. Still, maybe this initial phase of extreme popularization of therapy speech and the mental health discourse needed to happen, to break down some existing barriers, and now it’s just a matter of reigning it back in. “It may well have been that this was the first necessary stage and we now need to refine it from here, or sort of slightly change course a bit.”

It is no secret that the COVID-19 pandemic changed the world on a global scale. As individuals, we experienced huge changes to our daily lives, including working from home, social distancing, learning to spend extended amounts of time alone, and video calling our loved ones on holidays and special occasions. Some people adapted well to the change, enjoying the slower pace of life and the break from a once rigid nine-to-five lifestyle, and others struggled with the isolation and the fear of the unknown. What was my experience? As someone who has lived with Generalised Anxiety Disorder (GAD) for most of my adult life, I was one of the fortunate ones who settled well into the new routine that the lockdown created for me. I was much happier working from home every day instead of commuting to the office on a crowded bus or train, and I enjoyed the financial benefits that came with not being able to go out to bars and restaurants on the weekend. The one thing that surprised me the most during that period was the number of people who started talking about anxiety. I found myself speaking to people about mental health who had never experienced anxiety before the pandemic, some of whom had been quite dismissive of my anxiety in the past when they didn’t understand it well. As the first lockdown began to lift, bars and restaurants opened, and we were encouraged to socialise again in small groups. At this stage, the repercussions of a summer indoors became apparent. People who had fallen out of their routines were suddenly nervous about being outside – perhaps from a fear of catching COVID, or because they had spent so long inside, away from other people. I had also grown accustomed to the quiet tube carriages and the empty buses. I had felt at peace when I was standing in a queue and the people in front of and behind me would stand two metres away. I had gotten used to socialising in small groups instead of large ones. At the start of the lockdown, my manager at work gushed about the possibility of us working from home permanently, but suddenly the demand was that we all return to the office three days a week. My life quickly changed from sipping tea on my sofa and working at my own time and pace to the old way of life: crowded public transport, large in-person meetings and presentations, and huge social gatherings. Whether your anxiety was born out of lockdown, exacerbated by it, or brought on by a return to reality, there are a few important things to do and remember to stop it from becoming all-consuming. Keep doing things For many of you who are new to the world of anxiety, I am quite confident that you will see it dissipate as we readapt to a busier world. It is crucial to keep doing the things you used to, even if those things suddenly seem frightening and overwhelming. When you avoid doing something, your anxiety temporarily reduces, and you teach your brain that avoiding it was the right choice. The next time you try to do it, the anxiety and adrenaline comes back to make you avoid it again. To reduce the anxiety, we must do the things that scare us. This is within the principles of Cognitive Behavioural Therapy (CBT). Do something that scares you, realise that it's not as bad as your thoughts told you it would be, and experience a less intense fear the next time you do it, until the anxiety is gone. Take your time. Do things at your own pace. If you don’t want to get on the crowded train, wait for the next one. Take an alternative, quieter route. But you must keep trying to get on that train until you are no longer scared of it. Requesting changes One of the fundamental shifts in my thinking during the lockdown was centred on my workplace. I became more confident at challenging my managers and saying no when I disagreed with something. Perhaps conducting conversations over a Teams call makes it easier to do so, or maybe we feel more confident when we are sitting in our own homes, surrounded by our home comforts. When my employer insisted on returning to the office three days a week, I knew it would be too much for me to manage, at least without a phased return. I spoke with my manager and told them that I would be more than happy to attend the office one day per week, but any more than that would need to come with a work-related explanation as to why my presence in the office was necessary so often. Not everyone is comfortable with citing mental health at work, but it is much better understood in recent years, especially since the pandemic. My plan worked, and I currently only go into the office one day per week. Immediately changing from a quiet schedule to a hectic one would be detrimental to my anxiety. It is important when we suffer from anxiety to understand our triggers and know what would help diffuse any stress. Furthermore, we should try where possible to talk about mental health at work and break the stigma that surrounds it. Nobody should feel ashamed of talking about their mental health. Take time out From spending seven days a week at home to suddenly being in the office, surrounded by friends at bars or navigating your way through a crowded train station, you may find it overstimulating and exhausting to be around others so frequently, even if you missed it during the lockdown. Make sure you take time for self-care to decompress, switch off from the world around you and focus on yourself. Taking time out from the world can help reduce anxiety and better prepare you for the next outing. Professional help If you are struggling to do things that you used to do before the pandemic and are not coping by yourself, seek professional help. Contact your GP or local IAPT (Improving Access to Psychological Therapies) service. Waiting lists can be lengthy, but if you do not seek help and cannot manage on your own then your mental health may suffer further. As humans, we adapt quickly. Entire countries stopped what they were doing and stayed home for months, and it was often referred to as ‘the new normal.’ By the same logic, we will adapt again to bustling streets and packed trains, provided we take the time to check in with ourselves regularly and learn the right tools to keep ourselves prepared and calm. The number of people suffering from anxiety increased because of the pandemic, but it can and will go back down.

All my life, I have been told I was just a picky eater. Even as a toddler, I struggled to eat and drink without gagging. Doctors told my family that this was something I would eventually grow out of. My “picky eating” was framed as a conscious choice instead of something out of my control. It’s often assumed that so-called picky eaters are stubborn, childish, or closed-minded, but this isn’t always the case. One day, I came across an article about a condition called avoidant-restrictive food intake disorder, or ARFID. Suddenly, everything clicked. I wasn’t picky, I had an eating disorder. ARFID is an eating disorder involving the avoidance of certain foods (or food in general) due to a lack of interest or extreme discomfort when eating. It can cause nutritional deficiency, weight changes, and anxiety regarding food. Unlike other eating disorders, ARFID has nothing to do with body image or wanting to lose weight. As I worked through my undergraduate degree in neuroscience, I was disappointed that I never came across this disorder in my studies. ARFID is often left out of conversations about eating disorders, and as a result, many people are unaware of it. ARFID expresses itself in many ways. My experience is that certain tastes, smells, and textures make me feel physically sick, causing me to gag. A common symptom of ARFID is the fear of vomiting or choking which furthers the cycle of avoidance. Some people suffered from an illness or medication, such as chemotherapy, that made eating difficult and still struggle with food after recovering. Others are diagnosed with ARFID as a comorbidity (or co-occurring condition) of autism spectrum disorder, obsessive-compulsive disorder, or a number of anxiety disorders. Many people find the sensory experience of eating to be overwhelming. Lots of people with ARFID have a lack of interest in food because the act of eating can be anxiety-inducing. People can have one of these reasons, a combination, or none of them. It’s different for everyone. Many people with ARFID have diets limited to “safe foods” that they’ve tried and know that they can eat. Some people have specific “fear foods” that they can’t eat while others struggle with “foreign foods” that they haven’t tried before. Others have wide diets but can’t stand a certain food group like meat or vegetables. Lots of people with ARFID struggle with the inconsistency of non-processed foods like fruit because the taste and texture tend to vary, making it difficult to predict how the food will feel. Heavily processed foods, like chicken nuggets and fries, are generally popular among people with ARFID because the taste and texture are consistent. One misconception about people with ARFID is that we refuse food because we don’t like it. For me, this is not the case. I regularly eat foods that I don’t like, but there is a big difference between a food I don’t like and a food I can’t eat. For me, eating can feel like the chills you get when you’re sick. It’s a very visceral feeling that goes beyond annoyance or dislike. Sometimes, I can’t even keep chewing, even with food I like. I personally don’t feel anxious when trying new foods, but many people with ARFID fear eating things they haven’t had before. ARFID can be a very vicious cycle. Not eating makes me nauseous, which makes me not want to eat, which makes me more nauseous. Sometimes I start to get hungry around dinner time, but hunger during the day isn’t something I usually experience. Reaching 2,000 calories per day is a lot of work. I have to consciously remind myself to eat because I usually don’t have an appetite. It can be nauseating to keep eating when you already feel full or never felt hungry in the first place, which can make it difficult to even begin. ARFID can sometimes cause or exacerbate weight gain. Anyone can suffer from an eating disorder, regardless of size. Overweight people can have a harder time getting treatment because they don’t fit the typical image of disordered eating. Many treatment programs require a person to be clinically underweight to be eligible. As a result, many people are excluded from treatment because of their size. Furthermore, most eating disorder treatments focus on body image, which isn’t a factor for people with ARFID. Living with ARFID can feel very isolating. Many social events revolve around food, so it’s nearly impossible to avoid questions about eating. As a result, social anxiety often co-occurs with ARFID because people become increasingly self-conscious about their eating. This isn’t helped by the fact that our choices are frequently scrutinized by those around us. People often comment on my portion size, the fact that I ordered just a side, or the lack of condiments on my food. While I’m usually open to answering questions and helping people understand, I don’t always want to discuss the details of my disorder with strangers. Sometimes I just want to enjoy a meal out with my friends, without someone making a comment about my food. Eating privately is often easier than answering questions or hearing others comment on your order. I often eat before I hang out with my friends because I feel bad about making them accommodate my food choices. The process of ordering food and eating it publicly can be incredibly stressful, which makes doing so an act of courage for many of us. One of the most frequent and frustrating questions that I’ve been met with is “how do you know you don’t like it if you don’t try it?”. I find this question condescending because it implies that I don’t know myself well enough to know what I can and can’t handle. It also ignores the fact that you can draw a lot of conclusions about a food without tasting it. Texture and smell can be triggers for people with ARFID, so we can usually figure out if these things will cause a reaction simply by looking at and smelling the food. We can also mentally compare it to similar foods we’ve tried before and consider each ingredient individually. We’re not being close-minded when we say we don’t want to try something, we’re trying our best to manage our eating disorder while remaining polite, which can be quite the high wire act at times. I don’t think most people are being malicious by asking these questions, but it gets tiring when you’ve been asked them so many times. I hope that if more people are educated about ARFID, they will be more respectful of others. Not every so-called “picky eater” has ARFID, but if this article feels true to your experiences, it’s worth discussing with a doctor and/or a psychiatrist. Help can be hard to access because of the general lack of awareness regarding ARFID, but progress is being made. I wrote this article because I spent most of my life thinking I was the only person in the world with this problem. Once I realized that my experience had a name, I could identify it as something real and quantifiable. Sometimes just having an explanation and knowing that you aren’t alone is life-changing. Resources ARFID Awareness UK BEAT Eating Disorders Header image source: A painting by @brainless_drawings, an artist with ARFID

The historical journey of a retired professor. I was appointed to the Chair of Psychiatry at Newcastle University in 1990. I was involved with research into the neurobiology of severe affective disorders (depression and bipolar disorder) and my clinical interests were with the same group of patients. I first sort of retired in 2011 at the age of 62. This was part-retirement with re-engagement three days a week as a Senior Research Co-Ordinator (I liked all three of these words!). This may not be for everyone, and in fact may not be available to many or all soon, but for me it was great. I gave up things I didn’t like or wasn’t much good at (for example, University administration and committee work) and did more of the things I liked (research and teaching postgraduate (PG) psychiatrists in training). I next sort of retired in 2015. I became Emeritus (NB the term has nothing to do with merit!) and ceased to be paid. Since then, I have continued to do some of my previous research, done some teaching (mostly with the British Association of Psychopharmacology) and some advisory work, e.g., with the Medicines and Healthcare products Regulatory Agency. All this has been rewarding, particularly as it allowed me to keep in touch with peers and junior colleagues. That is to say, this work had a social function. Not being paid for work does lead to the pleasant state of doing it when one can fit it in to one’s schedule, rather than feeling under perpetual pressure as before. I did some research on successful retirement and cognitive ageing around this time and to boil it down, three things stood out. Exercise (which should be a mix of cardio, stretching and muscle strengthening), keeping active socially and learning something new. (I let a medical student friend know of this evidence and he decided to take up dancing as a way of doing all three! Subsequently, he is both very well preserved and a very good dancer...). I was keeping physically active with walking, cycling and golf, and was reasonably social with my “old” work described above, friends and family. But what to do about learning something new? I knew I just couldn’t learn a language or to play a musical instrument… My first love at school was history and I had dabbled in it over the years so I thought I might study history. I quickly excluded being an undergraduate (UG) again (exams and having to be at lectures which might be before 11am!) so I decided to do a postgraduate (PG) degree, a PhD. This was partly because a lifetime of having been told what to do and working to deadlines left me in a situation when I, being a sad person, knew that these were necessary requirements to keep me on track rather than just dabbling. There is, of course, nothing wrong with dabbling, better known as taking an interest, it just wasn’t for me. But one can’t just swan in and do a PG degree in History without an UG degree in History. Unless, that is, you want to study the History of Medicine, in which case a medical degree can suffice as an entry requirement. Decision made. Now seven years part time on, I have finally been awarded my PhD in the History of Medicine. I was fortunate in finding an excellent supervisor (Dr Jonathan Andrews, Reader in Medical History at Newcastle University, and a real card-carrying expert in the history of the care of people with severe mental health conditions, or the “insane” as they were called, over the last three centuries) and a topic of interest to me. I investigated the causes of death of the “insane” in asylums in the late Victorian period by studying post-mortem reports in those who died under the age of 55. Infections particularly tuberculosis predominated as a cause of death, but about a third of patients had evidence of arterial disease (atheroma) in the heart or brain. These patients were mostly thin, didn’t smoke and were active so this may be evidence that vessel disease is part of serious mental illness and not just an artefact of drugs and obesity as some see it today. So, I think the results are of relevance today and I plan/hope to write some papers on the topic, sometime. Overall, my project and the study for it has been very rewarding. Being a student again was largely fun and as a byproduct, as it were, I have become very interested in the History of Psychiatry (HoP) more broadly and am now much involved with its Special Interest Group (HoPSIG) of the Royal College of Psychiatrists. But it was also tough at times. The key problem was unlearning years of training and practice in writing in a medical and scientific way and learning to write like an historian. This is an interesting topic in its own right (and one I could drone on about to anyone who is interested) but it was, and is, a real and ongoing struggle, relieved only slightly by the fact that historians find practicing medicine difficult too! Other difficulties included learning to type and battling with the complexities of formatting huge Word documents and tables. Long hours in various Archives collecting data were not exactly a joy, though the idea of it was worse than actually doing it. An example of an asylum post-mortem report is shown below. I looked at over 400 of these! (doctors handwriting has always been bad!). Lots of support and other pastimes (golf and grandchildren!) helped a great deal in distracting one from these issues. So, all in all, I can recommend formal study as a good way of structuring and enjoying retirement. But the key thing is that it is each to their own. Dancing and dabbling are great too! Whichever route one follows, I think the important thing is to think about retirement, plan for it and structure it, at least to some extent. If anyone has been stimulated by this story to study HoP before or after retirement, then all the better. HoPSIG Needs You! I continue to say that I have sort of retired. Good luck to you whenever and however yours comes along!

Directly connected to the infant need of contact with the caregivers, which I have discussed in the previous article in my column, another fundamental need of the baby is being comforted when crying. For little babies, crying is a powerful biological sign and, in fact, is the only way they have to communicate their needs. It can be anything: from the need to be fed or to sleep, to discomfort from a dirty nappy or an upset stomach, to the need to receive some physical comfort and reassurance. Babies are communicating and they expect their caregivers to respond. In fact, the caregiver role is to help the infant to regulate their emotional states, helping them to transform negative emotions in a positive state. Photo on Freepik Why it is important for parents to respond when the infant cries Even very little babies are able to adopt some self-regulatory strategies, behaviours aimed at handling negative emotions and reducing their level of stress, such as sucking or touching parts of the body (putting an hand or fingers in the mouth or touching their ears or hair). Photo by Eman Genatilan on Pexels However, in the majority of situations, they rely exclusively on their caregivers to help them with their emotional regulation (managing and controlling emotions and behaviours), as their brain is still very immature. In fact, 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 regulating their internal states and emotions, in a process called hetero-regulation. Through the experience of the relationship with the caregiver in the first years of life, with time and brain maturity, children will eventually be able to internalize the ability to control their emotions and behaviour independently (i.e., self-regulation) and will be able to move from a predominant hetero-regulation to a predominant self-regulation. This ability will help them to understand their own emotions and those of others, manage stressful situations, and maintain balance and wellbeing even during adult life. Therefore, if parents are available and respond sensitively to their babies’ requests and needs, babies will feel secure that they can freely express their negative emotions and seek proximity with the caregiver when distressed, and that the caregiver will respond and make them feel better. In other words, this creates a virtuous cycle of trust, which represents the basis for a secure attachment. Secure attachment is associated with long-term positive outcomes for the infant in terms of general wellbeing and development. Conversely, if parents don’t respond to their babies’ requests of help when distressed, they respond in inconsistent and unpredictable ways, or with atypical behaviours such as those perceived as frightening or confusing for the baby, babies may understand that their caregivers are not available. Depending on the specific behaviour of the caregiver, with time they could eventually start minimising the display of negative emotions and avoiding contact with the caregivers if they feel that they are rejecting them or are unavailable. Alternatively, they could exaggerate negative emotions (for example, crying and protesting a lot and not being soothed easily), to maximise the chance of response from an inconsistent caregiver, or they could display a mixture of these strategies. All of these behaviours represent the basis for the development of an insecure attachment, which is a risk factor for life-time negative outcomes in terms of wellbeing such as psychopathology. The risks of not responding to a crying baby Not responding repeatedly to a crying baby may have negative long-term effects. Research has in fact shown that excessive crying in the first stages of life doubles the risk of emotional and behavioural problems at age 5-6, such as behavioural problems, hyperactivity/inattention and mood disorders. Photo by Polina Smelova on Pexels There are different factors potentially involved in this association, but a crucial one is certainly the parent-infant relationship, as it is considered a very important factor for infant development. In fact, a lack of parental response to the infant cry is associated with the infant's production of high levels of cortisol, which is the hormone released during stressful situations. When levels of cortisol are too high for prolonged periods of time, these can impact the developing brain and, therefore, can have long lasting negative effects on cognitive function and on general physical and mental health. Of course, there will be times when it will not be possible to respond or soothe the crying baby. An example might be a baby who cries as she does not want to be in a car seat. As caregivers we can try to soothe the baby in different ways, but even if the crying persists we would not be able to remove the baby from the car seat, for obvious safety reasons. However, this situation should be an exception rather than the rule. Choosing to actively not respond to an infant crying not only can have long-term negative effects on their development, but also goes against an innate and evolutionary drive, which is to respond to the infant cues to promote their safety and wellbeing. Not only babies are programmed to seek help from their caregivers, but caregivers are also programmed to respond to their babies by nature. Photo by Sarah Chai on Pexels Prolonged exposure to the baby crying is stressful also for the caregiver. It triggers a stressful response in the body and, specifically the release of cortisol and of other hormones such as oxytocin as well as the activation of multiple brain circuits, such as the prefrontal cortex, the insula and the amygdala. These are involved in the processing of emotions and in specific cognitive processes, which all function to activate a response to the baby. The importance of parental self-care and social support All the evidence above serves to highlight the importance of parental response to the infant crying. However, it is also important to mention that responding sensitively and consistently to the baby is not always easy. In fact, the caregiving role can be very demanding for a new parent, particularly in difficult situations, such as during sleep deprivation, which often characterises the first period after childbirth. It is therefore also important for parents to activate self-care behaviours to make sure they can be more able to then respond sensitively to their baby. To this end, for example, it is important for parents to maintain some time, even if this is only short, to do something relaxing and enjoyable for themselves. It can be anything from reading a book, going for a short walk in the park, having a cup of coffee/tea, a hot bath, speaking with a friend, to sleeping. This can be very hard sometimes as parenthood is a 24/7 job and taking time for yourself as parents is often not easy. However, self-care time is very important and, therefore, parents need to work towards this. Photo by Karolina Grabowska on Pixiels Furthermore, in this first period, support is vital for parents’ wellbeing. Indeed emotional and practical support is a strong protective factor for mental health during the perinatal period. Research has in fact shown that a lack of support represents a strong risk factor for depression both during pregnancy and postnatally. So, whenever possible, if you are a new parent, ask for help, both emotional and practical, in all possible ways and don’t be afraid to ask. This will protect both you and your baby. Using the words of the child psychoanalyst Selma Fraiberg: ”when this mother's own cries are heard, she will hear her child's cries."

Borderline Personality Disorder (BPD) is a behavioural disorder marked by instability in relationships, exaggerated fear of abandonment, intermittent anger, sudden mood swings, and chronic feelings of emptiness. Discussing borderline states of emptiness is of great importance, as it is because of it that the person with BPD finds himself/herself in an unbridled quest to fill it with alcohol, drugs, sex, and/or self-injurious behaviour. Diagnosed with BPD 3 years ago, the chronic feeling of emptiness is, without a doubt, the symptom I struggle with the most daily. In this article, I intend to report in detail my experience with these intermittent states of emptiness, and how Schema Therapy has helped me to understand (and overcome day after day) what is behind this chronic feeling, marked by the lack of meaning in life (and the constant need for others' approval). Unraveling Schema Therapy in My Affections Schema Therapy is a distinctive form of psychotherapy that was originally developed by Dr Jeffrey Young during the 1980s / 90s to improve treatment for people who weren’t responding well to standard Cognitive Behavioural Therapy (CBT). It was originally developed to treat personality disorders and is often used to treat borderline personality disorder (BPD) in particular, although it has also been used to treat other disorders such as depression and anxiety. But what are schemas, and how do they develop in a person's life? My therapist explained to me that schemas are ways a person sees, perceives, and feels themselves in the world. It is how a person works in face of situations and interpersonal relationships. These schemes are formed in childhood and have to do with how our basic needs were met, whether adequately or not, as follows: Secure bond with caregivers and feeling of being accepted, Autonomy, with its own valued identity, Realistic boundaries during development, Freedom to express oneself and validation of emotions, Permission for spontaneity leisure activities. When these emotional needs are not adequately nourished, the person can enter adulthood with deficits in their social skills, thus generating maladaptive schemas. These maladaptive schemas, which can be described as ways in which individuals interpret life events and the behaviour of others, can later disrupt life: individuals may make unhealthy choices, form toxic relationships, lack fully developed social skills, engaging in destructive behaviour patterns, having a poor sense of judgment, and experiencing feelings of worthlessness or insecurity. Young structured maladaptive schemas into 18 structures, categorised into 5 different domains (set of schemas): Disconnection and Rejection: Expectation that needs for safety, protection, acceptance, and respect will not be met in a predictable way. The typical family background is detached, cold, rejecting, withdrawn, lonely, explosive, unpredictable, or abusive. Autonomy and Impaired Performance: Insecure expectations about self as well as family interfere with the child's ability to survive and function independently or perform successfully. The typical family background is overprotective, undermining the child's confidence to function well in everyday life. Impaired Limits: Deficiency in internal boundaries, leading to difficulty respecting the rights of others, or making commitments. The typical family background is characterised by permissiveness, overindulgence, lack of direction, or a sense of superiority. In some cases, the child may not have been trained to tolerate normal levels of discomfort, or may not have received adequate guidance. Direction towards the other: An excessive focus on the desires, feelings and responses of others, to the detriment of one's own needs - in order to gain love and approval. The typical family background is based on conditional acceptance: children must suppress important aspects of themselves in order to gain love, attention, and approval. Over-vigilance and Inhibition: Excessive emphasis on controlling or suppressing one's feelings, often at the expense of happiness, relationships, or health. The typical family background is punitive, demanding, and perfectionistic. There is often a concern that things might fall apart if the person fails to be vigilant. According to Young's approach, maladaptive schemas make up Personality Disorders. In practice, Schema Therapy works the Personality Disorder in parts, by stages of the person's life history. As if each of the schemes told a different pain in the individual's life. It is for this reason that, after the patient's anamnesis (an account of their medical history), the psychologist hands the person the schema questionnaire, to work on each unmet emotional need. When I arrived at Schema Therapy (1 year and a half ago), my main complaints were: fear of abandonment, a chronic feeling of emptiness, and a constant need for approval and recognition. What I can say is that during the therapeutic journey, I was able to understand that each of these complaints had a common denominator: the false Self. The false Self describes the Borderline's attempt to adapt to people and groups, imitating them by identifying with their characteristics, thus making exaggerated efforts not to be abandoned. For example, if a person with BPD starts dating someone from the literary world, they may start to "devour" books. If the person with the disorder relates to people who like a certain musical style, they may listen to, and appreciate, the sound preferred by this group. More than imitating someone, people with BPD do it because they fear not being accepted or abandoned by those they admire. Thus, the false Self (as the name implies) is not a true "me", but someone who seeks to shape his/her persona according to the people he/she meets and identifies with. Thus, the false Self has to do with the central wound of abandonment. The person is afraid of being abandoned because of feeling inadequate or unloved by parents and caregivers. In my life, I remember, in an argument with my mother at the age of 8, being abandoned by her in the middle of the street. I was away from home, and we were returning from the paediatrician. I had no idea where I was, but I ran as fast as I could to catch up with her around the corner. Since that day, I remember developing an enormous fear of being abandoned in the middle of the street, by whoever it was. The exaggerated effort to try to please someone forms a bottomless hole in the person with BPD, which he/she tries to fill with things like food, sex, alcohol, parties, work, without success. When the temporary pleasure these things provide is gone, the emptiness is there to remember that it exists. During my adolescence (and before starting psychotherapy), I tried countless ways to fill this emptiness. It was a pain that I compulsively tried to numb with parties, alcohol, sweets, unstable relationships, and academic studies (staying days and months, not wanting to see anyone, to be recognised for excellence in the final exams). But all this seems to have an explanation: According to a qualitative study of chronic feelings of emptiness in borderline personality disorder, people associate these states with feelings of disconnection from the self and others, as well as feelings of purposelessness and dissatisfaction. The exaggerated fear of abandonment and the constant need for approval intensified in my life after my mother's death in 2015, when I felt purposeless and dissatisfied. Despite her emotional lability, my mother used to be interested in my work and even gave me tips on what to write in my articles. Then, suddenly, I was alone again, in the middle of the street, without the person who, my whole life, had talked to me about everything. Thus, Schema Therapy emerges as a "therapeutic mother" for me, as it focuses on transforming that vulnerable child into a healthy adult. Schema Therapy in Managing the Patient's Emptinesses To transform the patient into a healthy adult capable of dealing with life's adversities, I filled out the Young Schema Questionnaire so that my therapist and I could work on my Early Maladaptive Schemas. As a result, the most activated schemas in my questionnaire were Abandonment, Distrust and Abuse, Social Isolation, Inflexible Standards, Grandiosity/Arrogance, and Seeking Approval and Recognition. During the sessions, I was able to understand the role that each maladaptive schema played in my life: The Abandonment Schema is characterised by a pattern of fear in interpersonal relationships, with a high expectation that important people will abandon them. Fear of loss can come from the fantasy of being left by someone else and that important people are no longer available, such as in the case of my mother, who, despite having abandoned me during an argument, is no longer here to support me in our conversations. In practice, my psychotherapist and I have been working on my character strengths, i.e. creative activities that I am good at doing, like writing this article. We have been working on meaningful experiences, that is, why I do what I do, and how my work has a positive impact not only on my life, but on the lives of those who request my work. I think you've noticed by now that my therapist has been playing my mother. But this time, in a good enough way, with limits, respect, and without the "valuation/devaluation" dichotomy. Whenever I have a crisis, I am allowed to cry, without fear, without shame, and much less without criticism. All this because I am a human being, who deserves affection and respect, without the pain of abandonment or rejection. Every day is a struggle, but it's a won struggle!