On the morning of February 24th, 2022, I was woken up at 5 am by a phone call from my mother, who simply said: “A full-scale invasion has begun. I am hearing explosions.” My flatmate, who is also from Ukraine, was standing in the doorway of my room on the phone with her parents, receiving the same information. We looked at each other, she ran up to me, we hugged and fell onto my bed. Since then the life of every Ukrainian has changed forever. I was in Kyiv just two days before the full-scale war began. The atmosphere in the city was very tense. I went because my passport had been stolen and I was full of anxiety that it would not be ready in time. Somehow, I was convinced that the war was just about to start. The media was full of messages about Russian troops gathering up on the border, information about the closest bomb shelters in each city, the foreign diplomats and journalists were warned to leave Ukraine as soon as they could. I was meeting my friends and asking them whether they thought the invasion was imminent, and if they did, why weren’t they leaving now before it became next to impossible. Most of them were joking around and saying that they didn’t believe something big would happen, that it is just Russian propaganda. People were sharing their creative plans for the next months and dreaming about the summer. The only ones who were as “paranoid” as me were internal refugees, already displaced from Crimea and the east of Ukraine. They shared a feeling of deja vu. They remembered how back in 2014 they also left their house completely unprepared that they would never see it again, and how now they carried their passports, power banks, water, snacks and all other necessities handy, in case the history will repeat itself. On February 24th, I opened my messages and all those friends I saw just two days ago, happy and smiling, were posting photos from a bomb shelter, crying videos, sending messages - “This is the scariest day of my life”. The next days, weeks and months seemed like a blur. Every day was spent in a flurry of trying to help everybody we know. Planning safe evacuation routes, raising funds for paramilitary equipment, collecting humanitarian aid, helping friends and family that made it to Berlin to find where to stay for those first months, trying to understand how to help those that stayed. Most of the Ukrainian people abroad that I know, temporarily quit their jobs and focused on simply assisting their close ones and complete strangers to survive. It felt absurd and surreal to go to your daily job, when there were rockets falling on the street, where you grew up on, and everyone you know is in mortal danger. Now it has been a year since the war began. We have all changed, we all found some kind of “war-life” balance. Some people, including myself, went back to their daily jobs and continue to raise awareness and donate, some people are still volunteering or working for the army, and some people are fighting directly at the frontlines. Some of us had a choice of whether to leave or to stay, which vector of activity to choose. Some of us don’t have it and, instead of “war-life balance”, their life IS war. We are not scared any more, we are angry, determined, and intoxicatingly alive. Being Ukrainian means being politically active. We realize that it is impossible not to be, when your life is at stake. Now every Ukrainian artist has at least one piece of work related to war, military, death, blood, and anger. This massive pain, anger and loss has become a part of our identity. Every Ukrainian has lost something or someone. We have all been confronted with thousands of deaths, exposed to brutal violence and have had to reinvent our lives in the new historical context. The saddest part of all is that we cannot go back to the somewhat naive pre-war version of ourselves that did not experience pain and loss of seeing people dead and tortured on a massive scale, that did not wake up to scroll through pictures of dead bodies and explosions, did not wake up hearing explosions nearby or seeing the city they have lived their whole life in erased from the face of earth, whose Instagram feed is full of obituaries and cries for help. I talk to my friend from Kyiv in Berlin and she says: “I miss this childlike, silly girl I was when I lived in Kyiv. I was always laughing, I had massive rose-coloured glasses on at all times and I did not know much about the world but I had so much fun with it. Now I really want to be as fun and carefree again but I know it is not possible because there is so much suffering in the background of my mind that I cannot unsee, and there are so many issues I have to struggle with daily, I cannot just pretend that they don’t exist and laugh the same way I did back in 2021. My life before the war seems like a distant fairytale, it was just so good. I like being in Berlin but I wish I was different, and not a refugee.” Her words mirror my own feelings. I look back at all the happy memories of pre-war Ukraine and I know we will never have another carefree summer like we used to do, because half of the people I was experiencing it with are fighting at the frontlines right now and they will never see the world in the same way. However, this year has also shown to all of us the power of unity, the value of freedom, and it has made us stronger and prouder than ever. We know our history and we are proud to speak our language. We have learned that even when everything in your life is breaking to pieces, together we can be a force much bigger than each of us individually and effectively fight to protect our home and our values. We learned that there are so many people around us that genuinely care and I am grateful for all the beautiful acts of kindness and generosity I have witnessed in those 365 days. When I visited Ukraine during the war, this feeling of unity was almost palpable. I felt like every taxi driver, every shop assistant, every person passing me on the street is my family. We are all living the same reality and the same experience, we often end up in a bomb shelter full of strangers, and leave it with a handful of new friends. Everybody is so warm and sensitive with each other, understanding just how much each of us has to handle and how fragile our reality is. Although I am worried about the future of our generation, in which every single person is burdened with trauma, I am also excited for the future of post-war Ukraine. The future, in which nobody will be a bystander, in which everybody will cherish the simple pleasure of being alive, and in which we know that we are the change that we want to see in the world. I hope this exciting future is coming soon. Header image: Artist Taya Kabayeva, from the VR performance "Neverland"

As a stress researcher from Turkey, I was finalizing a manuscript on the long-term impact of trauma when my world turned upside down with a text about the earthquake that originated in southeast Turkey. I am on a leave in New York, it's close to sunrise in Turkey, and I have racing thoughts from the safety of my loved ones and the extent of the damage, to what people would need immediately and the long-term impact of it all. So, I froze for a while, with my mouth open, staring at my computer screen... looking at a manuscript now felt ridiculous, but also quite painful with my awareness of the consequences of such trauma. How will we recover from this? It has now been almost a month after the two earthquakes with magnitudes higher than 7.5, directly affecting more than 20 million people in Turkey and Syria, with an increasing death toll over 50,000 people. For those who survived, they have lost their loved ones, homes, jobs, neighborhoods, and cities in the middle of the winter. Millions outside the region and abroad mourn for their loved ones, countries, and all that is lost. Figures created by and used with the permission of Emre Danisan. No one is fine... I reach out to relatives and friends in the region, shamefully relieved a bit that they are alive, and people keep saying "We are fine." I have friends who lost their houses saying, "We are fine, we are in our car for the night. I stutter but it would pass soon." Another says "We are fine, we are in a tent, but have plenty of blankets." Friends around the globe call me to ask how I am, I also find myself saying "I am fine" though I feel numb all over. One second, I find myself agitated buying blankets, diapers whatever I can find online, at another stunned to think about how this will all pass... The more I talk to people, the more I realize how everyone is broken. And these are people I can reach and talk to. I think about the millions that we can't, that are homeless, freezing, with no access to proper living conditions. I remember talking about the importance of keeping our daily routines intact during times of distress, but what happens when you lose the context of them all? When my dear friend and colleague Carmine Pariante kindly suggested me to write this piece, not a word came up for a while, followed by a period of intense emotions, questioning, and introspection pages and pages long. During this time, I am grateful to many friends around the world that reached out for support, which made me to shift the focus of this piece to contemplate on how we can find our road back to safety and stability. Where do we go from here? Researching the lifelong impact of stress, traumatic events like an earthquake is an example I often use in my classes to emphasize how the impact may change from one individual to the other. The most severe impact is in people who are directly exposed, and it is of utmost importance to provide immediate shelter and basic needs to at least ameliorate the physical conditions. Since the earthquakes happened, in addition to state organizations, there is pouring support from NGOs and people all over the two countries and the world. I hear stories from friends about the extraordinary lengths people go to travel to the region and help in whatever way they can. Social media is full of pictures of empty shelves in stores outside the region, online shopping sites are overloaded with orders. There are meetings, concerts, scholarships organized all over the world to raise donations to support people affected. In the midst of this tragedy and chaos, seeing this solidarity among people creates a little breather. However, as a doctor friend of mine in the region says, "the damage is too big and the numbers affected are just too much". The news report millions left without housing, mountains of rubbles to be removed to build hundreds of thousands of new houses to accommodate the people affected. Until then, there is still an enormous need for temporary shelters and access to basic needs. A friend says, "I have nothing left, thankfully I remembered to grab my coat and purse rushing out. Then I look at people spending the night in the rain while we are in our car, I feel devastated for them." Therefore, if you are reading this article, know that any support is still needed and would go a long way... Some links for donations: https://donate.tpfund.org/campaign/tpf-turkiye-earthquake/c465112, https://www.akut.org.tr/en/donation, https://www.basmeh-zeitooneh.org/ Apart from these, thousands are in need for medical care and mental health services that the nearby cities cannot handle. I read about all the people losing their limbs, those searching the rubbles for their loved ones, and those who are too afraid to sleep or stay indoors. All over the internet people post their CVs and search for jobs, stating things like "I lost my wife and kid, but I need a job in a nearby city to look after my other kid that survived." People are in a constant "survival mode" and grief is a luxury. There are different national and international NGOs and agencies in the area supported by volunteers, psychological centers opening their resources online and organizing trainings to send volunteers to the region, while others focus on creating safe areas for women and children. These efforts are extremely important to start with, but the challenge is to reach the whole region and stay there for a long time. Different initiatives to support affected individuals from the region have started, such as scholarships and work opportunities, and more will be needed, especially for specific risk populations, like pregnant women and children. So distant but so close While people in the region are fighting for survival, the pain, grief, and fear spreads across the countries, moving beyond borders. Undergraduates I talk to experience this much of a trauma and loss the first time in their lives, mentioning they are overwhelmed by waking up to death news from friends every day. Everyone is fixated on watching the news for hours, crying after lives lost or celebrating rescues, days after the earthquake. There is a deep anger, sorrow, and guilt associated with being away. Our minds are constantly occupied with the news and what we can do to help. At the same time, everyone is bombarded with the news of the fault lines of Turkey, filled with fear of sleeping, thoughts of moving to different cities, and feelings of insecurity all the time. It's been almost 24 years after the 1999 Izmit earthquake that killed over 17,000 people. The recent earthquakes triggered the trauma of many who experienced the 1999 earthquake, whereas the younger generation is afraid it could happen to them at any moment. Therefore, no matter where they are, people of Turkey and Syria are going through a debilitating period of loss, grief, and pain. So, those friends at a nearby school, workplace, or neighborhood are in dire need of emotional support, even though they will rarely express the need and keep silent. I know that acknowledging their pain and showing support even with a text or a hug will help them move forward during these times of despair. Life teaches us that social connection is most helpful during times that we feel like completely isolating ourselves. Looking ahead... Almost a month after this tragedy, I wanted to express how people are affected and what might be done to support their healing, knowing that this writing only represents a minimal portion of the story. There will be many others to emphasize different aspects, and things will get better in time, but for now I think we can all gather around the idea that support is critical. In that respect, I hope this piece may give you some more personal insight into what is happening and the ways in which you may help us get better.

As a person from Ukraine, living in Berlin, I never understood when people here complained about lousy winter weather. The temperatures in Ukraine throughout the winter months sometimes fall as low as -27 degrees Celcius. This winter, Russia knowingly, attacked the critical infrastructure of Ukraine, with the aim to leave its citizens without access to basic amenities in extreme temperatures. Although Ukrainians are working hard on fixing the damages as they come, the civil population is faced with waves of power blackouts and unreliable access to water and heating. Doing a Ph.D. in Medical Psychology, I find it important to talk to people, who chose to stay and persevere, and learn what is keeping them afloat. For this series, I interviewed two women, who agreed to share their stories of surviving, quite literally, the darkest times of their life, and a psychologist, who helped me understand what consequence this daily struggle has on the mental health of many Ukrainians, who have no other choice. The first story is from my friend Darya, who spent a part of her pregnancy and now the first months of her son’s life in war-torn Ukraine. Her story is told in the first person. Darya, the mom of a newborn When the war started, I was pregnant with my long-awaited baby. We were convinced that this was a perfect time to have a child, so the war came as a huge shock. For the first few months, I left for Poland but could not bear being separated from my husband. It was already difficult to take care of the newborn baby, while the air raid alarms were going off multiple times a day. When the winter started, we immediately felt the even harsher consequences of the attacks on critical infrastructure. Even though we live in the relatively “quiet” region in the West of Ukraine, power outages are frequent and unpredictable. Sometimes we have planned outages, which make it easier to plan the day. That is when I start running around, putting the washing in, loading the dishwasher, and charging the devices. However, most outages happen at random, leaving the power off for eight to twelve hours. It has a very demoralizing effect, especially because during this time, there is no mobile connection or Internet, and one feels isolated from the world. Now add the air raid sirens on top of that, while we cannot access the news, and that’s when anxiety really starts to kick in. Sometimes air raid sirens stop working because of the outage. We live close to Belarus, and they can attack at any moment, without us knowing. In the beginning, the water supply was also scarce. We quickly realized how much water we use daily, in a house full of people. We had to cut down on flushing, I washed my baby every two days, and myself even less than that. Once we had to sleep without bedding because I had put it in the washer and then we ran out of power for a few days! After a long outage, the house temperature can go down to 10 degrees Celsius, and we all have to wear multiple layers. I get worried about the development of my four-month-old baby. He just started to acquire a sense of routine but now he is quite moody and confused because he does not understand when to play and when to sleep. Here, daylight ends at 4 pm, and around then, everyone starts to feel sleepy. People and businesses have adapted by now. Almost everyone has a generator so most shops, cafes, and other businesses have reopened and are functioning in an energy-saving mode but with electricity available. This means that we can live a little closer to how we used to. However, I am really questioning the impact of all these generators on our ecology. Generators are very expensive — it can cost up to 50 euros per day to use one. They are also very loud, and when every neighbor has one, walking down the street is impossible — everything is just noise and smoke. And most importantly, generators exude toxic fumes into the atmosphere and dramatically influence our air quality. There are a lot of fires happening around the city because of negligence in using them, so we decided not to buy one. However, our spirit is still not broken. We try to find romance by using candles and LED lights. Without the Internet, there is no online entertainment, and it really brought our family together. We are all forced to be in the same room, next to a fireplace, and talk. We are trying to stay creative: playing board games, learning instruments, and knitting. Those hardships really put life into perspective. I hear people complaining about the small things and I think — “I am just really happy that I was able to take a shower today”. Somehow I still feel a lot better than I did, when I lived in Poland alone. Our life is an action movie but I definitely wish it was a bit easier to handle. I look at Darya’s family and how much everybody glows up when they are playing with the baby, and I hope that there will soon be a light at the end of the tunnel and next winter they gather together as vividly, without any extreme circumstances, and just for the joy of it.

Co written by Prof. Andrew H. Miller and Dr. Charles L. Raison Despite substantial research showing that inflammation plays a role in multiple psychiatric disorders, the development of anti-inflammatory drugs to treat psychiatric illnesses is in peril. Inflammation is a function of the immune system — inflammatory cells are triggered in response to bacteria and germs typically, however research shows that some people may have higher levels of inflammation even in the absense of bacteria and germs. There is evidence of this for some people who have psychiatric disorders. Results of clinical trials using anti-inflammatory drugs to treat diseases ranging from depression to schizophrenia have routinely disappointed, leading to the conclusion that blocking inflammation to treat psychiatric disease is a dead end. This to the detriment of the vast number of patients who are intolerant or resistant to the conventional drugs (such as antidepressant medications) currently used in psychiatry. The impending death of anti-inflammatories is only the most recent example of a drug discovery engine in psychiatry that is failing the field. Almost unnoticed, a similar fate befell drugs targeting the hypothalamic-pituitary-adrenal (HPA) axis in the 90s. These drugs also disappointed and ultimately died, a loss totaling many billions of dollars in research and development funds. The sad truth is that the drugs are not at fault; it is the way psychiatry conducts its clinical trials. Clinical trials in psychiatry are based on outdated, overinclusive diagnoses, poorly defined outcomes, and the misguided notion that “one size fits all”. I am a psychiatrist at Emory University School of Medicine in Atlanta Georgia, and I am passionate about developing new treatments for psychiatric disorders. My research has focused on the role of inflammation in depression. I am writing this article because I want to voice my concerns about missed opportunities in psychiatry to develop therapies that are targeted at specific biological processes like inflammation and thereby support the development of more personalized treatments. I have co-written this piece with Dr. Charles L. Raison, Professor of Psychiatry at the University of Wisconsin Madison. In a recent paper entitled “Burning Down the House: Reinventing Drug Discovery in Psychiatry for the Development of Targeted Therapies,” Chuck and I highlight ongoing mistakes in psychiatric drug development by comparing mental health treatments with those developed to treat cancer. Both fields began their path to drug discovery through serendipitous observations of the efficacy of drugs that are effective for many disorders but nominally specific for any one disorder, chemotherapy in oncology and antidepressants, mood stabilizers and antipsychotics in psychiatry. But while advances in oncology mean that cancer is far more treatable than it was several decades ago, in that same period of time, no similar advances have been made in psychiatric pharmacology. Sadly, patients in psychiatry today are still treated with some combination of the same or similar drugs that have been available for over 50 years, and we still don’t know how they work. Even newly popular treatments such as psychedelics and ketamine, while effective in some patients, have been around for years and work in ways that are even more opaque than conventional medications. Aside from some improvements in safety and side effect profiles, this is not progress. Psychiatric research and drug development have missed opportunities to embark on a similar course as oncology, being stuck in the past with a misguided commitment to developing non-specific treatments for highly heterogenous (diverse), symptom-based conditions that lack consistent underlying pathological causes. This misguided approach is costly. More than 20% of Americans will experience a psychiatric diagnosis on a yearly basis, and the average cost of developing a new psychiatric drug ranges between 1 and 2 billion dollars. Yet far too many of these drugs are prematurely dismissed as ineffective because they don’t work for everyone in the overly inclusive diagnostic group being studied, even though they may have been effective for a subgroup of patients with an abnormality in the biological system targeted by the drug. In contrast, oncology has made striking advances as a result of realizing that conventionally recognized types of cancer are not one-size-fits-all entities. Instead of starting with a type of cancer and searching for a treatment, oncology has identified specific mechanisms by which different cancers grow and spread and has developed treatments to identify and target those mechanisms. This has led to the realization that tumors which appear similar may require very different pharmacological treatments, and tumors that appear different may share underlying biological mechanisms amenable to a similar pharmacological treatment approach. We contend that pharmacological treatments in psychiatry will only advance when a similar strategy is embraced. Although psychiatry continues to search for one-size-fits-all type treatments for conditions such as depression or schizophrenia, more progress will be made when the diverse biological causes that drive symptom development are identified and addressed with treatments that specifically target these causes. For us, this mechanism-pathway approach emerged from our work with inflammation. In a 2013 study, we tested a powerful anti-inflammatory agent as a new treatment, based on the assumption that, because inflammation can cause depression, then major depression is wholly a disorder of inflammation. Instead, the findings were more nuanced: For those with increased inflammation, infusions of the anti-inflammatory drug worked significantly better than a placebo. But for those who reported depression symptoms but did not have increased inflammation, the anti-inflammatory treatment was no better than placebo (“dummy”) infusions of salt water. Thus, inflammation can be a mechanism that causes depression in some patients, but not everyone who is depressed has increased inflammation. So, we began to see that our labels of depression masked a whole variety of different and more specific biological mechanisms. Studies on anti-inflammatory drugs should therefore focus on patients with increased inflammation; otherwise, the drugs will fail. Unfortunately, most studies to date have lacked this focus, and therefore the disappointing results are not surprising. But there still is hope. In our paper, we offer a radically different approach for the future of psychiatry with specific recommendations including funding translational research that realigns findings from the clinician’s office with findings from the research bench, an openness to identifying patients by specific pathologies rather than traditional diagnoses and an approach to research funding that prioritizes truly transdiagnostic studies. We acknowledge there will be hesitance for these recommendations — especially from a pharmaceutical industry and insurance billing system built on the existing diagnostic categories used in psychiatry (i.e., those in the Diagnostic and Statistical Manual of Mental Disorders). We also recognize that targeting more specific mechanisms of pathologies may cost market share in some disorders, being limited to subgroups of patients with a given diagnosis. Nevertheless, enhanced specificity means pharmaceutical companies are likely to ultimately gain market share by targeting mechanisms that are transdiagnostic and therefore relevant to multiple psychiatric disorders. Such mechanism-based specificity will also greatly benefit patients with treatments that are ideally suited to their specific disease processes. 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 — regardless of the diagnosis in which those symptoms occur.

There are several seconds before a client enters my office or I open the “Zoom room” for a session, where I take a few deep breaths, ground myself, and imagine holding space for what a client might bring to therapy. It is a small ritual that I’ve had since I started practicing — a necessary one that helps me regulate, connect with myself, and be emotionally present. While I have some regularity in the folks that I see, every day is different. Humans encounter new challenges, reach new milestones in their healing journey, and discover new emotions that need time and space to process. I don’t always know what to expect, but in a way, that is one of the things I like most about being a therapist. Several weeks ago, I noticed a theme that kept coming up repeatedly: loneliness — and more specifically, queer loneliness. As a queer couples’ therapist, a majority of the clients that I see identify somewhere within the LGBTQIA+ umbrella of identities. Sometimes a person’s sexual or gender identification plays a central role in what they present to therapy with, but certainly not all the time. However, on this particular day, I had multiple clients share that they had noticed an experience of loneliness within their queerness that was impacting their well-being. Defining Loneliness According to professor, researcher, and lecturer Brene Brown, it is common for people to describe the experience of loneliness without naming it directly. This can include the naming of exhaustion, of emptiness, of a lack of connection. As a working definition, it can be best understood as “an emotional state where social needs are not being met by desired qualities and quantities of social interaction.” In some cases, you can have people around you and still feel lonely. In the context of queer loneliness, it is critical to consider the unique factors that members of the LGBTQIA+ community face. These factors include stages of identity development, including identity confusion or identity comparison, as well as the perceived or actualized threat of discrimination, rejection, or disconnection from community members or their family of origin. Taken together, we can understand queer loneliness as the experience of psychological, relational, social, or emotional isolation as a result of experiencing gender or sexuality in a way that is subversive, different, or counter to the established norms of a given community. Real Life Experiences, Real Life Impact “Coming out” is a term understood within the mainstream as the process of revealing a part of your identity to the world. What is important to note is that this process is non-linear, often requires years (and years) of emotional work, and can take place in phases. Once we understand that coming out is a complex journey for many, we begin to see the layers of loneliness that can exist within the queer experience. For example, when a person begins to question their sexual or gender identity, they may have questions that they don’t feel like they can ask others out of fear of judgement or shame. Keeping these thoughts, feelings, or curiosities to oneself can create a vibrant inner world, but a disconnection from social support. Even once a person is “out”, they may have experienced rejection from family members or struggled to build a new community in the process. Unlike cisgender or heterosexual folks, queer people often have to build a new community of support that doesn’t come with established relationships like old friends, family, or colleagues. Moreover, if a queer individual lives in a place with very few other queer people, they are more limited in building connection and a felt sense of belonging (at least in a physical sense). As I have sat across from my clients facing these different types of loneliness experiences in their queer journey, the impact of loneliness is undeniable. Loneliness has been connected to a variety of mental and physical health issues including, depression, anxiety, stress, suicide, low self-esteem, poor decision-making, increased risk of cardiovascular disease, sleep problems, high blood pressure, and even death. The evidence is clear: loneliness has major impacts on queer communities. If you are a helper in any sort of way and you work within the queer community, use curiosity and compassion as your guide and inquire about how a person is experiencing social connectedness and belonging. Ask about the barriers that exist. Explore ways for support to be possible. Queer folks have often had to do so much alone in figuring out who they are — we should at the very least provide a warm, welcoming space to propel a larger community forward. Leveraging Our Resiliency As we gain a better understanding about queer loneliness, there are ways in which we can promote the antidote: connection, community, and belonging. Of course, any of these steps require safety, bravery, and strength. Proceed with caution, clarity, and hopefully, a good therapist. Self-care, self-care, self-care. Combating loneliness doesn’t work well on an empty tank. Before doing anything, prioritize what you need to take care of your mental wellness. This might be taking a walk, staying on top of your medications, stretching, reading, or engaging in a spiritual practice. Talk about it. Whether with a trusted friend or therapist, it is important to process through all of the complex feelings that come with loneliness. Pink Therapy is a great resource in the UK; Therapy for Queer People of Color or Pride Counseling are great options in the United States. Seek out queerness in the media you consume. Whether through books, podcasts, magazines, movies, or television, a great way to feel a part of a larger community is to see that community come to life. Representation reminds you that you are not alone in your journey. Consider the role of online communities. Venturing out into visible, public, and queer spaces might be a big leap when first starting to tackle loneliness. As a first step, consider looking into digital queer spaces that might offer other ways for queer people to connect. This is especially a great option if you happen to live in a place that doesn’t have a large or accessible queer scene. Research community events. Explore options for meet-up groups that are queer focused or for the LGBTQIA+ community. If you have another lived identity that is important to you (for example, practicing sobriety), you may want to look at events or groups that include both of these identities. However you or we begin the process of shifting the effects of loneliness, know that one step at a time is all that it takes. We are in this together.

Trigger warning: The following article discusses violence against women and has mentions of suicide and murder. Some readers may find this distressing. On Sunday 5th February 2023, Emma Pattinson and her daughter Lettie were killed by her husband and Lettie’s father, George Pattinson, in a murder-suicide killing. To put it plainly, Emma and Lettie are now two more people to the rising prevalence of femicide in the UK. Soon after the BBC reported Emma’s and her daughter’s murder by her spouse, a Daily Mail article asked whether “living in the shadow of his high achieving wife lead to unthinkable tragedy”, while the murderer was described in a way that might be perceived as sympathetic, reporting his own description of himself as “a career accountant desperate to find something better to do with his day”. I am a Thames Valley core psychiatry trainee, and I have written before in Inspire the Mind on topics such as “Mental Health of Women and Children in Conflict Zones: Their Bodies and Health are the Battlefields” and “Rape and Conflict-Related Sexual Violence in Ukraine: The Cheapest Weapon of War”. In this piece, I want to discuss the media’s depiction of violence against women. In the UK, two women are killed weekly by a man; in 2020, 52% of these femicides were by current or former partners; 70% of these femicides took place in a house (that of the victim and perpetrator, that of the victim or that of the perpetrator). Violence and abuse against women and girls have a vast impact, not only on the individual woman but on the locality, the community and public health. Gender-based violence is a “shadow pandemic” that was unmasked during the COVID-19 pandemic. On 13th February 2022, Femicide Census released its’ 2020 annual report as its “most comprehensive study of male violence towards women” during the pandemic. Although the number is the lowest since 2009, we’re warned that there is a significant decline in the number of women being recorded as “killed by a male suspect”, especially by current or former partners, as a result of COVID-19. The rising femicide is a public health issue, and the media should focus on raising awareness of those campaigns, highlighting what are the statistics of these gross acts of violence, and what are the percentage of male perpetrators being held accountable under criminal law. Over the course of 10 years (2009–2018), 111 men had been implicated in their femicide killings, but at the time, only 79 had been found or pleaded guilty to their crimes. In 2020, 60% (n= 47) of male perpetrators were found guilty of murder as the outcome of criminal justice. In November 2021, in honour of International Day for the Elimination of Violence against Women and Girls, the Royal College of Psychiatrists did a podcast highlighting the significant prevalence of the femicide pandemic. The disappearance of Nicola Bulley, since 27th January 2023, was also poorly reported; there were no suggestions of violence and abuse, but the focus on her past alcohol history and being “peri-menopausal” already sent a dismal portrayal of her. Her body was found 23 days later. Bulley’s family had expressed distraught as they saw the media press had “misquoted and vilified Bulley’s friends and family”. Victim blaming and family of victim-blaming media narrative do not help with future femicide deaths. The patriarchal cultural belief that “high-achieving women” is what provoked their male partners into killing them, as indicated by the Daily Mail in the case of Emma Pattinson, can be strengthened and perpetuated by headlines and articles from tabloids that’d rather focus on explaining male violence as “actions out of character”. However, it should be pointed out that the media language was very different when Caroline Flack, a celebrity well-known as Love Island presenter, was charged with assaulting her boyfriend Lewis Burton, and was prosecuted by CPS (Criminal Prosecution Service). The tabloids’ language depicted Caroline Flack as a “toxic woman” and an abuser in all her relationships. This does not minimise the very high numbers of male victims of domestic abuse and homicide: ManKind Initiative published a report in April 2021, stating that 2.9 million men between the ages of 16–74 were domestic abuse victims, compared to 5.9 million female victims (2019- 2020); between March 2018–2020, out of 362 victims of domestic homicide, 86 were men. Nevertheless, it is a starching difference in how the media portrays domestic femicide as “what did the woman do to make him angry and kill her?” compared to a domestic androcide as “what is wrong with that woman to become violent?” The avoidance of media in reporting the complexity, risky and uncomfortable issue of domestic violence can result in the negative stigma attached to the victims of femicide. By avoiding discussion on the high prevalence of femicide, by “normalising” the gruesome actions as “to be expected” from men in our culture, by blaming the victim, and finally by blaming the police and criminal justice system, then the individual male perpetrators in each case are avoided public opinion’s blame and are sympathised as “having acted out” due to being provoked or as being deviant from “normal behaviour”. However, these men often demonstrated controlling, gaslighting and manipulative behaviour toward their female victims. In 2020, 42 (53%) perpetrators were known to have previous histories of violence against women. The UK charity Level Up campaigned for a press code of conduct on how to report intimate partner homicides sensibly. This campaign has been adopted by leading press regulators IMPRESS (Independent Monitor for the Press) and IPSO (Independent Press Standards Organisation) since 2019. Zero Tolerance, a Scottish charity aiming to end male violence against women and girls, has also released detailed guidelines for media reporting and a language guide on femicide cases, cases of violence against women and girls, and cases where men have been victims of violence. Time for all media narratives to adhere to these.

We all have struggled with self-esteem issues at some point in our lives. Our perception of our own competence gets skewed. We start questioning our worth and believing in a lesser version of ourselves. A rollercoaster ride with emotions comes as a part and parcel of being human. Doubting our own selves is a natural outcome of the pressure to be the best when all we have to do is accept our unique selves and keep growing. I am a writer with Inspire the Mind and other magazines and today we shall explore facets of self-esteem. Is it embedded in our genetic coding? Is it overrated? Does cultural upbringing have a role to play? Are there any ways to work around it? Who, me? Self-esteem? Self-esteem is mostly a situational trait that develops as the child grows up. As you would expect, parents and guardians have a significant influence on self-esteem; unconditional love, care and support from parents who allow their kids to voice their opinion from the early stages of their life help them develop a stable sense of being. Then, these feelings translate later into healthy self-esteem. But a lack of these factors is not the only cause behind low self-esteem. It may emerge due to other adverse situations in life as well — a personal loss, a series of rejections, belief systems, social media, perceived emotional and physical well-being, or serious illness, to name a few. “Self-esteem is made up primarily of two things: feeling lovable and feeling capable.” — Jack Canfield Genetic link Is it possible that we are born with the self-dislike gene? While the Tabula Rasa theory, supported by great thinkers and psychologists, that we all are born blank slates and that our characters develop over time, shaped by our families and the societal environment we grow up in, UCLA life scientists identified a particular gene’s link to self-esteem, optimism, and a sense of mastery. Before we blame genes, scientists would like you to know that genes may predict behaviour but do not determine it. Spiritual Link What would happen if you help a butterfly to get out of the chrysalis? Most probably, it won’t be able to fly. It must struggle out on its own and go through the whole process so it can spread its wings and not fall on the ground. That’s how our journey is. The tough environments and struggles were a part of what determined our life path and transformed us into the wonderful human being that we are today. The aim is not to have ‘a lot of’ self-esteem but just ‘enough’. Just enough to help us to trust ourselves and take the next step even when it’s foggy ahead. Just enough to make our inner voice whisper confidently ‘whatever it is, I can face and cope with it.’ Many studies have concluded a link between a spiritual belief system and healthy self-esteem. Perhaps it is because it provides perspective on how everything is interlinked and the unique role of our existence. Cultural link Too little or too much, both can create issues. I heard a real-life instance where a mother of an eight-year-old expressed how she went overboard in praising her kid, telling him he’s the best in everything, thinking it would be healthy to do so. One day, the kid played piano at home as usual while everyone was busy with their own chores. The kid had a huge meltdown demanding everyone to clap. Unknowingly and unintentionally, the parents created a mindset of seeking validation when self-esteem simply means the opposite. No one is at fault here. It’s a fragile line and at times, we have to correct the needle of self-esteem ourselves when we grow up. Also, parents aren’t supposed to be perfect. There is a stark cultural difference when it comes to understanding or applying the significance of self-esteem. For instance, Asian culture eldersmight give you a raised eyebrow and a look of disapproval if you tell them the ways to build self-esteem in kids. Childhood is a championship race. The only therapy they believe in is discipline. Lenora Chu, in her book, ‘Little Soldiers’ explains this difference in great detail. Times are changing of course, and new-age parents understand the significance, but the percentage of these remains less. Researchers from the London School of Economics and CWR University figured out discrepancies between high self-esteem scores and poor social skills. This led them to consider that self-esteem might be overrated and at times might be the culprit. They concluded that people with low self-esteem may do just as well in life as people with high self-esteem. In fact, they may do better, because they often try harder. There were interesting results published by Roy Baumeister in Stanford Social Innovation Review 2005. Self-esteem doesn’t make people nice or popular. Instead, people with high self-esteem run a greater risk of thinking “Wow, they loved me,” when others are thinking “What a narcissistic jerk!” The new research rejected the earlier popular claim by the psychologist Nathaniel Branden who stated that every psychological problem — from anxiety and depression to fear of intimacy or success, to spouse battery or child molestation — is traced back to the problem of low self-esteem”. The paper, ‘Rethinking self-esteem’, also specified no correlation or at times, the opposite correlation between the use of alcohol, drugs, violence, and self-esteem issues. Improvement link There is no one sure-shot way to address self-esteem issues but, surely, it can be raised by working on ourselves and increasing the dose of self-care. Rejections aren’t a question on your abilities but a compatibility error. Comparisons have no end. Know that no one has it all together. Social media is a façade. It’s your living room where everything is kept tidy for display. The dishevelled cupboards and the insecure shelves are kept hidden. Life is not meant to be conquered, just to be lived in all its emotional capacities. Try therapy if you feel a support system is required until you can walk without help. Learn a new skill that provokes your interest; it’s a good way to help esteem that’s dented due to certain let-downs in life. Apart from various intervention-based therapies that show results when done by a skilled psychiatrist, there is a Japanese response-based therapy called Morita therapy that personally gels well with me. It is based on the premise that all emotions — even negative ones — are a part of the human experience and they guide us to live a more authentic life by helping us grow and develop by accepting emotions and seeking a balance. Begin with the journey of self-awareness and liking the person you see in the mirror. What you believe, would be your worth. To a better version of us!

By Dr. Ava Easton and Dr. Thomas Pollak Trigger warning: The following article describes research about suicidal ideation, suicidal attempts, and suicide. Some readers may find this distressing. You think you are going mad, but in reality you have a life-threatening neurological condition that you and eight out of 10 other people around the world have never heard of. This is the experience for some patients affected by certain types of encephalitis, especially those triggered by autoimmune causes. I am the Chief Executive of the Encephalitis Society, and Honorary Fellow in the Department of Clinical Infection, Microbiology and Immunology at the University of Liverpool; I have written this blog together with Dr Thomas Pollak, who is Clinical Lecturer and Honorary Consultant Neuropsychiatrist at King’s College London and the South London and Maudsley NHS Foundation Trust. I have specialised in outcomes for people affected by encephalitis and their quality of life for nearly 25 years. Since that time, I have seen much change in the condition, in levels of interest in it, and in our understanding. Yet, despite this, so much more needs to be done. And that is why World Encephalitis Day on the 22nd February each year is important. Encephalitis and World Encephalitis Day Since its launch in 2014, World Encephalitis Day has reached over 294 million people worldwide. If you are one of the eight out of 10 who don’t know what encephalitis is: encephalitis is inflammation of the brain caused either by infection (examples include Covid-19, measles, or the cold-sore virus) or by a person’s own immune system going wrong and attacking the brain in error (post-infectious or autoimmune encephalitis). It is an often-devastating neurological condition which can leave survivors with a permanent brain injury. In many countries the condition has a higher incidence than motor neurone disease (MND/ALS), bacterial meningitis, and multiple sclerosis (MS) — disorders that many more people have heard about. Encephalitis affects one person every minute globally; yet, according to a YouGov Plc survey on behalf of the Encephalitis Society conducted in UK, USA, Germany, India, and Australia, 77% of people do not know what it is. This lack of awareness leads to delays in diagnosis, treatment, and poorer outcomes for patients. Encephalitis is a thief. In the same way we have watched in recent months COVID-19 (and yes there have been over 1 million cases of encephalitis as a result of SARS-COV-2!) rob people of their lives and loved ones, encephalitis has quietly been at work for thousands of years, robbing families of their loved ones, and even in those families in which the person survives, it robs them of the person they once knew. Encephalitis steals their capacity to remember as well as their personalities and the types of abilities we all generally take for granted: concentration, attention, thinking, judgement, inhibition. For many there are additional outcomes such as epilepsy and levels of fatigue so great that returning to work or education are mere pipe dreams. This is of course, when the person survives. Many don’t. New Ground breaking research released… Now, however, two new ground-breaking research papers, published for World Encephalitis Day, identify that encephalitis patients are also at a high risk of suicide and self-harm. In one paper, up to 37.5% of survivors of the condition reported they had thought about or attempted suicide (4.4%). In a further paper, 12.5% of patients affected by an autoimmune form of the condition (anti-NMDA receptor encephalitis) had suicidal behaviours during early stages of the illness, with nearly half of the 12.5% of patients (6%) carrying out a suicide attempt. The World Health Organization lists suicide as one of the top three (among five) causes of death among people aged 5–29, and a 2020 study in Denmark found that suicide rates in patients diagnosed with a neurological disorder were significantly higher (nearly double) that of people not diagnosed with a neurological disorder (44 per 100,000 person-years compared to 20.1 per 100,000 person-years). In encephalitis specifically, they found the suicide rate to be nearly double that of people without the diagnosis of a neurological disorder (39.7 per 100,000 person years). Mental health issues, self-injurious thoughts, and suicidal behaviours following encephalitis may occur for a number of reasons: the direct biological effects on the brain during the early stages when people are very poorly; as a result of disease-related psychological or physical consequences or disability, leading to impaired self-image, limited social life, reduced financial security, dependency on others, pain, and substance use; or as an adverse effect of treatments given to help with the encephalitis itself or its consequences. Psychiatric symptoms and syndromes have been far less investigated than neurological deficits and symptoms, particularly in autoimmune encephalitis patients, which means that these symptoms may likely be underdiagnosed in this patient group — but emerging evidence suggests that anxiety, depression, personality change, and post-traumatic stress symptoms are much more common than first thought. Thus, there is a need for more research addressing the breadth, nature, causes, and impacts of psychiatric symptoms in patients who have had encephalitis. Stigma around talking about mental health can also be a real barrier to speaking up about symptoms too, but it is an important barrier to overcome, and we hope that by talking about mental health and encephalitis this World Encephalitis Day, we are one step closer to breaking down that barrier for patients affected (and their family members who incidentally can also have their mental health impacted). Making a difference As a result, this World Encephalitis Day, Wednesday 22nd February, the Encephalitis Society is calling for: More awareness of the risk of mental health problems during and after encephalitis including suicide and self-harm, and encouraging all treating health professionals to ask about and risk assess for these issues during all stages of encephalitis — early hospitalisation, after discharge, during any relapses and even during so-called ‘recovery’; Awareness that suicidality can be a common and serious manifestation of encephalitis; that swift diagnosis and treatment, along with careful risk assessment during encephalitis can reduce suicidal thoughts and behaviours in many cases (reducing patient death and disability). Consideration of the potential in survivors of encephalitis for developing mental health problems later during their recovery and rehabilitation, and the negative effects that this can have on a survivor’s recovery journey. Anyone affected by encephalitis and any associated mental health problems, including thoughts of suicide and self-harm, to know that symptoms are often highly treatable and help is available from the Encephalitis Society wherever they live in the world. To help us shine a light on this important global topic, famous landmarks and buildings around the world have agreed to light up in red for World Encephalitis Day. Among many others pledges include Niagara Falls, the Jet D’Eau in Geneva, BBC Television Centre in London, The Optus Stadium in Perth, and the Dancing House in Prague. Get Involved! Don’t be silent on this — you can get involved too if you like — we are urging people to wear red on the day, post selfies and use #Red4WED and #WorldEncephalitisDay on their social media. You can visit http://www.worldencephalitisday.org to find out more and get involved. Other resources You can listen to Hannah’s story of being initially misdiagnosed here and the often thin line between neurology and psychiatry in conditions like encephalitis. You can read Steve’s Story of LGI1 encephalitis. Encephalitis Society is a multi-award-winning charity and the leading global resource providing support and information, raising awareness of the condition, and collaborating in research.

There was a time, five or six years ago, when I got very interested in philosophical pessimism. The idea that looking at life through a dark lens could actually make you feel better intrigued me, and I explored a number of different — and sometimes conflicting — positions and points of view, from Buddhism as an early form of pessimism to Simon Critchley’s neo-existentialism. In a world headed for climate catastrophe or technological self-annihilation, intellectually inhabiting the worst of all possible worlds seemed to me like a sensible thing to do. I am writer of literary nonfiction, and mental health issues have always been important in my work, but it soon became clear to me that my interest in philosophical pessimism wasn’t just theoretical. It’s not hard to guess that I wasn’t in the happiest moment of my life. I was almost always sad, and sometimes downright depressed. It was during one of these trips in the land of nothingness that I came across the concept of depressive realism for the first time. The idea was formulated in 1979 by two American clinical psychologists, Lauren Alloy and Lyn Yvonne Abramson, who were at that time working together at the University of Pennsylvania. Alloy and Abramson’s field of research is mood disorders, such as depression. In a study conducted with 144 depressed and 144 non-depressed participants, and later published in the “Journal of Experimental Psychology”, they found out that depressed individuals are much more likely to formulate an accurate overview of the reality they were asked to assess, whilst non-depressed individuals tend to overestimate their ability to exert control over the world outside of their heads. In other words, they argued, depressed people are more “realistic” about the degree of control they have over life’s circumstances. Their tendency to expect the worst makes them better judges of reality compared to their non-depressed, often overly optimistic, counterparts. Alloy and Abramson’s aim was to understand how the biology of depression works, and their study had no philosophical undertones. But, from a philosophical point of view, the implications are clear: it looked like depression helped people understanding reality “as it is”, rather than reality as we would like it to be, and idea that would have found the uber-pessimistic philosopher Arthur Schopenhauer in complete agreement. Moreover, the concept of depressive realism resonates with another interesting psychological hypothesis, formulated just one year before the publication of Alloy and Abramson’s study, the so-called Pollyanna principle, also known as “positivity bias”. In their 1978 book of the same name, cognitive psychologist Margaret W. Matlin and David J. Stang argued that people remember positive events better than negative ones, which in turns means that they are more likely to base their actions and beliefs on an overly positive perception of reality. Both the Pollyanna principle and the depressive realism model affirm the same core philosophical idea: unless we are clinically depressed, we tend to understand reality as more positive than it actually is. Depression, therefore, is no longer (or at least not only) an invalidating mood disorder, but also the door through which to peer at “reality in-itself”. In the 80s and 90s, these ideas remained mostly confined to the field of clinical experimental psychology. But in the new century, they started resurfacing, as philosophical pessimism began to look like a valid approach to face the challenges of our difficult times, and gradually left their original academic context to be applied to fields as diverse as politics and literature. To give just a few examples, depressive realism has been discussed in relation to the work of the French writer Michel Houellebecq, whose work depicts a grim reality of social and sexual Darwinism, and of Christine Smallwood’s debut novel The Life of the Mind, a description of “the abyss between what we think about and what we actually do” in the words of Jia Tolentino. Although he never mentions it directly, Thomas Ligotti’s The Conspiracy Against the Human Race clearly shares the idea at the centre of the depressive realism hypothesis. Ligotti is probably the most influential horror writer of our times, and his weird, mechanical worlds stem out of the “degree zero of thought” of life as seen through the lens of depression. I can’t deny that the concept of depression as a way of looking at reality from a privileged position, in a somewhat clearer and more “objective” way, appealed to me back then, around the time my interest in philosophical pessimism arose. And, in some sense, it still does: there are very good reasons why pessimism should be considered a valid tool to understand the present and act on it intellectually and politically. And yet, over the years I grew more and more convinced that there is a hidden, and possibly dangerous, subtext in this broadened idea of depressive realism. That, in other words, depressive realism is also an ideological construct. I find it significative that both the depressive realism and the Pollyanna principle hypothesis were formulated at the end of the 1970s in America — that is to say, in the very same years and place where neoliberal capitalism was born. In Britain, it was Margaret Thatcher the first to link neoliberal economics and an idea of “realism” when she famously said that “there is no alternative” to capitalism: that is to say, “realist” people don’t dream of or fight for another world. Cultural critic Mark Fisher called this grim outlook on social change, aptly, “capitalist realism”. Fisher struggled with depression his whole life, and eventually died by suicide in 2017. I am not suggesting that Alloy and Abramson, when they studied depressive realism, worked on a political agenda, of course. But it is possible that the Zeitgeist, the spirit of time, influenced their research interests, or at least that their discoveries fed into the political atmosphere of the 80s and 90s. Be it as it may, Thatcher’s self-fulfilling prophecy became reality: depression has been on the rise for decades, and there are good reasons to suggest that this increase in numbers is at least partially connected with capitalism and its consequences, such as climate change. Which was the very point that Mark Fisher tried to make during his lifetime. Treating depression as a somewhat “privileged” outlook on the world, as if depressed people were more objective, can be dangerous, because it could lead us to think that we must accept that “there is no alternative” to the present political and economic system. Pessimism can be a useful tool in our philosophical toolbox: it helps us see uncomfortable truths, and in times of climate catastrophe and mass extinction it can be necessary as a speculative practice, that is to say to imagine the worst possible outcomes of our actions and act upon them before it’s too late. But thinking about the worst of possible words should also be a way to allow us to imagine a better world for the future. It should not become a mean to stop social change.

Growing up, I was never taught much about periods or the female anatomy… and I was certainly never taught about mental health issues related to the menstrual cycle. I’m a Trainee Clinical Psychologist at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, studying how the menstrual cycle influences emotions, thought patterns, and behaviours in hormone-sensitive women and AFAB (assigned female at birth) individuals of reproductive age, with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Back in my early 20’s, when I started to experience shifts in my mood and anxiety levels, I felt confused and out of character. Of course, at this point, I hadn’t made the connection that these mood shifts were happening every month in the week before my period. All I knew was that half the time I felt like myself, and the other half I was a different person, and I couldn’t work out why. That ‘different person’ was full of anxiety. They didn’t want to socialise, they’d cancel plans at the last minute, and they’d be impatient and easily irritated. I’d do my best to ignore that person, trying to bring out the ‘real me’ and hide away the other. I’d enjoy the weeks where I felt confident, motivated, sociable, and generally at ease, but inevitably weeks would come where I’d shut down and try to avoid everything. I wondered if the stress and anxiety, along with the physical shifts I was experiencing, were just a product of starting my first job and getting older. But the sudden shifts were making me feel increasingly out of sorts, and I would feel embarrassed and ashamed of things I’d said and done. My Lightbulb moment Years passed where month after month I’d do my best to manage and mask things. I saw my GP who offered to prescribe me anti-depressants and refer me to psychological services for social anxiety disorder, but neither treatment felt right for me — they didn’t feel like they were targeting the root of the problem. So, I struggled on, with my alter ego in tow. I can’t remember exactly when I started connecting my difficulties to my menstrual cycle, but when I did, things really clicked. I do remember reading an article about Premenstrual Disorders (PMDs) on the National Association for Premenstrual Syndromes (NAPS) website, after which I decided to start tracking my menstrual cycle and mood over consecutive months. A few months in, things started to make sense. I noticed fairly quickly that my mood would drop, and my anxiety would increase in the 7 days before every period. And it was a very consistent pattern. I went back to the GP with my tracking data in hand, and they agreed, it looked like severe PMS. PMS — of course, I’d heard the term. But what was severe PMS and what could I do to get things under control? Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD): What’s the difference? Nearly all reproductive-age females experience the menstrual cycle, and despite what the media might try to tell you, most actually do not experience cyclical changes in their moods, cognition, and behaviour. However, a minority of females (approximately 6%) do experience very impairing hormone-related changes in mood and behaviour that only occur in the weeks before their period (DSM-5 Premenstrual Dysphoric Disorder or PMDD). The key difference then between PMDD and other psychological disorders is that for people with PMDD, when they are not premenstrual, they’re totally symptom free, whilst for people with other affective disorders, their symptoms might worsen premenstrually (something called Premenstrual Exacerbation), but they don’t disappear during the rest of the cycle. Relative to PMDD, a larger proportion of women (roughly 15–20%) experience milder premenstrual symptoms, leading scientists to believe that PMDs likely exist on a continuum, where the severity of cyclical mood change can be totally absent, mild, moderate, or severe. Receiving a diagnosis To receive a diagnosis of PMDD, strict criteria must be fulfilled. Women need to show, via daily ratings of symptoms, that at least one of their cyclical symptoms is emotional (e.g., mood swings, sensitive to rejection, anger, irritability, conflict with others, depressed mood, hopelessness, feelings of worthlessness and guilt, anxiety). They must also show that five or more physical or behavioural symptoms are present premenstrually (e.g., decreased interest, concentration problems, lack of energy, increased appetite, sleep problems, feeling overwhelmed, breast tenderness, muscle pain, bloating, weight gain). For a diagnosis of PMS on the other hand, criteria suggests women need to show via daily ratings of symptoms that at least one physical or psychological symptom is present premenstrually, is causing significant distress, and subsides within 4 days of the period starting. The causes of PMDs Researchers are actively trying to find out more about the causes of PMDs. Clearly, the timing that the symptoms switch on and off in PMS and PMDD suggests that hormone changes across the menstrual cycle are a key part of the explanation. However, what is surprising is that people with PMS and PMDD don’t appear to have different hormone levels or patterns or hormone metabolisms compared to people totally absent of any premenstrual symptoms. Instead, scientists think that women with PMS and PMDD may have an altered neurobiological sensitivity to normal hormonal fluctuations that occur during the menstrual cycle, and that this sensitivity likely exists on a continuum. This could explain why we see some women totally absent of premenstrual symptoms, some who experience mild or moderate difficulties, and some whose symptoms are so severe that high rates of suicidal thoughts, self-harm, and suicide attempts feature. Treatment options Researching what we know so far about the causes of PMS and PMDD helped me normalise my own experience, and better understand what was going on in my brain and body that meant I was changing so much premenstrually, while others I knew seemed to get by without many difficulties. In terms of first-line treatment options, I found that a huge focus was on medication such as hormonal birth control or antidepressants, as well as advice around lifestyle change. I also know that for many individuals with PMDD, who have often gone through the exhausting process of trialling the above options, that referral to a gynaecologist and hormonal and surgical treatments are usually explored next. At no point in my own journey was I offered psychological therapy for my difficulties. Even now, although guidelines state that CBT should be considered routinely as a treatment option, the treatments available are likely to be generic CBT techniques, rather than a more personalised treatment that truly takes into account the multifaceted nature of PMDs. From my own perspective, despite there being no official evidence base for their use, I have found techniques from Dialectical Behavioural Therapy and Compassion Focused Therapy to be helpful for emotion regulation and reducing self-criticism during the premenstrual phase. Ongoing research and PMS Premenstrual disorders represent an important public health problem, and much more can be done for women living with these difficulties. Psychologists don’t routinely receive basic training in this area, but I believe that psychological professionals are in an excellent position to acknowledge PMDs and provide support. Furthermore, psychologists can initiate more research into psychological factors involved in PMDs, so that future psychological treatments can be adapted to specifically target the key mechanisms at play. As part of my own research at King’s College London University, I’ve recently launched a new study looking into how we process and think about our emotions across the cycle. We’re currently recruiting women with mild, moderate and severe PMS (including diagnoses of PMDD). If you are living with PMS or PMDD and you’re interested in supporting research I would love to hear from you. Please don’t hesitate to get in touch, by following us on twitter (@PMSEmotionStudy) and emailing me at ellen.r.lambert@kcl.ac.uk

“Record numbers of women are reaching the age of 30 child-free, new official figures have shown” —  The Guardian “Half of women in England and Wales had not had a baby by their 30th birthday for the first time ever” — The Independent “Half of women are childless by the age of 30 for the first time since records began” —  Mirror “Half of women are now childless at thirty for the first time ever” —  The Daily Mail While these are all factually true, why do they sound so demeaning towards women? As a woman in my 20s, I don’t understand why headlines continue to make such a big deal out of my age. Ever since I was around 6 years old, spending my afternoons playing happy family with my teddy bears and toys, I knew that I wanted to one day become a mother. I have also always known that this was a choice I make for myself and changing my mind would never be met with any judgement. Luckily for me, I never felt any family pressure or hurry in that regard. To this day, my parents continuously encourage me to do what is best for myself and allow me to make my own decisions. However, I am aware that I am incredibly lucky to have this, the ability to make that choice, and who isn’t surrounded by society’s expectations. I also know that I have had a predestined feeling of wanting children for as long as I can remember, yet it was only ever that. A choice, an idea, a wish. Never have I ever thought of it as a deadline, an age by which I would have to accomplish this to be accepted by others. Growing older, I find myself often scrolling through news and media outlets reading article after article about how women today choose career over family and freedom over a domestic life. Or about how the average age at which women have children continuously increases, alongside research highlighting the rising concerns over fertility levels in older women. Last week, the Office for National Statistics (ONS) revealed that, for the first time since records began, half of women in England and Wales haven’t had children by the time they hit their 30th birthday. To me, this isn’t surprising. My mother had my brother and I in her 30s, and so did the rest of the women in my family. I always perceived that as of 30, one would have enough steady income to welcome children into this world. However, the more I read, the more I realise that I relate to the heaviness of turning 30. Why does 30 have such a big impact? What is it about turning 30 that changes a woman’s life? ONS statistician Amanda Sharfman commented, “We continue to see a delay in childbearing, with women born in 1990 becoming the first cohort where half of the women remain childless by their 30th birthday”. Continuing with “lower levels of fertility in those currently in their 30s indicate that this trend is likely to continue”. While it is true that there are biological concerns over fertility levels once a woman hits 30 years of age, why don’t we also include societal changes, an ageing population, and current financial struggles in the conversation? According to the American College of Obstetricians and Gynecologists, a woman’s peak reproductive years are in her late 20s, with fertility starting to decline as of 30. Where it becomes especially low after the age of 35. This is due to a decrease in the number of eggs, as well as a decrease in egg quality as women get older. However, women are living longer and while expert Elizabeth Duff acknowledges the higher risk of complications, especially for older first-time mothers, she stresses that “for individual women who are fit and healthy, there’s no reason not to plan for a straightforward birth”. Dr Quinton Fivelman, chief scientific officer at London Medical Laboratory adds “while postponing childbirth until later in life isn’t without risks, they can be mitigated by regular check-ups and tests”. Plus, not everyone wants children — and that’s okay! When looking at the statistics published by the ONS and current media headlines, I can’t help but wonder: what about all the women who never wanted children? What about the rising number of adoptions or surrogacies? The ONS clearly states that in this release “the number of children is based solely on the number of live-born children a woman has had. Stillbirths, adopted, fostered or stepchildren are excluded”. Moreover, the term ‘childless’ is defined by the ONS as “The proportion of women who had not had a live birth by a specific age. No distinction is made between voluntary and involuntary childlessness.” This data gives no insight into women’s choices, whether they are deliberate or due to an external factor. It is frustrating that this study doesn’t take into account the entire female population. We have finally started talking about the various ways to have children, and same-sex parenting, and yet in 2023, the media still fuels society’s fixation on women and our bodies. Where is the equivalent data showing the average age of men becoming parents? Recently, there have been multiple studies confirming sperm counts are falling, so why isn’t that data making headlines? The report itself is also comparing data from over 50 years ago, when gender equality was a very different conversation. Luckily, today, women have better opportunities and are allowed to focus on themselves, their careers, and their dreams, even if headlines like these make it seem like we are still stuck in the primeval, domestic, belief that every woman’s destiny is to become a mother. Dr. Pragya Agarwal, a renowned behavioral and data scientist, commented on the discussion saying, “for me, such headlines are highly problematic because they perpetuate the belief that women’s bodies and reproductive choices can — and should be — monitored”. And I agree. Besides the many ways in which women today can raise a family, we cannot hide the reasons why some may choose not to. Between the UK’s lack of childcare support, the rising cost of living, the current economic climate, the constant pressure of environmental doom, and the current break down of family structures and communal parenting, to name a few, we are still experiencing microaggressions and a constant pressure to have children. All too often, the conversation shifts towards “time is running out! You’re already…”. “Even as the concept of parenthood and gender identity become more fluid, the gendered notion of reproduction fails to move away from traditional norms, and womanhood and motherhood remain inextricably linked, while men are allowed to choose for themselves — free of societal pressures and expectations”. — Pragya Agarwal, 2022 So why are women’s reproductive choices still being judged? Why is it still taboo? Despite these figures, it seems that being childless is still something people feel they can openly question; something we collectively try to ‘fix’. For me, this isn’t a conversation about statistics, it is a direct representation of the media’s portrayal of society. I believe it is a mirror that’s reflecting our need for change. It is about considering how we communicate motherhood to young girls in the next generations, and how we can collectively change the narrative.

Trigger warning: This blog contains discussions of mental health struggles (e.g., eating disorders, self-harm) and suicidal thoughts, which some readers may find distressing. I am Penelope Maran, I have a dual master’s degree in Brain and Mind Sciences from UCL and Sorbonne Université, and I am currently undertaking a conversion postgraduate course in psychology at the University of St Andrews. I wanted to write this blog because, due to my lectures and research, I have been exposed to the importance of early interventions for mental illness, and I have known many people who were afraid of not being considered ‘sick enough’ and doubted their own eligibility for seeking treatment. Here, I talk about a few reasons why people may shy away from speaking about their mental health, and why it is crucial to access treatment as soon as possible. People’s ideas on mental health Whether it is the school shooter with ‘mental health issues’, the neighbour who had history of depression taking his own life, or that one person we know who suffered horrible trauma, we are confronted with extreme and sometimes sensationalised misrepresentations of what mental health problems are supposed to look like. It is therefore unsurprising that besides the fear of being ostracised, another concern is that one may think that they’re not sick enough to seek help and speak up about their own suffering. Why should I speak up? I have not suffered any remarkable trauma that would explain why I feel so empty, sad, lonely, anxious most of the time. Why should I speak up? I’m not on the verge of attempting suicide. Yet. Knowing that one deserves help means knowing one’s own worth But when should someone consider themselves “sick enough” for help? This is a tricky question for many affected people. People struggling with their mental health often try to pin down the pressure of suffering to a set of ‘criteria’. Such criteria consist of having to prove to oneself and to others, that one is indeed ‘sick enough’ to deserve help and unfortunately, this is also a result of the illness. Therefore, ‘feeling sick enough’ is more an expression of a person’s (lack of) self-worth, rather than an assessment of health based on realistic criteria. I’m not sick enough until I can no longer go to work. I will only be sick enough when I have lost another 5 kg. I will only be sick enough when other people notice that I am not well. Research has shown that a lack of self-worth is a psychological trait which is present in most mental health sufferers and often crucial to the development and maintenance of illness. If people have a low view of themselves, asking for help may feel like they are a ‘waste of resources’ or ‘undeserving’ of it. Some people may even feel like imposters as they do not meet their own (quite often skewed and extreme) idea of how poor mental health should look like. Eventually, being ‘sick’ then becomes a new normality. While a healthy outsider would likely not consider this as ‘normal’, people who are dealing with mental health issues, often start to perceive these issues as inevitable and part of the daily routine, despite their suffering. Other people suffer more. Things could be worse. But things could also be better, couldn’t they? Often the realisation of how bad things actually were, comes during and after treatment, when one starts to feel better again and realises that thoughts, feelings and actions are changeable. Longer duration of untreated illness makes recovering harder Seeking and getting the appropriate treatment as soon as possible is crucial for a successful recovery from mental health illnesses. This not only seems logical and evident at first glance, but has been demonstrated by numerous peer-reviewed studies for a variety of mental illnesses, be it eating disorders, depression, or psychosis. The common conclusion is clear: The longer people do not receive help, the longer the time taken to recover, and the higher the chances of their illness becoming chronic. Physiologically, mental illnesses can progressively alter brain functioning and directly affect behavioural traits such as attention, concentration, mood, or motivation. These changes in the brain make the recovery harder. Prolonging the duration of untreated illness can also be psychologically debilitating. The longer people suffer, the more it manifests itself in a disconnection from the social environment, and increases problems at work, school or university and the loss of beneficent structures. The more supporting structures are lost, the more space the illness occupies in their lives. Ironically, a patient can be even considered ‘too sick’ for psychological outpatient treatment and may require more care, such as hospital stays, than just typical conversation-based therapies. How dismissal by healthcare services reinforces pathological beliefs- a vicious circle Considering the overwhelming scientific evidence arguing for early interventions, it is safe to assume that although individuals with the illness might not consider themselves as “sick enough”, clinicians would help them understand that treatment is not something that has to be deserved or earned. Right? Well actually, no. Unfortunately, the sufferers’ skewed definition of what is sick, and a criteria-based assessment is prevalent in the health care systems as well. It is not a rarity for cases of affected individuals who have reported not to have been taken seriously in GP offices, because they did not meet specific cut-off points, such as acute suicidality or BMI-thresholds. With a growing number of patients (especially in these post-pandemic times), underfunded healthcare systems, would more likely treat acute symptoms and provide treatment to the ‘most severely’ affected people. Having only limited resources, the concession is made to go against the scientific evidence which clearly indicates that the later treatment is started, the longer it takes for people to get better, and the chronicity rates increase. This, in turn, means that the very people who were dismissed as ‘not sick enough’ earlier may be the people who then need all the more resources to get better at a later time. It has also been shown that when people are on the waiting lists for treatment, they tend to use maladaptive strategies, such as self-harm, and report a feeling of a lack of validation from mental health professionals. The irony is clear: sufferers fear not being considered ‘sick enough’ and they fight their mental illness alone every day. Among them, few muster the remarkable courage to seek help and improve their lives, however, they may be reinforced in their pathological belief system by being rejected by the health services. This vicious cycle must be stopped. While it may be part of mental illnesses, to have a lack of self-worth, to doubt that you deserve help yourself and to normalise pathological structures, health services should counteract such beliefs. Sick is sick. There is no such thing as ‘sick enough’.