A Journey Through the Literature of Ukraine: From a pet penguin to a slice of cherry pie Eastern European literature is close to my heart and a home for most of my favourite books. Singing to the song of “reading enriches the mind and expands the imagination”, I always felt it did so incredibly well and beyond words when it came to Eastern European literature. Perhaps it has something to do with me being Polish, or perhaps there are literary gems that truly take you on a journey to places you hadn’t imagined existed. The tragic events of the past month made me reflect about the literature of Ukraine, trying perhaps to find an understanding of the events of today, and also of how this country is responding. I am a mental health scientist (and well, you already know one of my passions!), and in this blog, I would like to invite you on a journey through the literature of Ukraine. I would like to start with Ihor Pavlyuk (born 1 January 1967 in Uzhova, Ukrainian SSR), a Ukrainian writer and poet, and a winner of several international awards including the English PEN award, whose books were translated into several languages. His selected poems “A flight over the Black Sea” was published in English in 2014 and contains beautiful poems that awaken your imagination and transport you in the idyllic landscapes of the North-West of Ukraine. In the poem “Bread of the Childhood”, the author invites all our senses on a trip to his childhood home, Polissya, where you can smell the spring and taste the freshly baked cherry pie. Today, some of this territory, close to the border with Belarus and Russia, is held by the Russian army. The skilful wordplay used by Ihor Pavlyuk reminds me of the works by Bruno Schulz (July 12, 1892 — November 19, 1942), a brilliant Polish writer born in Drohobych (current Ukraine). Though they use different techniques — synesthesia, the mixing of the senses to describe an object, in Pavlyuk’s case, and personifications of inanimate objects, in Schulz’s case — both authors effortlessly bring images of their childhoods to life. Reading Pavlyuk’s poems, you can really “fly over the Black Sea” and taste that cherry pie, except that when the current reality hits, you find yourself hearing the sounds of the war, the smell of explosions, and the images of the ruins around you. If you, like me, adore the literature of grotesque, you might like the novel “Death and the Penguin” by Andrey Kurkov (born 23 April 1961 in Leningrad, USSR) which talks about the bleak reality of post-soviet life in Kyiv shown from a satirical perspective. Surrealistic events that take place in the novel, where the main protagonist, who lives with a pet penguin, embarks on a new job (writing catchy obituaries for high profile people in case they die), give a humorous tone to the dreary and chaotic life depicted in the novel. This type of bizarre humour, the irony of dark and comical being intertwined and inseparable, are amongst my most enjoyed forms of writing. One of my favourite books from the literature of grotesque is “Master and Margarita” by Mihail Bulgakov (15 May 1891–10 March 1940), a writer born in Kyiv who wrote and lived in Russia. The book was written during the Soviet Union period and it is a masterpiece in its cynical portrayal of the reality at the time, written in the most amusing form where unusual and supernatural are the norm, and the dark reality is set in surrealism. If you are interested in feminism you might like Field Work in Ukrainian Sex by Oksana Zabushko (born 19 September 1960 in Lutsk, Ukraine), a prominent novelist, essayist, and poet whose works were translated into several languages. Zabushko’s literary interests also include the modern history of Ukraine and issues of national identity, which you can discover more in the award-winning novel The Museum of Abandoned Secrets. The devastating effects of the Ukrainian-Russian War and the trauma that follows it is portrayed in one of Zubushko’s stories “No Entry to the Performance Hall after the Third Bell” which is part of the book “Your Ad Could Go Here”. There, the main protagonist, who never fought at the frontline, lives through the pain of the war by dating a soldier who was left an invalid following the 2014 Ukrainian-Russian War. The physical and psychological trauma of the war reaches far further than imagined; it’s the trauma of the collective, the trauma of generations to come. For our last stop, I would like to travel back to the 19th century to meet Nikolai Gogol (1 April 1809–4 March 1852), born in the Ukrainian Cossack town of Sorochyntsi, in the Poltava Governorate of the Russian Empire, and a brilliant writer of the Realism — an artistic movement that embraced the representation of everyday life. He wrote in Russian. As we read in this recent Guardian article by Keith Gessen, one of the famous Soviet songs says that “The motherland begins with the pictures in the first book your mother reads you”. This homely feel of Ukraine shines through in Gogol’s “Village Evenings near Dikanka and Mirgorod”, where he portrays the Ukrainian folklore, the home of his childhood and youth — now on the main route of Russian army movement to Kyiv, and home to missile airstrikes. Gogol was also one of the first authors to introduce grotesque and surrealism in his style, which is seen in his works such as “The Overcoat” or “The Nose”. As we approach the end of this blog, I hope that its content will invite people to get to know the Ukrainian culture, and that you will enjoy the beautiful literature it has produced. Inspire the Mind continues to be deeply saddened by and concerned about the terrible events in Ukraine and our thoughts and prayers are with the people affected. It is heartwarming to see the kindness and solidarity shown in these frightening times with campaigns such as the JustGiving page from Dennis Ougrin, a psychiatrist who has been delivering medical supplies to those in desperate need. He was interviewed by InSPIre the Mind here. Header Image Source: Marie G. on Unsplash

A Letter from Lviv: Courage in Ukraine and Beyond Today marks three weeks since Russia invaded Ukraine on all fronts and a bit more than a month since I came from London to Lviv, the westernmost Ukrainian stronghold. At the start of the year, I was a special projects curator at the Ukrainian Institute London and a research fellow at the Birkbeck and Goldsmiths colleges of the University of London. Three months in, I have helped my Ukrainian parents evacuate from the east of the country to Germany and joined the civic response to the Russian war in my homeland. Choices I spent the eight years since Russia first invaded Ukraine panicking and frying my brain with the impossible logistics of saving everyone I loved from the inevitable further escalation. Accepting that I could not outsmart the fates and would not outlive my worst nightmares was surprisingly liberating. Like many western intelligence agencies, I realised that the full-scale Russian invasion of Ukraine was imminent at the start of the year. Unlike many western intelligence agencies, I acted on my insights. In February, I travelled to Lviv. Today, I remain in this city, which has become a haven for the internally displaced and would-be refugees. While helping my friends, relatives, and complete strangers navigate their escape from under the Russian bombs, I have been confronted with the impossible choices of others. Was remaining in eastern Ukraine safe? Was the prospect of reaching Lviv worth spending days on the jammed roads which could be shelled at any moment? Was crossing the Polish border and venturing further into the unknown even reasonable? What I can give is not an answer but my hand. What I can promise is a temporary shelter in the city of the displaced. Homes From 2 am till 7 am, I lie in my bed listening to the longest-lasting siren since the day of the invasion. I feel protected by the thick walls of the nineteenth-century building where I’m renting a corner. The residents of Lviv call these buildings ‘Austrian’ in honour of the Austro-Hungarian Empire which once ruled over these lands. I am reminded of the Ukrainian cities to the east of the Dnieper, on the territories once colonised by the Russians, and of their no-frills apartment blocks made of concrete. These buildings are now being turned into dust; their Russian-speaking residents, slaughtered, tortured, or made to flee. For two days, a retired couple whose testimony I translated for the French radio stood on their feet in a crowded evacuation train from Kharkiv to Lviv. While they were making the journey, their house was bombed. ‘Kharkov is our home’, they told the reporters using the city’s Russian name, ‘we will come back when the invaders are thrown out’. What the invaders did not account for is that with every act of destruction and violence, our love for our home, our land, and each other is growing ever more fierce. It won’t let us surrender. Dreams On a regular night during wartime, I take some valerian pills and try to sleep. Then a news alert brightens my screen: there has been a massive explosion at one of the four Ukrainian nuclear power stations. My heart misses a beat. I sit in my bed. I realise I’ve been dreaming. I close my eyes only to be interrupted in half an hour by another alert: the governmental quarter in Kyiv has been erased by the Russians. My heart misses a beat. I wake up. Another nightmare. I take more valerian pills. I haven’t really slept since it started. Or has it been one ongoing nightmare? Rage at the invaders and pain for this country keep all of us awake at night. And if we manage to doze off for a couple of hours, we jump in our beds — be it in the bomb shelters of Kyiv, crowded rented apartments in the west of Ukraine, or guilt-infused bedrooms abroad — when the enemy fire hits places and people we love. I come from Zaporizhzhia. Always so strange to the western ear, this name has become somewhat familiar since the Russian military shelled and then captured the Zaporizhzhia Nuclear Power Plant. Since the beginning of the Russian war against Ukraine in 2014, this scenario has haunted me. On 2nd March, I submitted my latest article about this threat to a British newspaper. That same night, I woke up with a start at the very moment the Russian military shelled the building of the Zaporizhzhia Nuclear Power Plant. I knew what happened even before checking the news. I spent the rest of the night praying the way I never knew I could. Today, the Zaporizhzhia Nuclear Power Plant is under the control of the Russian occupiers who had fired from tanks at the largest nuclear station in Europe. Actions My cousin is also in Zaporizhzhia. She is a restoration artist at the Museum of Zaporizhzhia Cossack History. The Zaporizhzhian Cossacks are the quintessential heroes of the Ukrainian past. Warriors who escaped serfdom, they established a semi-autonomous proto-state which existed between the sixteenth and eighteenth centuries. The museum where my cousin used to restore works of art is where the Zaporizhzhia Cossack Host used to be before its demolition by Catherine II of Russia. This month, my cousin has spent night after night in the corridor next to the load-bearing wall, listening to the air raid sirens. She has refused to leave Zaporizhzhia. Recently, she has sent me a photograph with an assault rifle. An artist, a poet, a boho girl with bangles and braids, she looks anything but natural holding a weapon. I wish I could stand between her and anyone who would make her use it. I can’t. But Ukrainian allies worldwide can — by enforcing a no-fly zone over Ukraine. Having failed to crush the Ukrainian army on the ground, Russia is waging its war against the civilian population, targeting hospitals and museums, nurseries and objects of critical infrastructure — with rockets and 500-kg bombs. While the aim is to undermine the morale and break the resistance, what these attacks lead to is more boho girls, schoolteachers, and farmers taking up arms. Ukrainians have no choice but to fight for their lives whereas the west is choosing whether to supply us with the means of air defence we desperately need. The fear of the Kremlin has crippled western deterrence and allowed the full-scale Russian invasion of Ukraine. The fear of a direct confrontation with the Russian military is crippling Nato’s support of Ukraine and allowing the Russian military not only to slaughter Ukrainian population but to move towards the Europe proper, which Nato is obliged to defend. Russia has recently launched 30 rockets at the training base in Yavoriv, Lviv region, killing 35 and wounding 134 people. The distance from Yavoriv to the Polish border is about 20 km. The war is already at the European doorstep, while Russian nuclear terrorism renders meaningless the very concept of doors. Watching our allies watch us fight for our freedom and theirs, I dare ask them to have courage. Or is this quality limited to one country, one nation, called to shield the world from the Russian aggression with the bodies of its civilians? Editors Note We would like to say a heartfelt thank you to Dr Sasha Dovzhyk for taking the time to write this piece. While we have left Sasha the freedom to express her wishes of a no-fly zone, we as a blog would like to acknowledge that we understand the complexity of military solutions as such. Our focus remains on the devastating human suffering and not the endorsement of any specific military action for which we do not have the expertise to engage in discussion or advocate. More discussion on such military action can be read here. Inspire the Mind continues to be deeply saddened by and concerned about the terrible events in Ukraine and our thoughts and prayers are with the people affected. It is heartwarming to see the kindness and solidarity shown in these frightening times with campaigns such as the Emergency Appeal from a fellow KCL/IOPPN psychiatrist who will be delivering medical supplies to those in desperate need.

The Fight for Better Working Conditions and Equal Pay: What do the university strikes mean, and how do they affect student and staff mental health? The members of the University and College Union (UCU) and King’s College London (KCL) UNISON announced that they will take strike action for several days during February and March. The UCU membership is comprised of academics, lecturers, and some administrative services, whereas UNISON consists of staff from HR, finances, student services, libraries, and other professional services. I am a former undergraduate student at KCL and I currently work as a Research Assistant at the Stress, Psychiatry and Immunology lab. I have spent the last three weeks engaging with staff and students to understand the reasons behind the strikes and the impact it has had on their mental health. Why are the strikes taking place? UCU members have turned to repeated strike action to protect their pensions since 2018, and this was the primary focus this year as well. UCU members estimate a substantial 35% cut to staff’s guaranteed pensions, on the basis of a valuation conducted in March 2020. Moreover, as of the 22nd of February 2022, Universities Superannuation Scheme (USS) have rejected a counterproposal by UCU, and with no clear negotiations in sight, this dispute is likely to escalate. Furthermore, UCU members are also striking for their pay, contracts and working conditions, which is a shared sentiment among members of KCL UNISON. Both unions say that staff wages have not kept up with inflation, amounting to a pay cut of nearly 20% in real terms (for UCU members). In addition, there is approximately a 15% gender pay gap in UK universities rising to 17% among different ethnicities and those with disabilities. Both unions also want to eliminate precarious contracts and increase opportunities for staff career development. KCL have stated that, since these are national matters, they will do their best to influence and secure the best outcome for the staff, but the final decision is not theirs to make. However, they do recognise the issues raised during the strikes, such as workload, equity and equality, and short-term contracts, and continue to work with the unions in a constructive and collaborative way. How do the staff feel about these strikes? I spoke to Dr. Ewan McGaughey, who is a Reader in law and has been working at KCL since 2014. He is striking as a member of UCU, mainly for their pensions, and he thinks that pension cuts and increases in employee pension contributions are not justifiable by the university, as the university made a surplus of £36.4 million in the year 2020–21. On asking how conducting the strikes impacted his physical and mental wellbeing, he mentioned that there are always challenges that come with strike action, such as coordinating and resolving conflicts among members, however, discussing these issues and taking a step towards reforming them is even more important. He is also campaigning to build a KCL council that is democratically elected by staff and students which is open to dialogue and good-faith negotiations across the university. I also spoke to Pablo Paganotto, a member of UNISON and from the Libraries and Collections department. He has been an active member of UNISON since 2013 and is excited about the overwhelming support they have received from both union and staff members to conduct the strikes. He mentioned how high economic inflation, the removal of staff wellbeing days, and the lack of support from the university for staff returning to offices, have made them feel underappreciated and overlooked. These reasons could have contributed to around 89% of UNISON members agreeing to strike action. Pablo also mentioned that it has been difficult to organise a trade union online, but they had very effective and dedicated members who have made the strike possible. Moreover, Simon Hoar, a newer member of the union, emphasised that the strikes may have a short-term negative impact on the staff, however, the long-term consequences of having fewer wellbeing days and excessive workload poses bigger challenges to staff mental health in future. How do students feel about these strikes? According to a poll conducted by the National Union of Students (NUS), 73% of students agree to support the staff. Many students and staff believe that their fights are intertwined; only when staff have a good work environment, can they then provide the best education to students. Therefore, the last day of the UCU strike action, the 2nd of March 2022, coincided with the student strikes organised by the NUS where the students took a stand to campaign for funded, accessible, and democratised education. It is important to highlight, however, that although historically, the KCL student union (KCLSU) has fully supported strike action, the student body did not opt to support the strikes this year as many students desire greater stability in their education after the pandemic. The students’ pursuit for improving education became clearer through speaking to them. I spoke to third-year and fifth-year medical students, and dental trainee students who said that they have had little or no impact on their learning due to the strikes. In addition, the dental trainees mentioned that they have been trying to discuss other concerns with their course organisers. The students I spoke to from the Institute of Psychiatry, Psychology and Neuroscience, told me that they were made aware of the strikes by the lecturers, and, with most of their module content being uploaded online, the strikes did not detrimentally impact their learning and mental health. Indeed, KCL has been focused on minimising the impact of the strikes on students’ learning and teaching, they have kept the campuses and facilities open and available during these times which have been helpful to many. I also interviewed Abhay, a KCL law master’s student, who missed out on a lot of lectures across different modules. However, he says that this has not had an impact on his emotional wellbeing because he understands the reasons for the strike and empathises with the lecturers. Such feelings were also shared by Callum, a master’s student at Imperial College London, who had to write his exams during the strikes and his lecturer was unavailable to answer queries. With a year to complete an intense course which has a higher tuition fee, master’s students like Abhay and Callum feel that they should be compensated for the time they have lost, and some universities are implementing financial support schemes for the industrial action. Additionally, I was curious to understand how the impact of this year’s strikes was different from strikes in earlier years, so I spoke to Yasmin Michael who graduated from SOAS University, where the staff had undertaken industrial action in 2018. Her classes were cancelled for 4-weeks, and it was hard for her to make up for the lost lecture content once the lectures began. Moreover, crossing the picket line to go to the library or suitable study spaces had also been quite challenging for her. Her example highlights the importance of resolving the ongoing conflict, and the NUS has launched a petition asking university executives to negotiate with UCU. What do I think of these strikes? As a current researcher and a student who graduated from King’s in 2021, I have been able to form a unique perspective on this issue. Back in 2020, when some of my lectures were cancelled, I too shared Yasmin’s feelings of disheartenment and frustration with the interruptions caused by lecturers; however, upon close reflection and with a better understanding of the reasons behind the strikes, I now support their cause. Staff members at universities have 12-hour long workdays, work during odd hours and struggle to achieve a good work-life balance. They are passionate about their fields and passing their knowledge to the next generation of lawyers, scientists and professionals, and their efforts must be valued. For a majority of staff members, making the decisions related to undertaking strike action, standing on the picket lines and getting no pay for days can be extremely stressful. We must all remember that staff working conditions are students’ learning conditions, and it is of grave importance to bring an end to this dispute. Lastly, I would like to thank all the students and staff members who took the time to speak to me for this blog; their courage and determination is remarkable. This blog is also a testament to how honest and open conversations can help us understand others’ perspectives, and contribute to effective conflict resolution.

How can architecture support our mental health? - Part One Good architecture, like psychology and psychiatry, runs the gamut from hard science to soft skills. The creation of environments that nurture our well-being is a skilful dance between the understanding of building physics and technology, human interaction and empathetic instinct. Eventually, between the emotive and the objective, design ideas emerge into reality. As an architectural designer and recipient of this year’s RIBA Journal Future Architects Writing prize, I am particularly invested in putting into words how architecture makes us feel. In this vein, I appreciate the subjective nature of architecture: What delights one person may not be to another’s taste. So, how could I possibly claim to design buildings and environments that make us feel good? In case you are not overly familiar with what architects do, let me first describe their role in its most basic form. Using tools ranging from the humble pencil to state-of-the-art 3D software, architects design by practised intuition trained over many years, identifying and developing viable options rapidly and and visualising the best results for their clients. In my experience, designing a building involves a lot of moving parts: As I go through the process, I constantly balance options with budgets, form with construction methods, and materials with physical performance so that I can deliver the best solutions. In combination, all these different elements contribute to the overall experience of a building. When I think back to my first few years in architecture school, the most important thing I was taught was to seek out and create light, views, pauses and through-routes where there are seemingly none. The results can be profound, helping humans feel in tune with the seasons and their circadian rhythm, as well as facilitating a sense of orientation, gentle guidance and connection. By contrast, poorly-lit, intrusively loud and labyrinthian spaces can feel oppressive, confusing and hostile. Interestingly, we can measure some of these experiences in objective units. Concepts such as ‘thermal comfort’, ‘visual comfort’ and ‘acoustic comfort’ can be translated into acceptable ranges of celsius (temperature), lux (light) and decibels (noise). However, being able to interpret these numbers into well-built, practical and delightful spaces is one of the main skills of a good architect, as the different requirements can be contradictory. For example, planning sufficient access to daylight and views to improve our mood can quickly compete with the need to prevent glare and overheating, especially as energy-hungry air conditioning in glazed buildings is nowadays a big environmental issue. Intelligent architectural strategies are needed to preserve the basic human need to connect with the outside through generous views, while also saving energy and making our environment more comfortable. Glazed buildings I have worked on or lived in have employed many creative solutions to this problem, ranging from frit, which is a ceramic pattern fused to and therefore shading the glass, to big movable façade elements that provide protection from the midday sun. The latter strategy is one I am very familiar with from my current dwelling, the Oskar von Miller Forum in Munich, which is a live-in scholarship programme for architecture and engineering students. Two buildings that showcase architectural approaches to well-being When the Oskar von Miller Forum was built, it replaced an office building on a busy artery into the city. At first, the site appeared too noisy for a residential building. However, by setting back the building behind a tree-lined forecourt, locating sleeping areas to the rear, and designing a façade with a folded double-skin that breaks up sound instead of reflecting it, the designers of Thomas Herzog Architekten successfully solved the conundrum. As a result, the view of the traffic flow now resembles a gentle silent film, fronted by seasonally changing treetop views. Especially in dense urban environments, city planners and architects must carefully engineer spatial relations and provide access to nature to make environments liveable and aid our physical and mental health. As well as promoting and maintaining mental well-being through good design of homes and offices, good architecture can also support effective treatment of mental health conditions. For example, social prescribing is a holistic practice that complements clinical treatment with beneficial social activities such as volunteering, art or exercise. In this vein, Kentish Town Health Centre in London was designed by architectural practice Allford Hall Monaghan Morris to house a variety of services, ranging from a GP practice, a dance school, and a social work team to an arts and health charity. By synthesising a wide range of activities into one building, the spatial proximity of a range of services can reduce barriers and inhibitions to try something new. The Health Centre is a fascinating hybrid building that connects various uses in new and unexpected ways. Yet, when we discuss architecture and mental health, another much less salubrious building type springs to mind: the institutionalised environment. For today, I will conclude this blog and continue tomorrow with another instalment, where I will tell the history of mental health asylums, and showcase a number of groundbreaking new approaches to creating more nurturing environments for healing mental health.

On the Road to Help Ukraine: An interview with Dennis Ougrin What is most surprising about my conversation on the phone with Dennis Ougrin, a Ukrainian Consultant in child and adolescent psychiatry working in London who has raised more than £60,000 for urgent medical aid and equipment to bring to Ukraine through his JustGiving page, and driven the almost 1,900 km from London to Przemysl, on the Polish-Ukrainian border, and back, in the first few days of the war in order to deliver a portable ultrasound scan to the Lviv Military Hospital in western Ukraine — what is most surprising, I was saying, is that he finds the time and energy to have this conversation with me in the first place. He is talking to me from his car while driving back to the Polish-Ukrainian border (this time to deliver first aid kits) for his second time in so many weeks, with a friend, and at the head of a convoy of cars that includes four ambulances (that will remain in Lviv) as well as journalists from the BBC and the Sunday Times. Talking to me from Belgium in the evening of the 10th of March, he is planning to stop soon in Germany for the night, and arrive to Poland the next day. He is calm, lucid, determined. I hear his tiredness in his account but not in his tone: since the war has started, he has woken up at dawn every day for organising what he calls his “large scale operation”, the concerted efforts of people donating to his page, NGOs, charities and NHS organisations, in order to bring medical equipment to his war-torn country — and driving back and forth in the meantime. When he first arrived in Przemysl only a few days after the war started, he found the situation perfectly managed by the Polish government and NGOs like the Red Cross, an organised environment where the first refugees that were arriving from Ukraine were well cared for, all sheltered, fed and warm, notwithstanding the freezing temperature. This was before the number of refugees in the city reached hundreds of thousands. A recent interview with the mayor of Przemysl, Wojciech Bakun, explains that about 300–350,000 refugees have passed through the city in two weeks, moving forward west into Poland. Dennis is concerned about what he will find at the border this time. When Dennis arrived with his wife on his first trip, he was hosted in a big house near the border that had been rented by a Ukrainian family who was skiing in Austria when the war broke out. This family had remained in the border area since then, helping the transport of food and other necessities into their country. Dennis connected with them through the Ukrainian Scouts organisation. For this second trip, he has managed to secure hotel accommodation in the area. I was curious about why his first delivery was a portable ultrasound scan, of all possible medical equipment? He explained to me that soldiers often die because they cannot access an ultrasound machine that can identify if they have shrapnel in their bodies, and where. Before his first trip he called Lviv Hospital and asked what they needed most, and this is what they asked. In his subsequent regular conversations with them after his first trip, he had been reassured that the machine he had delivered was already saving lives. Lviv Hospital is not only a military hospital but also a regional hospital for trauma in the Western region. Being close to the Polish border, Dennis adds, it will also be the last hospital to fall. A report from two days ago describes Lviv — a Unesco World Heritage site 50 miles from the border with Poland, a symbol of Ukrainian nationalism, and currently hosting 200,000 internally displaced people — preparing for the arrival of the Russian army. In this second trip, Dennis plans to bring first aid kits destined to the city of Mykolayiv, in the south of the country. A recent report describes the city under attack of the Russian artillery, and their inhabitants fleeing to the Palanca border crossing in Moldova. Soon the phone conversation with Dennis moves from the organisational to the personal. To his friends and family. His parents and his wife’s parents, all in their 70s, have chosen to remain in Ukraine and to fight. Was he surprised by the heroism shown by Ukrainian people who have remained in the country, or that have returned to Ukraine from abroad, in order to fight? He was not. And the reason is in Ukrainian history. Ukraine has always been culturally and historically distinct from Russia, while maintaining strong ties with this country. A brief excursus into Ukrainian history gives me more information. Russian and Ukrainian languages are different (they separated in around the 13th century) and Ukraine has its own distinct literature. The country was an independent nation in 1917, but this experience was short-lived, before it became part of the Soviet Union in 1922. It has always been an industrialised country with a well-educated population. Dennis also reminds me of the different histories of the different areas of Ukraine. The West remained fiercely independent and was only included in the Soviet Union in 1939, following the Molotov–Ribbentrop Pact; this was the first time in history that it had come under the control of Moscow. Central and eastern Ukraine, under Soviet control since 1922, experienced the “Great Famine” in 1932–1933: according to a UN report, “women and children fell victim to the cruel actions and policies of the totalitarian regime (…) The Great Famine of 1932–1933 in Ukraine (Holodomor), which took from 7 million to 10 million innocent lives and became a national tragedy for the Ukrainian people.” The recent history is also important, Dennis continues. The country was unprepared when Russia invaded Crimea in 2014, but they prepared this time. He recalls the recent success of the Ukrainian army in holding back Russian invasion, and the heroism of the civilian population engaged in fighting. He is sure that Ukraine will win the war, that Russia will not be able to control the territory post-occupation. Dennis is also convinced that the war will end soon. He tells me about what he calls a “horrible mathematical equation”. On the one hand, there must be a limit to the number of Russian soldiers that the Russian people are prepared to sacrifice, beyond which they will intervene internally to stop the war. On the other hand, there must be a limit to the number of Ukrainian civilians and children killed in this conflict that Western countries will tolerate, beyond which they will intervene directly in the war. He is adamant that, through one, or the other, or both these factors “in the equation”, the war will end soon. Yesterday’s report from the Office of the UN High Commissioner for Human Rights (OHCHR) has recorded 1,663 civilian casualties in Ukraine: 596 killed and 1,067 injured, although they say the actual figures are considerably higher. These figures include 85 children that had been killed and more than 100 injured. Up to 4,000 Russian soldiers may have died in Ukraine, but this estimate is from a few days ago. I really hope that Dennis is right and that the war will end soon. “Let’s have a beer when you are back in London”, I say to Dennis at the end of our phone call. “I have stopped drinking alcohol since the war has started”, Dennis replies, “as I need to be always sharp in my mind. Let’s have coffee instead”. You can support Dennis’s campaign to buy medical equipment and supplies for Ukraine here.

Using MRI to Investigate the Brain Response to Inflammatory Stimuli In my previous blog, The Inflamed Brain: How inflammation can affect mood and behaviour — I talked about the FLAME study, a journey between body and mind that was part of my PhD, and I promised that I would come back and tell you the second part of my results. I completed my PhD almost a year ago, and my research experience keeps shaping and feeding my current work as a clinical psychiatrist. Moreover, the implications of my research studies are still very relevant, and results are still being published (click here to read more of my recent research). So, here I am, keeping my promise and telling the second part of the story. My PhD focussed on the link between the immune system and depression, and how inflammation in the body could reach the brain and become brain inflammation. To better understand this concept, you could have a look at my previous blog, or even think about what happens to you during times of stress or when you have an infection. In these instances, the activation of the immune system triggers the release of inflammatory cytokines (these are specific inflammatory proteins) in the bloodstream. It is thought that if inflammatory cytokines reach the brain, this could lead to a series of brain inflammatory processes, that can could be responsible for the onset of depressive symptoms. If confirmed, this would mean that inflammatory conditions (such as obesity, cardiovascular disorders, infections, diabetes, etc.) might also follow a specific biological pathway leading to the development of depression. Whilst it is possible to measure inflammation in the body with a simple blood test, how can we confirm the presence of inflammation in the brain, too? This has been possible by using imaging techniques, such as Positron Emission Tomography (PET). This is a type of brain imaging technique that involves an injection of a small dose of radioactive tracer compound. The radioactivity can target specific tissues of the brain and is detected by a camera, resulting in generating a sequence of brain images. However, a limitation of PET is that it is an expensive technique and involves exposure to radiation. That is why in my PhD, I wanted to explore the potential of another imaging technique, Magnetic Resonance Imaging (MRI). MRI is considered to be less specific than PET in detecting brain inflammation, but it is much cheaper and less invasive for participants (See below for a brief explanation of how MRI works). In the FLAME study we wanted to compare these two techniques, so participants received both a PET and MRI scan. What is the FLAME project? The FLAME study, partly funded by the NIHR Maudsley Biomedical Research Centre, was conducted together with a team of neuroscientists and neuroimaging researchers at King’s College London (a special thanks to Andrew Lawrence and Tobias Wood), under the supervision of Dr Valeria Mondelli. Its aim was to trace inflammation in its journey from the body to the brain, by triggering temporary inflammation in healthy men. We recreated the conditions of inflammation in seven healthy male volunteers, by administering a drug called Interferon-alpha. Interferon-alpha produces a temporary state of mild inflammation, which lasts up to 72 hours. A single injection of Interferon-alpha is quite safe, producing mild flu-like symptoms which can be easily treated with paracetamol (the study was approved by an ethical committee and all participants gave their consent to take part before starting the study). After the injection of Interferon-alpha, we measured the resulting body inflammation with blood tests, and brain inflammation with PET imaging and with MRI. Our aim was to test whether the activation of a temporary state of inflammation caused by Interferon-alpha in the body was also associated with inflammation in the brain. An illustration of the study measurements is shown below. Potential of MRI scans in detecting brain inflammation We all know that science is hard, most of the time. What we plan to find with an experiment might not lead to the expected results, but to something completely different, although (hopefully) still relevant. In this case, PET imaging was not able to detect the presence of brain inflammation, but the PET data were published in a scientific journal because they were considered interesting and helpful. By contrast, the unexpected result was that MRI was able to show some changes in the brain of our participants after the injection of Interferon-alpha, which could suggest the presence of inflammatory processes. To understand how MRI can detect some of these changes, we need to consider how an MRI works and what it represents. MRI images of the brain show different shades of grey, which reflect different tissue types in the brain. Two important features of brain tissue that are measured separately by MRI are “T1” and “T2” relaxation times. At a microscopic level, these features depend on tissue components (cells/proteins/lipids) and associated water. Changes in water and/or tissue due to biological processes (like inflammation) will cause changes in T1 and/or T2 features. In the FLAME study, the injection of Interferon-alpha and the associated inflammation in the body as measured in the blood were followed by increased values of T1 in brain MRI. This could indicate an increased amount of water in brain tissue (known as oedema), which is a well-known consequence of inflammation. This was found specifically in the hippocampus, which is an area of the brain that is particularly involved in the development of depression. Interestingly, those participants with a greater degree of “body” inflammation (measured by the blood tests) showed the greatest T1 values in the hippocampus, suggesting that the two mechanisms are somehow related. Our study, which was published in Brain, Behaviour & Immunity — Health, was done on a very small sample of participants, and so should only be considered preliminary. Moreover, MRI could be useful to assess the inflammatory response in the brain indirectly, by measuring the effect of inflammation on water and tissues. But if these findings are confirmed in future (larger) studies, this data would highlight the potential of MRI to indirectly investigate inflammatory processes in the brain, in a cheaper and less invasive way than PET. This would allow early identification of people who have both depression and increased inflammation, especially among those who are not responding to antidepressants, and make them eligible candidates for additional treatments, including anti-inflammatory medication. Our findings add to the growing evidence that psychiatric disorders, including depression, are overall medical disorders, and that the body and mind are definitely in this together!

Recognizing & Healing the Inner-Child The world of adults believes that they’ve grown up and left the silly child they once were behind. However, once in therapy sessions, they are reminded of how their current self is a mosaic of the childhood antics, fears and beliefs. To heal their adult self, they need to get in touch with that child they once were. I realized that the roots of the “good-girl syndrome” and unexplained anxiety I experienced as an adult stemmed from my childhood conditioning. I went through all the phases of a healing journey: from blaming to breaking down to finally accepting and working on myself. For me, it has been a gradual process but indeed a necessary one. I write on mental health among other topics and today, my dear reader, we will explore the concept of the inner child together. Who is the Inner Child? The inner child is your subconscious self that starts shaping up since you are born on this earth. The experiences, emotions, environment — both positive and negative — begin weaving your persona and conditioning behaviour long before you can even understand and process them. Numerous research papers demonstrate the connection between childhood trauma and mental health issues in adult life, and this is fairly well established in the field of psychology. Indeed, childhood trauma has been linked with long-lasting changes in cognitive and brain development. One of these changes is structural alterations in key regions of the amygdala. The amygdala is a structure in the base of the brain that detects and responds to threats, among other functions and that in recent years has gained popularity as the fight-or-flight part of the brain. An enlarged or overactive amygdala is associated with an increase in reaction to danger thereby associated with anxiety disorders. Issues rooted in childhood Low self-esteem can stem from emotional abuse, invalidation, harsh criticism, frequent punishments, bullying while growing up. If you were told you were not good enough in many ways as a child, the ‘adult you’ lives in the same misconception until the seed of self-love is sown. Unfortunately, some children face physical abuse; in adult life, they frequently take upon shame, regret and unworthiness. When severe, these adverse life events can also result in stress and Post Traumatic Stress Disorder (PTSD). Another product of unhealed underlying trauma is addiction. A study in 2011 concluded that people with substance use disorder have a childhood history of physical abuse and suffer from lower self-esteem. Trauma can also stem from financial issues that the child was a witness to. If a child saw parents struggling to make ends meet, the financial trauma may last in adult life. One might get into the habit of impulse buying as a way to bridge that gap and regret later or focus only on making money neglecting their mental health. Many such permutations determine present trauma in adult life. Gifts of Resilience It is not always dark clouds, there are silver linings too. A study published by Georgia Southern University provides evidence that there is an association between a history of trauma and being helpful to others. It goes like this: a child becomes empathetic because they relate to other adults’ stress, they are more resilient because they are not new to life’s adversities, they are creative as any form of art becomes their outlet to let out their emotions, their sense of humour develops as a coping mechanism. While I agree that there might have been adversities and emotional invalidation towards all of us, it is equally important to note that our experiences do not always amount to clinical trauma. What is perceived as traumatic by one person may not be traumatic to another. Interestingly, the impact and severity of the same traumatic event have been shown to differ on siblings too — when they both grew up in the same environment! To paraphrase Dr. Richard J. McNally, Professor of Psychology at Harvard University, “Let’s not overmedicalize normal emotional responses to stressors and undermine human resilience in the face of adversity.” Healing Revered spiritual leader, Thich Nhat Hanh says, “The cry we hear from deep in our hearts comes from the wounded child within. Healing this inner child’s pain is the key to transforming anger, sadness, and fear.” I spoke to Areena Narang based in Thailand who is a holistic healer, a trauma therapist and practices inner child healing. Areena is also a student of renowned physician and author Dr. Gabor Maté. She helps her clients re-parent their inner child based on the kind of issues they are facing. She uses hypnotherapy — a form of psychotherapy where the individual is placed into a trance-like state in which they have heightened focus and concentration so that they can explore memories of their past. She told me: “The problems that we face are to some degree based on the disconnect from the self. Whether that problem shows up as depression, anxiety, psychosis, eating disorders, addictions, or even chronic inflammatory conditions, they often go back to childhood trauma that began with that disconnect. In the need to feel ‘in control’, we develop different coping mechanisms to avoid the real feeling.” Areena also told me about one case where the client suffered from a binge eating disorder. During hypnosis, she was able to uncover her childhood situations where she felt unsafe and unworthy. A severe family financial crisis that rendered them almost homeless rose as one of the prime causes. Food became her comfort. Through several sessions and a post-session toolkit that included behavioural and mental exercises, the client has been able to eat consciously since then. She quotes Carl Jung, “Until you make the unconscious conscious it will direct your life and you will call it fate”. In closing… Before you prepare your journey towards transformation through inner child healing, there is something that you should be aware of. There are no culprits in this scheme of things. The parental figure behaved that way because they were wounded too and never knew how to heal. If you’re deciding to heal, you are the cycle breaker- breaking the generational cycle of wound-hurt-wound. You are deciding to unlearn the unhealthy coping mechanisms and polishing your core being. That is powerful. You are powerful. May our healing journey be rewarding!

Under Attack: Associations between childhood trauma and inflammation in adulthood Trigger warning: This blog discusses topics of emotional, physical and sexual abuse and emotional and physical neglect. This content may be distressing for some readers. Resources for support are provided at the end of the blog. Did you know, an estimated one in five adults across England and Wales have experienced at least one type (emotional, physical, and sexual) of childhood abuse (intentional harm toward a child by an adult or another child) before the age of 16? That’s a staggering 8.5 million people in England and Wales alone. Working as a Research Assistant in the Stress, Psychiatry and Immunology Lab (SPILab) at King’s College London, I had the opportunity to co-author a review (search and evaluation of the available literature in a topic area) on the associations between childhood trauma and inflammation in adulthood, for the journal Pharmacology, Biochemistry and Behavior. Updating a previous review by Baumeister and colleagues, the following studies postdated, and thus were not included in, the original review. Briefly, inflammation is a protective immune response regulated by small molecules known as pro-inflammatory cytokines. When initiating inflammatory response, these cytokines promote ‘sickness behaviours’ that are often seen with physical and mental illness — for example, depressed mood, reduced social exploration and loss of appetite. These are also common in those with experience of childhood trauma. As a topic of interest across several InSPIre the Mind blogs, the associations between inflammation and poor health outcomes are well known. Such associations have also been extended to experience of childhood trauma. In a previous blog, Eleonora Iob outlines the association between adverse childhood experiences and inflammation in her investigation of the gene-environment interplay in depression. Discussing a wider range of inflammatory markers, the current blog shares greater detail on the effect of childhood trauma on inflammation, and the influence of variable factors on this association. So, what did the studies in our review find? Inflammation in adulthood may be associated with traumatic experiences in childhood though significance often varies across different types of inflammatory markers and traumatic experiences. Additional factors such as biological sex (male or female), body mass index (BMI) and presence of a psychiatric condition may also have an effect on the association. Type of inflammatory marker Let’s first consider the individual types of inflammatory markers investigated in this review: Tumour necrosis factor-alpha (TNFα), Interleukin 1 beta (IL-1β), C-reactive protein (CRP, an acute inflammatory protein primarily produced by the liver) and Interleukin 6 (IL-6). Collectively, studies found that childhood trauma was more often associated with increased levels of CRP and IL-6 than TNFα and IL-1β. Of the six studies reporting on IL-1β, only two studies (Li et al., 2015; Bock et al., 2020) found significant elevation in those with experience of childhood trauma. For TNFα, correlational analyses (a statistical technique that quantifies the strength of a linear relationship between two variables) found no association between childhood trauma and inflammatory levels in adulthood (Imai et al., 2018; Gouin et al., 2020). Only one regression analysis (a statistical technique that helps to find the effect of one variable on another) found trauma to significantly predict TNFα levels (Grosse et al., 2016). This, however, was dependent on the trauma type. Comparatively, several studies found elevated levels of CRP to be associated with a history of childhood trauma (Fanning et al, 2015; Baldwin et al, 2018; Finy and Christian, 2018; Mitchell et al, 2018; Pinto Pereira et al, 2019; Powers et al, 2019). This, however, was dependent on the type of traumatic experience, the measurement of trauma history, and the participant’s characteristics (sex, BMI, and psychiatric condition). Similar findings were also reported for IL-6. Overall, though predominantly a non-significant association, greatest consistency in findings were evident for TNFα and IL-1β; for CRP and IL-6 reports on significance varied more often between studies. This could, however, be related to a larger quantity of studies investigating CRP and IL-6. Type of childhood trauma So, what about specific types of trauma? Studies in this review focused on 5 main forms of trauma: emotional, physical, and sexual abuse and emotional and physical neglect. Interestingly, abuse (intentionally harm by an adult or another child) more often than neglect (the persistent failure to meet a child’s basic needs) was significantly associated with elevated inflammatory marker levels in adulthood. More specifically, the experience of emotional trauma (abuse and neglect) was more often linked to higher inflammation than physical or sexual trauma. By contrast, the original review by Baumeister and colleagues found no association for emotional abuse. Again, associations differed between inflammatory markers — for example, sexual abuse was more often associated with increased levels of IL-6 than TNFα and CRP, while physical abuse was often associated with elevated CRP. Conversely, in the original review sexual and physical abuse were significantly associated with TNFα. The severity of traumatic experiences Restricted to three studies (Takizawa et al., 2015; Powers et al., 2016; Boeck et al., 2016), investigations for the effects of trauma severity on the association in question suggested that levels of inflammation remain similar between those with low, moderate, and severe trauma. This was consistent across two different categorization systems for trauma severity (Powers et al., 2016; Boeck et al., 2016) and an additional form of childhood trauma (peer victimization, Takizawa et al., 2015). Number of traumatic experiences Based on the studies in this review, the additive effects of the number of traumatic experiences on inflammation in adulthood are inconclusive. Investigated in only 6 studies, findings were inconsistent and were predominantly restricted to association with CRP. While Baldwin et al (2018) found that participants with one type of trauma had significantly elevated CRP levels in adulthood, this was not the case for those with multiple traumas. Further to this, Kim et al (2019) found the total number of adverse childhood experiences to have no significant effect on CRP levels later in life. Comparatively, Aas et al (2017) found that those with experience of 3 types of trauma had significantly higher CRP than ‘no trauma’ controls. This was further supported by Hostinar et al (2015); those with experience of 3 or 4 types of adversity had higher inflammatory marker levels than those with with experience of 1 or 2 types. Effect of participant characteristics (biological sex and BMI) So we’ve established that external variables may contribute to the association in question, but what about the individual’s characteristics? A stratified analysis (a statistical technique using data sorted into distinct groups) found that CRP levels were significantly higher in female participants with a history of childhood trauma, but this was not translated to male participants (Baldwin et al., 2018). Though these sex differences were further reinforced by Kim et al (2019), 8 studies using female-only samples frequently reported non-significant associations. When adjusting for sex, further studies found no effect on the association. Similar findings were reported for BMI. Thought 4 studies (Petrov et al., 2016; Mitchell et al., 2018; Aas et al., 2017; Powers et al., 2019) found that BMI had an effect on the link between childhood trauma and inflammation, most studies accounting for BMI found no effect on this association. Similar to those reporting non-significant effects of sex and BMI, Baumeister and colleagues also found these factors did not moderate the association between childhood trauma and inflammation. Association with clinical characteristics And finally, as one of the main driving forces behind the investigation in question, what did our review reveal about the potential links with psychiatric health outcomes in adulthood? Frequently, studies comparing association in patients with major depressive disorder (MDD) and healthy controls found significant association between childhood trauma and elevated levels of inflammatory markers to be restricted to patients with MDD only (Grosse et al., 2016; Pedrotti Moreira et al., 2018; Munjiza et al., 2018; Müller et al., 2019; Ng et al., 2020). Such reports have also been extended to other psychiatric disorders including schizophrenia and bipolar disorder (Quide et al., 2019). Findings may suggest inflammation as a biological mechanism through which childhood trauma can affect mental health outcomes in adulthood. Conclusions To summarise, inflammation in adulthood may be associated with traumatic experiences in childhood, particularly experience of emotional trauma. Such associations are also dependent on the type of inflammatory marker with greater association for IL-6 and CRP than TNFα and IL-1β. Individual characteristics such as BMI and biological sex, however, may also have an effect on the association in question. Frequent restriction of significant association to patients with psychiatric conditions (when compared to healthy controls) may indicate a role of inflammation in the effect of childhood trauma on mental health in adulthood. Such findings warrant need for further investigation of the specific association between childhood trauma, inflammation and psychiatric conditions in adulthood. Resources Support for survivors of abuse: The National Association for People Abused in Childhood (NAPAC): Phone: 0808 801 0331 | Email: support@napac.org.uk |Website: napac.org.uk Victim Support: Phone: 0808 168 911 | Website: www.victimsupport.org.uk Support for children and young people facing abuse: Childline: Phone: 0800 1111 | Website:childline.org.uk YoungMinds: Parents helpline: 0808 802 5544 | Crisis Messenger for young people (text the letters YM) : 85258 | Website: youngminds.org.uk

How do you maintain recovery from an eating disorder, even when it gets boring? When we talk about recovery from an eating disorder, we usually focus on the ups and downs. The euphoric highs and the crushing lows. What we seldom acknowledge, however, is the mundanity. When I started recovery from my own eating disorder at the age of 19, while it’s impossible to be fully prepared for how strenuous the process is, I had expectations. I was as ready as I could’ve been for the dark moments crying in the shower and excited for the wins of eating my first sandwich. What I wasn’t anticipating, however, was how the day-to-day of recovery was going to be so much harder. My eating disorder started developing when I was 12 years old, and I struggled a lot before even admitting I had a problem worth doing something about. As I’ve pursued treatment and healed in ways I never thought imaginable, I’ve become aware of how boring recovery actually is after a while, which makes it tricky to maintain. As torturous and challenging as recovery is, it’s also very uninspiring and a far cry from how it’s portrayed in the media and online. When we see recovery from an eating disorder depicted in a film, it’s either very bleak or incredibly romanticised. And, if someone does fully recover, the camera cuts, the credits roll, and we’re just left to assume they went on to live happily ever after with an eating disorder-free life. We see it in To the Bone, a film about 20-year-old Ellen (played by Lily Collins) who endures a lengthy battle with anorexia as she struggles to maintain various recovery programmes. At the end of To the Bone, Ellen experiences an awakening. A lightbulb moment. Viewers are led to believe that, for the first time, she actually wants to get better. But then the movie ends after she returns home to continue her treatment plan. Then that’s it. She had her moment of realisation after hitting rock bottom, then built herself back up and recovered. When we see recovery from an eating disorder spoken about on social media, we see motivational quotes with picturesque backgrounds and TikTok videos of encouragement. Either that, or we read people’s stories of relapse and struggle. From the onset, recovery is painted as a long winding road, filled with hurdles and obstacles, but one that does have a finishing line worth crossing. But, what happens when you’re actually recovering yourself and you start to realise that life in recovery isn’t always black and white. Sometimes, it’s grey and murky. Sometimes, it’s just going through the motions. Sometimes, it’s just accepting that this is your life now and you’re expected to carry on with it. Once you’ve experienced those initial highs and the euphoria of that first meal, conquering that first fear food, once you’ve healed your relationship with exercise… it can get very monotonous, and that’s what makes recovery really difficult to stick with, because the rewards aren’t endless. There comes a time when no one cheers for you. You reach a point of just being expected to sit down at the dinner table and engage in conversation. There comes a time when people don’t acknowledge you doing the little things anymore because they’ve become a habit. It’s no longer news. No one is ‘proud’ of you for simply eating once you reach day 500 of recovery. Or day 1,000. Or 10 years down the line. Because that’s just what you do and who you are now even though, sometimes, that 1,000th day is just as hard as the very first. Once you no longer feel victorious after eating a meal, it all feels very same-y as you’re hit with the realisation that this is just it now, every day for the rest of your life. So, how do you persevere and maintain your recovery when you simply can’t be bothered, because eating is part of your life like it is everyone else’s, not something you’re congratulated for? One thing I find particularly helpful is switching up my meals so I’m less likely to skip them. Adding variety to what I am eating makes the mundanity of three meals and three snacks every day for the rest of my life a little less tedious. I also try to invest time and effort in my meal preparation. This might be making an experience out of a shopping trip, experimenting with new recipes, or dancing around my kitchen to Whitney Houston’s ‘I Wanna Dance With Somebody’ as I wash my peppers and chop my onions. Even as food becomes integrated into the fabric of my daily life in a way it wasn’t before, and comfortably sets up home there, that doesn’t mean I can’t have fun with it and make meals an event. Having goals and targets in recovery is very important, especially in the early stages. It gives you an incentive and something to work towards. It instils pride in you when you hit them as you realise, hey, maybe this is all worth it after all. So, carrying on with this even when recovery is just my everyday lifestyle can help me find new ways to make it exhilarating and life-affirming. If I’ve been to a restaurant for the first time, my next goal is to go back and order something different from the menu. If I’ve accepted an invitation from a friend to eat lunch out, next time I want to be the one asking them. If I’ve eaten a burger for the first time in ages, next time I want to have cheese on it. There’s also a risk of those eating disorder thoughts crawling their way back in if routine becomes very repetitive, so it’s good to spice things up to ensure every day and every mealtime isn’t predictable. Sometimes, even altering my breakfast time by 15 minutes adds variety. The biggest thing, though, is ensuring I have regular check-ins with myself. When I initially embarked on the recovery process, I had to constantly have moments of self-reflection where I reminded myself why I started. I was checking in with myself frequently to assess where I had come from, where I was at, and where I wanted to be. This was particularly useful in times of relapse or uncertainty, as it provided me with the push to keep going as I saw how much progress I’d already made. While I don’t consider myself fully recovered — because recovery is a process, not a destination — I like to remind myself that this normality that I’m tired of is something I once craved. At one point, it didn’t seem possible for me to put Netflix on and snack mindlessly while watching a new series. It never occurred to me that I could be someone who eats out without checking the menu of a restaurant days in advance. So, in my moments of reflection, I tell myself that this stability is better than the chaos of being up and down in recovery, and certainly better than the destructive depths of an eating disorder. Sometimes, I wish my recovery was as exciting now as it was when I did things for the first time. The first time wearing those shorts that show off my legs. The first time eating lunch. The first time trying a new food combination. The first supermarket shop. The first skipped workout. But, ultimately, boring can be good. Boring means I’ve conquered so much to reach this point of calmness. While recovery still feels utterly impossible at times, the dust has started to settle and I’m adjusting to my new life, allowing myself space to craft my identity beyond my illness. Sure, the initial euphoria of recovering has fizzled out, but I certainly don’t want to regress and have to do it all over again.

Eating Disorders in University Students: A snapshot of the prevalence, recognition and ways to seek help Do you have any food rules, such as not consuming carbohydrates or not eating after 7 pm? Do you feel pressured to spend hours in the gym and get into shape? Do you compare your appearance with your peers or catch yourself looking at your reflection in shop windows? If yes, you are not alone! Many young people, particularly university students, engage in disordered eating attitudes and behaviours and find it difficult to maintain a healthy relationship with food and their bodies. My name is Başak İnce Çağlar and I have a PhD in Clinical Psychology. My research and clinical work mainly focus on body dissatisfaction and eating disorders. While I was working as a therapist in a private clinical setting and a research assistant at university, I observed that the majority of young people have difficulty in coping with the sociocultural pressure of appearance ideals, and engage in at least some level of eating disorder behaviours, which in turn negatively affect their physical, psychological and social well-being. Thus, for my PhD project, I focused on identifying and reducing eating disorder symptoms and behaviours among university students, which is why I have chosen to write about this topic for today’s blog in honour of Eating Disorders Awareness Week. Prevalence of eating disorders among young adults Eating disorders are serious psychiatric illnesses “characterised by a persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning”. No single cause for eating disorders has been identified, though biological, developmental, psychological, and sociocultural factors can play a role. Although eating disorders can occur at any time throughout life, the incidence of eating disorders reaches the highest level during the transition to university. Starting university is generally considered to be exciting, however, some people find this transition period stressful. Separation from home and family, increased autonomy, social and financial changes, new academic responsibilities, identity pursuit and exploration, can all be challenging. These new challenges are likely to increase the risk of the development of eating disorders. In addition to these challenges, most university students frequently use social networking sites (e.g., Instagram, Pinterest, Tumblr) and mobile weight-related self-monitoring applications (e.g., MyFitnessPal, Runkeeper) which are associated with increased risk of body dissatisfaction and eating disorders. Moreover, a longitudinal study found that dieting, body dissatisfaction, internalisation of appearance ideals, self-objectification, and experience of unpleasant emotions in the first year of university can predict the development and/or maintenance of eating disorders. Extensive evidence demonstrates a high prevalence of eating disorder behaviours among university students, and low levels of help-seeking behaviour. For instance, a study reported that more than 25% of university students engage in unhealthy weight control behaviours at least once per week. More recently, another study on over 70,000 students showed that one-fifth of college and university students screened positive for an eating disorder. Eating disorder behaviours and symptoms bring extra challenges to students, such as impairment in academic success, social isolation, decreased quality of life and increased comorbid medical and psychiatric conditions. Recognition and Seeking help Despite the high prevalence, severity and negative consequences of eating disorder behaviours, only about 3% of university students receive treatment. Many young people do not seek help due to the following growing reasons: lack of self-recognition, shame, failure to perceive the severity, lack of support and encouragement, denial of the problem, fear of stigmatisation, lack of mental health literacy, high treatment costs, low levels of motivation, normalisation of diet culture among peers, and using eating disorders behaviours as coping mechanisms. As there is no single factor causing eating disorders, related attitudes and behaviours do not appear in one form. However, there are several common symptoms and warning signs that can help us to identify a problem that requires help: Strict dietary rules (e.g., “I am not going to eat any chocolate”, “I cannot consume 1,200 calories in a day”, “I can only eat vegetables”) Excessive exercise (e.g., skipping classes or missing social events to go to the gym, exercising in unsafe or inappropriate places and even in the case of injury, feeling stressed or irritated when cannot exercise, exercising to compensate for eating) Body & weight checking (e.g., frequent weighing, measuring body parts, pinching or squeezing flesh, and seeking assurance from others about appearance) Body & weight avoidance (e.g., wearing baggy clothes and avoiding being weighed, looking in the mirror, taking or looking at photos, and clothes shopping) Body & weight comparison (e.g., comparing appearance with peers, celebrities, or people around them, and comparing previous and current photos) Engaging in “fat talk” (e.g., “Summer is coming. Are you sure you want to eat this?”, “Does this t-shirt make me look fat? ”, “If you work hard enough, you can look like a supermodel”) Eating disorders are treatable illnesses and several evidence-based treatment methods are available, but it is generally quite difficult for someone to recover without professional support. Seeking help may not be easy due to individual barriers (e.g., shame, lack of motivation, underrecognition of need) and structural barriers (e.g., long waiting lists, high treatment costs, travel distance etc.), but getting help as early as possible is crucial for increasing the chances of a full recovery. If you are experiencing eating disorder symptoms or know someone who is struggling, here are some steps and resources I can recommend: Talk to someone you trust for support Make an appointment with your GP to discuss how you’re feeling and get a referral for assessment or treatment from a specialist eating disorder service Reach out to your university’s counselling centre to learn about available support on campus Have a look at the resources on Beat’s website, which is the UK’s eating disorder charity, or guides on FREED’s website, which is a service designed for giving youth rapid access to tailored and evidence-based treatment. Despite increased advocacy and awareness in the community, there are still myths, stereotypes and misunderstandings around eating disorders that we need to fight against. Fortunately, many researchers, clinicians and organisations are providing resources for understanding, preventing and treating eating disorders. While still evolving, several face-to-face and virtual interventions are available to help young people to reject diet culture, challenge their unhealthy eating attitudes and behaviours, build self-esteem, get involved in the body positivity movement, and gain social media literacy and intuitive eating skills.

Escape from Ukraine: Mental health in displaced populations. Since my days as head of Wellcome’s History of Medicine programme (2001–2012) and now as a member of a the SPI-Lab research team at King’s College London, I have a keen interest in historical perspectives of mental health. As I write this, the Russian president, Vladimir Putin is escalating his unprovoked attack on his peaceful neighbour Ukraine, thus demonstrating amongst other things, utter contempt and disregard for the health and wellbeing of the Ukrainian people. Whilst western governments impose hard-hitting economic sanctions, people around the world stand in solidarity with Ukraine and wonder where it will all end, and whether the country and its people will ever be the same again. Not only are the shelling and air strikes causing civilian casualties, but the future is also bleak for those who are ‘lucky’ enough not be in the direct firing line. A significant proportion of the population is on the move, looking for sanctuary in neighbouring countries to the west. This is obviously a common consequence of conflict — mass migration of population to a safe haven; but we know from other significant migrations in history this is not the end of the matter from a population health perspective. In 1947, the partition of British India for example, led to the creation of two independent nation states: Hindu-majority India and Muslim-majority Pakistan. As a consequence, millions of Muslims left their homes and travelled to either West or East Pakistan (now Bangladesh), whilst Hindus and Sikhs marched in the opposite direction. Unprecedented sectarian violence erupted within these communities that had previously co-existed peacefully for hundreds of years. By 1948, more than fifteen million people had been displaced and over one million were dead as a consequence of the migration. I cite this example as I was recently reminded of an enlightening conversation I had with Professor Sanjeev Jain at India’s National Institute of Mental Health and Neurosciences (NIMHANS) in Bengaluru back in 2009. I spent a fascinating afternoon in Sanjeev’s office just listening to his stories of the partition and how the mental health of millions of people was affected. He explained that, although the impact was huge and multifactorial, mainstream psychiatry had largely ignored the psychological scars of partition on both the Indian and Pakistani populations. It was this silence that led him to highlight this important but hidden part of medical history in India with his research and resulting edited volume. I am glad to say his keenly anticipated book, “the Psychological Impact of the partition of India” (with Alok Sarin) was finally published in 2018 (Sage Books). In their book, Jain and Sarin examine potential reasons for the silence surrounding the mental health consequences of partition asking whether, for those with lived-experienced, the mental trauma of the partition was too intense to allow into the consciousness of the nation. Or perhaps it was because those affected were just ‘ordinary’ people who were never given the opportunity to verbalise their feelings and the impact of their poverty, disempowerment or marginalisation. Whatever the reason for this ignoring of the effects on mental health caused by the Partition, it is, according to Jain and Sarin, in stark contrast to the wholly justified consideration given to the psychological impact of the aftermath of the Second World War and the Holocaust. Research on the psychological consequences of WW II initially, quite-rightly focused on Holocaust survivors, but by the 1990s researchers began to investigate the psychological impact of WW II trauma on civilian populations, specifically looking at the prevalence of post-traumatic stress disorder (PTSD). Impact on the post-war Polish population provides a relevant salutary tale with what may begin to unfold in Ukraine. As we know, Poland suffered huge losses and social upheaval, and as a consequence had PTSD rate of over 30% (in 70–96yr olds all born before 1945). Not only that, because of the socio-political situation, i.e., coming to terms with the communist regime, Polish people faced often insurmountable barriers in coping with their trauma. This repressive environment meant that they were not able to share their war-related trauma experiences in a stable, safe, and supportive community. We know that pre-migration trauma does predict mental health disorders and PTSD, and there is little we can do about that now given the invasion and bombing is underway in Ukraine but post-migration factors are key to recovery. Unstable living arrangements, lack of economic opportunities in their new home or when they return to their country of origin, and lack of political resolution of the conflict, are all associated with poorer mental health outcomes. Loss of and separation from loved ones as well as the nostalgia for the homeland are often cited as a source of psychological distress that creates an overwhelming sense of sadness. Today, the United Nations estimates that there are over 65 million people (UN Global Trends Report) worldwide who are currently displaced by conflict or persecution, — a number added to by at least 0.5 million so far during the current situation in Ukraine. Europe, of course, has recent experience of dealing with a sudden, mass influx of displaced peoples. One only has to look back to 2016 and the arrival of half a million refugees from Syria to realise that we (the West) don’t exactly have a glowing track record in dealing desperate people displaced by war. In the summer of 2016, public opinion and government policies fluctuated wildly and led to a chaotic response whilst European nations wrangled about how many refugees to accept and tried to stop the influx from countries such as Greece and Italy. Furthermore, we know that Syrian culture (similar to Ukrainian) is family orientated and a major cause of trauma in the Syrian crisis was family separation. Families become separated when they are forced to flee at different times or, as we have seen this week in the news from Ukraine, men stay behind to fight whilst the women and children flee to safety. We will need to provide safe family reunification pathways for split families which may involve several European countries. As European nations come to together and rightly open their borders to any Ukrainians who wish to leave, we in the west need to heed the lessons from history. We cannot ignore the impact on mental health and therefore we need to ensure we provide supportive mental health services and psychosocial interventions as well as welcoming environments to mitigate against the psychological scars on the Ukrainian nation. For Ukrainian people’s sake, we have to hope we do much better this time around. Editor’s Note We are deeply saddened by and concerned about the terrible events in Ukraine. Our thoughts and prayers are with the people of Ukraine and we will continue to raise awareness for this frightening humanitarian crisis. It is heartwarming to see the kindness and solidarity shown in these frightening times with campaigns such as the Emergency Appeal from a fellow KCL/IOPPN psychiatrist who will be delivering medical supplies to those in desperate need.

Do eating disorders impact the brain? Eating disorders affect the lives of so many… Anorexia nervosa, bulimia nervosa, and binge-eating disorder, but to name a few of the eating disorders that exist and affect the lives of so many. In fact, it is estimated that roughly 1.25 million people in the UK have an eating disorder. So, it is likely that most of us, if not all of us, know someone, whether it is a family member or a friend, who has struggled with how they feel about their body and about food, or perhaps you may be someone who has experienced this yourself. Introduction… I’m a Research Assistant within the Eating Disorders Research Group at King’s College London, and I am part of a research project that aims to improve help-seeking in young people who have recently developed an eating disorder. I wholeheartedly believe that research like this is so important because unfortunately, it can take a long time to seek help and eating disorders can really take a toll on both the brain and body. For me, a super fun part of my job is being involved in the creation of animations that will hopefully encourage more young people to seek help, recognise their symptoms earlier, and improve their awareness of what an eating disorder is. One of these animations is about eating disorders and the brain (currently being developed). So, it’s safe to say, that I’ve got my fair share of learning about this. And, let me tell you, it’s pretty interesting stuff that I’m excited to share with you. Let’s get into it. The brain is incredible… I might be biased as a Psychology graduate when I say this, but the brain is easily the most important organ in our body (and yes, it is an organ). It does so many incredible things for us. It controls our emotions, our memory, our vision, our breathing… the list goes on. Our brains work 24/7 365 days a year, so it needs to be properly fuelled. A car needs petrol… I need several cups of tea a day… and our brains need food. Research suggests that eating disorders impact the brain… In the world of psychological research, there is interesting and promising research that is being conducted on eating disorders. More specifically, research that uses brain imaging techniques, such as fMRI (functional magnetic resonance imaging), compares the brains of people who have eating disorders and those who do not. Some of the findings from this research suggest that eating disorders can impact the brain and the longer an eating disorder is left untreated, the more of an impact it can have. Eating disorder symptoms, including poorer nutrition and abnormal eating patterns don’t do the brain a world of good. As it stands, fMRI studies suggest that brain activity is altered in various brain regions in those with anorexia nervosa (a complex eating disorder predominantly characterised as restricting food intake). For example, one study found that there was an association between severe and enduring anorexia and smaller brain volume and decreased grey matter volume, which is a relatively consistent finding. Our grey matter makes up the outer layer of our brains and plays an important role in our day-to-day functioning, such as allowing us to control our bodily movement. Some studies suggest that reduced grey matter volume in the frontal brain regions can be related to difficulties in changing the focus of attention (i.e., constant thoughts about eating patterns which are common in eating disorders), among other cognitive difficulties in those with anorexia. Whilst there is research in this area that is relevant to anorexia nervosa, unfortunately, the research is limited for bulimia nervosa and for other types of eating disorders, such as ARFID (avoidant-restricted food-intake disorder) and binge-eating disorder. However, the existing research has suggested that with the increasing severity of symptoms of bulimia and binge-eating disorder, comes greater neural changes in the brain, which suggests that other eating disorders besides anorexia nervosa, can also impact the brain. These brain changes are not irreversible… So, do eating disorders impact the brain? According to research, they can. But that’s not all. Another arguably consistent research finding is that improvement in brain functioning comes with eating disorder recovery. One study looked at adolescent girls with anorexia and found that an increase in BMI (body mass index) and symptom improvement was associated with increased grey matter volume in various areas of the brain. So, even though eating disorders can impact the brain, these changes have been found to essentially be reversible when eating disorder symptoms improve in recovery. Although, I’d like to add that more research needs to be carried out in this area so that we are able to understand this all a bit better. When we consider all of the really interesting research that is out there about the brain and eating disorders, it’s imperative for us to understand that eating disorders need to be treated with urgency and the symptoms need to be recognised at an earlier stage. Eating disorders can be chronic and devastating illnesses and, as I said at the start of this blog post, can really take a toll on the brain and body. Help is available… What I’d like for you to take away from this blog post is newfound knowledge of the impact of eating disorders and the importance of seeking help if you are reading this and feel that you are struggling. These findings that I’ve briefly gone over can be incredibly scary to think about when our brains do so much for us. Please take it from me, you are worthy of more than you know and there is never any shame in asking for help. Support for eating disorders… UK’s Eating Disorder Charity (BEAT) https://www.beateatingdisorders.org.uk FREED: First Episode Rapid Early Intervention for Eating Disorders https://freedfromed.co.uk