Modelling is exciting until you experience it yourself. There are many hidden agendas that made me question the industry itself. I realised it was an emotional roller coaster and as a young girl not having any guidance led to me being thrown in the deep end. I am currently a BSc Cognitive and Clinical Neuroscience student doing a placement year with King’s College London, working as a research assistant on a clinical trial. I am also a part-time carer on the weekends, caring for patients who need palliative care. In this blog, I will be exploring the good and bad aspects of my personal experience in the modelling world and some ways I found to cope with the negatives. How I got into modelling Funnily enough, it all started when one day, while casually shopping for some clothes in Top Shop on Oxford Street, I was approached by a man who looked to be in his late forties. I thought to myself, oh no, what could I have possibly done. Unsurprisingly, a total stranger just walking right up to me made me feel really frightened. He informed me that he was from a modelling agency called Career Models and asked me whether I had done any modelling before, seemingly shocked when I told him no, I hadn’t. Previously, I had been told by many family members to try out modelling as they believed I had the right body type and look for it but I’d never really given it much thought. Not until that man showed up. He gave me his business card, took my number, and told me to get in touch if I was interested in starting a modelling career. I went home that day, sat down at my computer, and began researching what modelling was like. I found out that the industry has a wide range of models (different shapes, sizes, and complexions). I then realised modest fashion and commercial modelling would be where I would best fit in the industry. People never failed to realise that I had an enthusiastic, bold, and passionate personality which made me think maybe my attitude could be perfect for modelling. I always loved taking pictures and dressing up, using different looks and colours to always stand out from the crowd. This is where it all began… My first shoot Tuesday 7th July 2020. I would never forget the great excitement and nervousness I felt on that day. It was the very first shoot that I was asked to model in, and from this, the directors would decide which of these potential future models were good enough to sign. I did four different looks: winter, summer, sports, and classy. I felt like a celebrity; bright lights, cameras flashing. It was all eyes on me, I had to prove myself and show them my different styling techniques whilst posing in various ways at a quick pace to maintain a look and adapt to the niche of the shoot. I was in my true element. Witnessing so many beautiful young women of all colours, shapes, and sizes were so empowering. Despite this, there was a sense of competition in the air since they could only pick a limited number of people for the various modelling categories and thousands of us were at the shoot. I had a little feeling of uncertainty but decided to ignore it and just enjoy the moment. Almost immediately after an 8-hour-long shoot, I was told the news that I was short-listed and have been successfully signed to becoming a commercial model and that many different agencies wanted to work with me. I was ecstatic and could not believe what I had accomplished. My second shoot A few weeks later, during the pandemic, I got a call from a friend I met at a networking event called Make a Difference. She had asked me to model for a new dresses collection from a well-known company. Of course, I was delighted to be part of it! I wore a total of four traditional Somali dresses called ‘Baati’. I got dressed each time in a tent which was really uncomfortable but still worth the experience. My modelling career was taking off in such a short period of time and it was shocking. Modelling in front of civilians walking by really built my confidence up; the ability to shut out the outside world whilst you are the centre of attention, trying to look your best was really tricky but it was an environment where you had to adapt and get used to uncomfortable situations really quickly. Modelling for a YouTuber When a very well-known YouTuber directly messaged me on Instagram asking me to model for her new hijab (headscarf) line — someone who has nearly 80 thousand followers on Instagram, and over 500 thousand subscribers on YouTube, chose me to model for her! — I couldn’t believe it, I thought I was dreaming. However, this experience also was the turning point for me. It was brought to my attention that the power of everything, from head to toe, was given to the director of the shoot. And I started to hate the fact that I had no say in what I was wearing or how my makeup was done — for example, I felt as though I looked awful with the smokey eye look (and the reason I knew so much about makeup was that my other passion was makeup, hoping I would be a makeup artist one day). It started to dawn on me how the team on set disregarded my feelings, leading me to have really negative thoughts: ‘I do not look beautiful’ ‘Other girls’ makeup look better than mine’ ‘I have the worst outfit selection’ Despite modelling for someone I looked up to, I agreed to follow directions because I was scared to disappoint others — and from that shoot, things went downhill. Why things turned difficult There were many factors that eventually led me to quit, the main one being that it destroyed my mental health. The modelling industry is very competitive, and on top of that other women look down on each other because they believe their beauty is better than yours and there is a sense of jealousy if one model is on set longer than another. Automatically making the other one feel very less of herself, and comparing her beauty to another woman. I got thrown in the deep end with no guidance and proper management, and this led me to feel really insecure about myself. The girl who once was the most confident outspoken girl became the quiet girl that wanted to go unnoticed, the girl who hid behind everyone else’s shadows, that no longer wanted to be the centre of attention. I started to get sick of people touching me, and having no control over what I did on set scared me. I did not want to be given a schedule that told me what I was going to do; I enjoyed my independence. To add, people were not witnessing different types of beauty because the people who were in control of the publications and the designers in power are not making it happen. Having a ‘hijabi’ model was something very new to the industry and I have experienced feeling oppressed and not having any say in what I wore. The hijab is a religious garment that is meant to be worn with empowerment, but eventually, I drifted away and got into the confusing grey area of letting the team on-set to style my hijab. I thought: Why don’t I have a voice anymore? How I coped with these negative experiences One way I learned to deal with all these issues I was facing was to research every shoot I was taking part in, and knowing what it was for before I accept attending any shoots. Also, I researched my rights as a model and what is acceptable and what was not. This helped me be assertive about what I was going to tolerate, and I pushed myself to make my opinion known. However, speaking out and taking control enabled me to protect my mental health, but the industry has an opinionated model, and this is what I had become. Eventually, the team did not like my opinion and say so they reduced my shoots and it led me to terminate my contract. Since then I worked on my mental health and I am glad I walked away from not being able to take control or being appreciated. This was the best decision I have made and since then I have been the happiest.

If you have no idea what “psychoneuroendocrinology” means, no worries. It is not all that complicated and really just three words merged together. Psychoneuroendocrinology is a combination of psychology, neurobiology and the study of hormones, endocrinology. The main goal of Psychoneuroendocrinology research is to understand how the mind (psychology/psychiatry) and body (neurobiology, endocrinology, immunology) work together in terms of health and disease. I am a postdoctoral scholar at Iowa State University interested in the link between stress and health outcomes. Currently, I am the Social Media Editor for the International Society of Psychoneuroendocrinology and the associated journals, Psychoneuroendocrinology and Comprehensive Psychoneuroendocrinology. I studied medical psychology, which is a discipline that integrates medicine and things like psychotherapy, mental illness and other psychological topics, at Tilburg University in The Netherlands. I studied under Prof. Tessa Roseboom (Amsterdam) and Prof. Annemieke Hoek (Groningen) as a PhD student and wrote a dissertation in the field of Medical Sciences. I became interested in psychoneuroendocrinology research as an undergraduate student, involved in a project about the stress response. Stress is a typical psychoneuroendocrinology topic since it really is all about the mind, the brain and the hormones working together. Let me explain. Think about the last time that you were driving a car or riding a bike and you were almost in an accident. I remember a recent situation; the car in front of me was suddenly slowing down and I was about to crash into this car. I hit the brakes just in time. In a matter of seconds, my heart was pumping like crazy, my hands were sweaty and slightly shaking and my pupils were dilated. My mind was able to detect danger (almost crashing into the car in front of me) and activated my body. This type of mental and physical reaction is referred to as the acute stress response. This acute response triggers, in case of danger, a fight-or-flight response. You need your body to become activated. See these Inspire the Mind blogs for more details about stress and the fight-or-flight response. How does the response work? Well, for example, when you need to run away from or confront danger, your blood needs to be pumped around faster to make sure your body is getting the oxygen it needs, and so your heart rate picks up. You may need to see your surroundings better, so your pupils become dilated. You do not really have control over this bodily response, it is automatic. This reflexive stress response makes a lot of sense from an evolutionary perspective too. You have a better chance at survival if the human body is equipped with an automatic fight-or-flight response when you run into a dangerous predator like a lion. So why are psychoneuroendocrinology researchers interested in this acute stress response? The way that your body responds to acute stress can provide a lot of information about your future health and disease. Psychoneuroendocrinology researchers use what is called a “stress test” in a laboratory/research setting to test how people respond to acute stress. They measure different bodily responses, including heart rate, blood pressure, how sweaty your hands are, and stress hormones, while the participant is completing stressful tasks. Of course, a lot of questions come to mind and need to be asked when we talk about stress tests. First and foremost, are they ethical? We obviously do not want to traumatize participants when they are subjected to a stress test. An ethical committee is always involved and evaluates how ethical a specific stress task is. And so, decades of research in this field have led to a gold standard of stress testing; a task that involves social evaluative threat, which is just a fancy way of saying ‘a task where you are being judged by others’. A job interview is a good example of a situation that involves a social evaluative threat, which is why a mock job interview is often part of a stress test. Social evaluation is extremely important to many humans; almost everyone feels a strong urge to belong and cares to some degree about the judgement of others. As it has done so for so much else around the world, COVID-19 has also changed the way psychoneuroendocrinology researchers conduct stress studies. In-person stress tests are not possible at the moment, which has halted the work of many researchers in this field. However, there are promising results that online stress testing works as well! What is deemed ‘stressful’ varies from person to person. Of course, we must keep in mind that not everyone shows the same bodily response pattern during a stress task. Some folks are pretty relaxed before the task starts and have a heart rate of 60 beats per minute (bpm). Others are already freaked out before the test even begins by the laboratory setting and the uncertainty of what is going to happen and start with a much higher 100 bpm heart rate. Most people experience the classical acute stress response during the task, with increased heart rate and sweaty hands, but not everyone recovers — goes back to their ‘normal’ self — at the same pace. As mentioned before, the stress response includes different bodily aspects. Heart rate is one of those things you can usually feel (“my heart is pounding out of my chest!”) and measure with an EKG; those sticky pads on your chest. Sweaty hands are also not too difficult to detect yourself. Researchers use special sensors on your hands to measure electrical conductance of the skin, and a cuff around your arm to measure changes in blood pressure. However, you cannot “feel” changes in hormones. They need to be measured, in your blood or, more often, in saliva. The most studied stress hormone is cortisol, and changes in cortisol levels can be detected in saliva. Other hormones that play a role include testosterone (a sex hormone), DHEA, which is an important puberty hormone, and a hormone involved in love and bonding, oxytocin. To study these hormones, researchers often ask you to drool or spit in a tube when you participate in stress-related research. Saliva collection is not difficult and does not require expensive equipment to be collected, so it is also suitable for online stress testing where participants self-collect at home. So, how can we use this information and actually help people and possibly prevent disease? The cool thing about psychoneuroendocrinology research is that you can study the stress response at any age! The heel prick test or the vaccination jab are frequently used “stress tests” in babies, for example. That means that researchers can examine the stress response pattern very early in life, and help people through interventions to decrease the risk of future disease. What is next? There is an exciting new line of research that looks at using virtual reality in stress research, which gives researchers a wealth of possibilities; anything is possible in virtual reality. You can be surrounded by zombies or participate in a virtual dance competition. My own team is currently summarizing existing evidence of how effective virtual reality stress tests are in evoking a stress response. All of this information taken together tells researchers a lot about your stress response pattern, and in turn what it can mean for your health. For example, there is evidence that people who respond very strongly to a stress task, may be at increased risk for future disease (think heart disease, for example). There is also increasing evidence that people with no bodily response to a stress task are at increased risk for future disease as well, including poor mental health outcomes. This is how research in the field of psychoneuroendocrinology can help prevent disease and help develop future treatments. I am deeply interested in this field and can hopefully contribute not only through research but through our social media outlets as well! If you are interested in reading more about psychoneuroendocrinology and stress research: follow @ISPNE on Twitter and Facebook and the associated journals @PNECJournal@CPNECJournal.

I am a junior doctor keen to explore the meaningful connection between my two personal passions, the arts and health. Can the arts be used to help patients heal? Can the arts be used as a medium to educate; explore patient stories and experiences of their mental & physical illness; inspire medical professionals to give better patient-centred, holistic care? What is the current evidence behind the use of the arts, as therapy? These are all questions I seek to find answers for on my blog: @healinghumanities. Music is the language of the world. When lockdown began and videos of Italian residents singing and playing music out of their windows circulated online, fluency in the Italian language wasn’t what was needed to feel the sorrow, the hope, the passion conveyed in their song. The beauty of music communicated that. Music, as a language, has the power to capture emotions that simply can’t always be expressed in words. Music, as a language, has the power to connect people, bring people closer, build and nourish relationships. We all have vivid associations of music with our own memories. Whether it be a joyful song associated with a blissful summer’s day or a rhythmic tune that reminds us of a time where we danced all night long (yes Lionel, we hear you) —  music activates an associated emotional memory in all of us. But how does this association change in those who no longer remember as they once did? Dementia is a clinical syndrome associated with an ongoing decline of brain functioning, with Alzheimer’s disease being the most common cause of dementia. The symptoms include memory loss; difficulty in finding the right words or understanding others; confusion about time and place; difficulty in performing familiar daily tasks; changes in personality and mood. Such symptoms impact the patient’s emotional well-being, their quality of life, manifesting into depression and anxiety, agitation and aggression. These symptoms are known as behavioural and psychological symptoms in dementia (BPSD). It is a truly debilitating disease for both the patient, and their families. And yet, something that is so fascinating, and still not quite fully understood, is that, albeit such extensive cognitive deterioration, their ability to respond to music is still retained. “Where I work at a hospital and at a number of old age homes, there are a lot of people who have Alzheimer’s or other dementias… some of them are confused, some are agitated, some are lethargic, some have almost lost language. But all of them, without exception respond to music” — Oliver Sacks on the Power of Music in this YouTube video link The regions in the brain responsible for musical memory have been shown to be relatively well preserved even in the advanced stages of Alzheimer’s disease (AD). By exploring musical memory as an independent entity to other memory systems, researchers have identified an overlap of musical memory regions with areas relatively spared in AD, suggesting an explanation for how musical memory appears to be better-preserved than other types of memory in this neurodegenerative disease. Another study explored the theory that even in the later stages of dementia, when response to other stimuli has diminished, music is the one sense that still remains. Interestingly, it has been demonstrated that individuals with AD are better able to recall information when sung rather than when spoken. Healthy older adults in comparison showed no difference in recall. Whilst other areas of the brain begin to diminish, this illustrates how music processing may be preferentially spared in patients with AD. “Although we are not yet able to say why conclusively, the songs that carry these strong emotional memories for the patient with Alzheimer’s are the best retained. This results in a patient who can sign along with song lyrics but can’t recognize a formerly familiar face,” says Concetta Tomaino, founder of the Institute for Music and Neurologic Function in New York, in a ‘Music and Memory’ interview. This then poses our next question. Can music, as the universal language of the world, be used as a communication medium to connect with those with dementia? Does music really have the power to relieve these debilitating symptoms — the anxiety, depression, poor quality of life, agitation, aggression — associated with the disease? As a clinician passionate in promoting the arts to help my patients, I wanted to investigate whether my personal passion holds true scientific value. I have always seen medicine as a fine blend of the arts and the sciences. Therefore, my inquisitive nature researched the literature, to identify the evidence base behind the power of music on dementia. And the evidence is positive. A report by the World Health Organisation (WHO) that collated 3,000 studies from across the globe to identify the evidence behind the role of the arts in improving health and well-being, identified a positive correlation. This scoping review found evidence that music supports cognition and reduces anxiety, depression, agitation (repetitive acts, wandering, restlessness, aggressive behaviours) and behavioural problems in people with dementia. Another systematic review similarly suggested that music had a positive effect on disruptive behaviour and anxiety, and possibly on patient’s cognitive function, depression and quality of life; whilst a 2018 review concluded that music-based intervention probably reduces depression and improves overall behavioural problems, and may improve emotional wellbeing, quality of life and reduce anxiety. Due to the ethical challenges and side effect profile of medications for the management of the most challenging symptoms of dementia, non-pharmacological interventions (intervention without medication, such as art therapy, aromatherapy, behavioural therapy, and physical exercise) is recommended to take precedence to aid psychological distress and behavioural challenges in patients with dementia. An overview of a large number of these interventions concluded that music is a more effective intervention when compared to all other non-pharmacological therapies, like aromatherapy and massage therapy. Further research in this fascinating area however is still needed. To improve the credibility of the research, the use of more rigorous research methodologies is required. There are few, high quality studies that suggest music is beneficial for improving the psychological manifestations of the disease, but the evidence is less so in terms of improving patient cognition and memory. “It is estimated that whilst 80% of residents in care homes have dementia, only 5% of them, have access to art and music.” — International Longevity Centre UK A concisely formulated and intricately written report by the International Longevity Centre UK explores ways in which ‘Dementia and Music’ can become the forefront of our conversation. With the shocking statistic that only 5% of care home residents have access to art and music, the report’s six innovative recommendations, including developing the research base, raising public awareness about the benefits of music and growing funding, seems more relevant now than ever. But what about music simply being an art form that makes humans feel, good? As I immersed myself in the scientific literature, reading many a systematic review on the topic, to unpick the science and seek the evidence, a rather obvious and simple thought crossed my mind. Headphones on, me (somewhat) rhythmically nodding, humming along to the tune playing into my ear; I was reminded of just how easily accessible and enjoyable music is for many of us. Music is an intricate part of all our daily lives. Simply put, it brings us joy. It brings us happiness. It is a language that connects us. An art form that enriches the shared lived human experience. And perhaps, this is the simple answer to my original question and my curiosity. Perhaps the answer comes from music itself, from the power music has from bringing us joy, connection and meaning. Perhaps science isn’t required to remind us of how music is a fundamental basic human need. On that note, I wish to finish this piece by leaving you with the following words, that captures music as part of being human, written by Schulkin and Raglan in a recent paper entitled The evolution of music and human social capability: “As a social species, (music) remains essential to us; a chorus of expression in being with others, that fundamental feature of our life and of our evolutionary ascent. Music is indeed, as Timothy Blanning noted, a grand “triumph” of the human condition, spanning across cultures to reach the greatest of heights in the pantheon of human expression, communication, and well-being. It is in everything.”

It goes without saying, this pandemic has been hard on us all. Not being able to be with the people you love is tough and it’s not uncommon to feel a little lonely, especially for those of us who are living on our own. In fact, according to figures from the Office for National Statistics, loneliness reached record levels at the start of this winter. But have you ever wondered why the winter months often feel so lonely? I have to say, something about this lockdown has felt much lonelier than the others. Personally, I’ve been living apart from my significant other for the duration of this pandemic, and it has been challenging to say the least. But something about the cold winter months just makes being without loved ones that much harder. And since we have to stay at home, it often feels like there isn’t anything you can do about it. So, being the ever-practical person that I am, I’ve been searching for remedies. Also, being a psychology student, I was curious to understand the connection between the psychological state of loneliness and our physiological sensation of temperature. And I found a few tips that might help you feel better as we battle through what promises to be the last lockdown here in the UK: Put the kettle on and make yourself a nice, warm cup of tea. Or coffee. Or a hot chocolate if you’re feeling a little indulgent. Snuggle up on the sofa and bury yourself in layers upon layers of warm blankets. Or, how about a nice, hot bath? Seriously. Give it a go. You see, temperature plays a bigger role in our social lives than you might think. A recent study shows that even the first impressions we make when we first meet somebody could be affected by something as simple as holding a hot cup of coffee or holding an iced coffee. Studies have even found that after touching something warm we’re much more cooperative in a game involving cooperation and betrayal and, when made to choose between a reward to keep or gift to a friend, we’re more likely to give a present to a friend rather than keep it for ourselves. There seems to be a deep connection between physical warmth and interpersonal warmth, and that’s something that we can use to our advantage during these times of social distancing and isolation. Physical warmth may, to an extent, even act as a substitute for social warmth, as suggested by the findings of a recent study. They found that on colder days the participants reported feeling a greater desire for social connection than on warmer days. But, on those cold days, those who’d been given a heated back wrap reported less desire for social connection than those who’d been given an unheated one. In other words, touching something warm reduced their desire for social connection. This link between social and physical warmth is something we’ve always known about, at least subconsciously. We certainly have plenty of examples in our language and commonly used phrases. For example, when someone is unfriendly you might say that they are a ‘cold’ person. Love is often described as a warm, fuzzy feeling. When you move into a new place you might throw a housewarming party to befriend your neighbours and break the ice. We can see this in our behaviour too. When it gets cold, we tend to feel a little lonelier, and we tend to remedy this with warmth without even realising. One study found that lonelier people tend to take longer and more frequents baths and showers. Likewise, another study found that people who live further from the equator, where it’s colder, have higher levels of social integration. So, what’s the theory behind this and why does it work? One theory psychologists have proposed is that this is actually an energy-saving function. According to the theory of social thermoregulation, it takes a lot of energy for us to maintain the perfect core body temperature, and so by huddling up together we can share heat with each other and save energy. Like how penguins huddle together during a snowstorm! Newborn babies actually can’t regulate their body temperature properly because they have tiny bodies but a relatively large surface area of skin through which heat can be easily lost. And so, from the very beginning we rely on our caregiver’s touch for warmth and affection. As well as keeping warm, skin-to-skin contact is also very important for bonding between the caregiver and the baby. It therefore plays an important role in the development of a baby’s first relationship, and, according to attachment theory, the kind of relationship a baby has with its caregiver acts as a model for all future relationships. From a young age, warmth is deeply associated with forming social relationships. The effect this has as we continue to grow is best illustrated by a study of kindergarten children and sharing. After assessing the attachment styles of the children with their friends, the researchers found that those with a secure attachment (i.e. those who were confident in their relationships) were more likely to share stickers with their best friend in warm conditions than in cold. Whereas the temperature had no effect on children who had an insecure attachment with their friends (i.e. those who were anxious or ambivalent in their relationships) and they were overall less likely to share. The link between physical warmth and intimacy is an important part of our early development and stays with us throughout our lives, playing a key role in our social wellbeing. So, if you don’t have someone with you to warm you up, here is your excuse to take a nice hot bath and do a bit of self-care. Sure, it may not be a complete replacement for having someone physically there with you, but maybe the next time you call friends or family, a warm cup of tea might make it feel like you’re a little closer to the ones you love. A nice hot beverage in your hands can cheer you up like a warm hug.

I was 12 years old when I started starving myself. By the time I was 13, I had a full eating disorder. My eating disorder has lasted longer than most friendships and is still present in my life almost a decade later, aged 21. At times, it’s felt like a stronger bond than any connection I’ve had. And that’s why letting it go has felt like mourning the loss of a loved one. In my previous blog on this platform, I wrote about managing an eating disorder through times of crisis. Now I want to talk about grieving the loss of an eating disorder in recovery. I chose to pursue recovery in spring 2019 after my illness tarnished every memory of my teenage years and, despite knowing it was the right thing to do, I was convinced my eating disorder always had my best interests at heart, and I guess that’s what’s made recovery so painful. My eating disorder made me feel loved and accepted when I felt completely alone. It made me feel successful when I felt like a failure in other aspects of life. It gave me things to aspire to when I was confused about what paths to follow. It provided me with a safety net when I felt insecure. It comforted me in times of distress. It built me up when I lacked confidence. And it gave me purpose when I felt lost and inadequate. So undergoing treatment and being told by medical professionals that this thing I have cherished for seven years wasn’t actually what I made it out to be? That stung. It was like finding out a partner had been cheating on you your entire relationship. It felt like discovering your best friend has been bitching about you behind your back. It was like reaching the top of Mount Everest after a long, torturous climb only for somebody to kick you with their dirty boot straight off the top, leaving you to free first into nothingness. Coming to terms with my eating disorder being a monstrous sickness has been a brutal process and one that has felt like burying a close relative then attempting to build a life beyond them. Grief is not solely reserved for the deaths of family members and friends — grieving can happen any time we let go of something we treasure, and because my eating disorder was aggressively omnipresent in my life for almost a decade, forcing myself out of its grasp has felt like losing parts of myself. Eating disorders take up so much of our time, energy and thoughts, so it’s natural to feel lost and scared as parts of it begin to weaken and dissipate. It’s understandable that we feel alone and anxious at the thought of no longer having an eating disorder there 24/7, because it crawled into every corner of our lives and brainwashed us to believe we are nothing without it. Whilst the rose-tinted glasses have been removed and I now realise that isn’t true, unlearning those thoughts has been — and continues to be — difficult and messy, as I had come to believe my entire identity was wrapped up in an eating disorder. And now, as I construct an identity outside my illness, I realise every day that I don’t really have a clue who I am without it. For so long, not eating was all I did and having an eating disorder became who I was. I was the girl who starved herself and the skinny friend. I was the butt of all jokes about not eating and became known for hating my body. In all honesty, I miss my eating disorder. I miss it in the same ways I miss anything. And I hate to type that. I hate to admit how much I yearn for an illness, an illness that has tarnished all my precious memories and stolen so much time I won’t get back… but I do, or rather, I miss what we had and how it made me feel. I miss our closeness and the secrecy we shared. I miss having something that was just mine no one else could touch. I miss feeling special and having its undivided attention. I miss feeling secure in everything I do and feeling talented whilst doing it. I miss having goals and being handed promises on a plate. So now I grieve daily for the companion I thought I had as I attempt to construct a future out of the rubble it has left of me. I now have to establish goals that don’t include weight loss or starvation. I have to unlearn toxic coping strategies and learn new ones. I have to rebuild broken relationships after my eating disorder made me someone I am not. I have to overcome my fears to find true freedom. I have to rekindle my love for myself and find appreciation for my body. And whilst doing that, I will mourn losing something I once thought would be by my side forever. The grieving of my eating disorder is comparable with how my once best friend in primary school gave me a Winnie The Pooh mug for Christmas. As we progressed into high school, she started to bully me and we quickly separated… yet I still have that mug, because, well, it’s a really cool mug, but it also reminds me of happier times gone by. In some way, I guess it is me partly clutching on to more precious times. Grief is a personal, unique process for everyone. It also is not linear, but there are some commonalities in the stages and the order feelings are experienced when we grieve, known as the stages of grief, a theory developed by Elizabeth Kübler-Ross, a Swiss-American psychiatrist in 1969. First is denial. Pretending something isn’t happening. Thinking life with an eating disorder can still continue despite knowing better. Second is anger, which I have directed at myself for not being “strong enough” to maintain my eating disorder. Third comes bargaining and looking for ways to regain control when control has been lost. It’s those moments of, “If only I had been better, my ED — this huge part of who I am — might have stayed.” Next is depression, as I stop running from my emotions and feel like life has no value if I am not sick. And finally… acceptance. This stage is not necessarily happy or uplifting, and it isn’t necessarily a time of relief or moving past the grief. For me, acceptance is coming to terms with what I have lost, but also what I can now gain, and understanding how my life is going to be different. Healing from an eating disorder is never not a positive thing, because eating disorders are cruel, twisted and wicked. They will stop at nothing to keep you trapped in their web of lies for eternity. However, it’s okay to need to mourn their loss. It isn’t weird or pathetic. It’s normal to miss something that was once a great force in your life, and you can do that whilst knowing you are better off without it as your brain gets stronger and logic starts to replace those harmful ED thoughts. You can miss your eating disorder AND still want recovery. Those feelings CAN coexist. It’s alright if you need to grieve and if the grieving process is a bit all over the place. You can grieve for things that you once found comfort in. You can grieve for things that have been influential parts of your life. And then you can move on as a wiser, healthier, more authentic version of yourself. I will most likely miss my ED for a long time as I reclaim my life, continue rediscovering who I am beyond it and have to find ways of doing things for me, not it. A hurdle comes up every day, and I am continuously reminded that there are many things I actually have no idea how to do as a person without an eating disorder. It’s understandable why we mourn the loss of EDs, but what’s important is that we don’t view the life our EDs offer as more meaningful and fruitful as the one recovery offers, the one that allows us to pursue passions and pour energy into what truly makes us feel alive. For me, that’s everything my eating disorder prohibited me from enjoying growing up, from going on family holidays, writing, going for walks in nature, playing board games, learning new skills, and connecting with others to advise and inspire them. What matters now is that we are able to channel any grief and sadness we feel into shaping a future — a future that fulfils us more than a life under the thumb of an eating disorder, that would only feel truly satisfied once we are dead, ever could.

My first encounter with mental illness was in books. I have been a researcher and a teacher in philosophy for about ten years and I encountered the question of normality and psychological abnormality first of all from a purely historical perspective. My doctoral thesis focused in particular on the thought of Michel Foucault, who provided the 20th century with fundamental reflections for critically rethinking the history of psychiatry, psychology, and the human sciences. Nourished by this theoretical background, I looked at mental illness in a somehow detached way. But in recent years I have also resumed training as a psychologist, which has led me to compliment my activity as a philosophy teacher with internships in psychiatric hospitals and mental health care centers. This clinical practice has both questioned and stimulated my theoretical thinking: though people coming for help in a moment of psychological distress can be very lucid and critical of psychiatric institutions and their limitations, they still need to find support to give meaning to their suffering. I thus realized that philosophy and psychiatry still have a long way to go together, meeting precisely on this question of the subjective meaning of illness. Why does an individual, at a certain point in his life, find her/himself in psychological distress? How can this suffering be objectively defined and measured, but above all, how can it be helped and cured? To answer these questions, it seems important to me to propose here a journey through the complex history of the relationship between philosophy and mental illness. These relations have often seemed to be a struggle over the definition of “human beings” and “their reason” rather than an objective questioning of different forms of concrete existence. As I write from a historical perspective, I have deliberately chosen to use, at times, terms that seem anachronistic today, such as “madness” and “madmen”. Luckily, nobody addresses patients as “madmen” anymore in health care settings. And yet the history of the psychiatric clinic is also the history of “madness”: the history of how philosophers, doctors, and politicians, in Western civilization, have stigmatized, excluded, rejected the mentally ill — the “madmen”. Something of this stigma probably still remains in the subjective perception of psychological distress, and precisely philosophy, among other disciplines, can help to question and to overcome it towards a more welcoming understanding of the suffering human being. 1. Nobody is normal up close “Nobody is normal up close”. Franco Basaglia — the Italian psychiatrist who led the closure of mental asylums in Italy in the 1970s — chose this slogan for the ex-psychiatric hospital he ran in Trieste in the 1980s, based on a song by Brazilian composer Caetano Veloso. The complex relationship between “madness” and philosophy begins precisely in this definition of what normality is for humans as rational beings. The person we used to call “mad”, even before any medical diagnosis, is an individual who presents abnormal behaviours, who has incoherent speech, and whose perceptions and judgments are impaired. But how can we define this “abnormality”? It is the “normal” functioning of reason that needs to be understood in order to define its “abnormalities”: mental illnesses. We should know what “reason” is before defining its absence. But isn’t it actually the opposite? What other point of reference should we choose to understand human reason if not mental illness itself, which makes the various rational structures visible through their specific abnormalities (hallucinations, loosening of associations, paranoid ideation, delusions)? In other words, normality cannot be defined from within. It needs an external anchor. And that external anchor could be offered — philosophically speaking — by mental illness. Historically, it was, for example, the study of aphasia (an impairment of language that affects our ability to communicate, following brain damage) in the 19th century that made it possible to understand the neurological basis and functions of language. Thus, one could say that it is the ‘mad’ man who holds the keys to the truth of ‘normal’ man, since reasonable behaviour is reconstructed from its disappearance into delusion. As soon as we begin to reflect on mental illness and its history, the very conception of being human, and of human reason and human subjectivity, at risk. 2. Was philosophy afraid of madness? Can a philosopher be mad? Philosophically speaking, reason and madness are a matter of statistics: the madman is mainly someone who is different from the others, from the crowd. The philosopher too is different, being the one who can see the real truth of things, beyond common sense. So the philosopher could also be considered “mad”, since they are going against the norm. Their discourse will be dissonant and will appear as a delusion. The philosopher could also be right yet will be mocked and rejected because their truth will not be accepted at that moment. But things are actually more complicated than this. Until the 19th century, philosophy was defined in Western civilization as a rational and methodical enquiry of reality as a whole, and of human experience in particular. An irrational, “mad” philosopher was therefore an oxymoron, a contradiction in terms. It is therefore obvious that mental illness, with its potential of delusions and irrational behaviour, was considered the opposite of philosophical practice. As Michel Foucault says in his History of madness, modern philosophy operated a “strange coup de force”, formulated in the Cartesian First Meditation. Descartes (French philosopher, scientist and mathematician, generally regarded as the founder of modern philosophy at the beginning of the 17th century) describes the philosophical enterprise as the search for a primary truth that would resist all possible doubts. His thoughts on “madness” are worth reading in its complexity as written in the First Meditation: … although the senses sometimes deceive usabout objects that are very small or distant, that doesn’t apply to my belief that I am here, sitting by the fire, wearing a winter dressing-gown, holding this piece of paper in my hands, and so on. It seems to be quite impossible to doubt beliefs like these, which come from the senses. Another example: how can I doubt that these hands or this wholebody are mine? To doubt such things I would have to liken myself to brain-damaged madmen who are convinced they are kings when really they are paupers, or say they are dressed in purple when they are naked, or that they are pumpkins, or made of glass. Such people are insane, and I would be thought equally mad if I modelled myself on them. and his own reply to this argument: What a brilliant piece of reasoning! As if I were not a man who sleeps at night and often has all the same experiences while asleep as madmen do when awake — indeed sometimes even more improbable ones. Often in my dreams I am convinced of just such familiar events — that I am sitting by the fire in my dressing-gown — when infact I am lying undressed in bed! Philosophical discourse therefore, at least till the 19th century, maintained an ambiguous link with “madness”, a link of rejection but also of fascination. Sometimes philosophy recognised “madness” for its ability to cross the limits of reason and glimpse truths inaccessible to “normal” people. There is something “divine” about “madness”, wrote Plato (in Phaedrus), as he likens “mad people” to oracles, lovers, or poets, all capable of brilliant intuitions. But in madness there was also an inability to see “the true nature of things”, and reason saw in madness its disturbing double. We can say that philosophy was, until recently, afraid of madness, and, just wanted to silence it. 3. Philosophical and clinical implications from the 19th century onward The Cartesian negative perception of mental illness began to change radically within the philosophical discourse from the 19th century onwards, when philosophy started to approach the clinical reality of mental illness or the discoveries of psychiatry to find sources of inspiration and reflection. Phenomenology, existentialism, critical thinking: these are some of the philosophical currents of the 20th century which have entered into an important dialogue with the sciences of the mind, and in particular with psychiatry. And it all started with Nietzsche, who himself suffered from mental illness toward the end of his life. Phenomenological and existential approaches in psychopathology (Binswanger, Minkowski) have made it possible to re-evaluate and to value the subjective experiences of psychiatric patients, without disqualifying them as mere expressions of chaotic unreason. Phenomenological psychiatry proposes to return to the meticulous observation of psychological symptoms in their appearance (their “phenomenology”) in order to see them not as a catalogue of objective and pre-defined illnesses but rather projects of existence, unique forms of appraisal of reality. This is the “existentialist” approach to mental illness: delusions is, above all, a universe of meanings that the patient unfolds from their own existence and whose dynamics can and must be described. With this new approach, philosophy thus shifts the meaning of “the truth” of the illness, which is no longer an objective and fixed clinical truth. The truth of mental illness lies in what the patients say and live from their reality. There is a meaning in the pain of mental illness that belongs to the person and that it is imperative to respect. Furthermore, contemporary philosophy has provided psychiatric medicine with “epistemological instruments”, that is, instruments relevant to the study of the nature, origin, and limits of human knowledge. It has allowed psychiatry to reflect on its own history and the way in which its reflexive paradigms have been constructed, in their scientific as well as political values. We have already mentioned Michel Foucault, whose reflections on the “history of madness” and on “psychiatric power” have nourished the anti-psychiatry movements since the 1960s, and have helped to affirm new attention for the dignity and freedom of patients with mental disorders. According to Foucault, psychiatry represents not only the truth of science, but also an institutional power, articulated to deliver public health management and centred around hospitals and clinics. This is how the dialogue between philosophers and psychiatrists must continue today, and how philosophy and psychiatry can converge. On the one hand, in the need to give form, meaning and voice to the real existences, to the physical experiences of psychiatric patients. On the other hand, in the possibility of building critical movements to question the social and political dimensions of the treatment of mental illness. 4. Body and mind interface and future directions: the call for immunophilosophy? The challenge for a renewed dialogue between psychiatry and philosophy today is all the more evident as a new paradigm is emerging in the treatment of mental illness, putting the body back at the centre of the theoretical and therapeutic approach. It is an innovative epistemological model, for which behaviours and emotions would find an explanatory principle in peripheral immune mechanisms (“immunopsychiatry”). To put it very schematically, the novelty claimed by immunopsychiatry concerns both the object and the etiological scope (the search for causes) of psychiatric research. Research on immune mechanisms as possible explanations for a wide range of psychiatric disorders, from autism to depression, from eating disorders to addictions, has multiplied over the last few years. It is then the body as a whole, or more precisely the “peripheral” body, that is involved in mental illness. The idea of the immune system being implicated in mental health is something that has been touched upon in previous InSPIre the Mind blogs, you can read some examples here, and here. As I devoted many years of my academic life studying the philosophical meanings of the human body, this seems to me quite an important shift, not only from a medical but also from a philosophical point of view. Mental illness affects the body in all its expressions, down to the slightest feelings of somatic existence — this body taking shape as a complex and open experience, adapting to the surrounding environment and being transmitted from one generation to the next. Is mental illness therefore a matter for the body and not for the mind? Is its meaning to be determined at the level of a global bodily experience, rather than in neuropsychological dynamics? With immunopsychiatry, psychiatry puts the body back at the centre of its theoretical and therapeutic approach, inviting philosophy to rethink the body in the context of mental illness. The immunopsychiatric paradigm allows then a new reflection on the subject (healthy and sick — normal and “abnormal”), escaping the body/mind dualism that has caused so many words being produced by the pen of philosophers. If mental illness emerges from the dispersed and tortuous networks of somatic immune responses, psychicological subjectivity itself is structured from the plural dynamics of bodily experience, both on a spatial dimension (other bodies, individual or social) and a temporal dimension (generations of bodies communicating through genetic filiations and the experience of pregnancy). The very identity of the subject is questioned, being shaped in complex and heterogeneous bodily experiences. Research on mental illness and the body thus makes it possible to reopen the question of the self, in its development and definition. But it also makes it possible to take up again and reconstruct, in a coherent discourse, the intricate paths that have led this specific individual, in his or her own history, to psychic distress. And these themes of identity, subjectivity, history and existential meaning, are all obviously familiar to philosophy. Immunopsychiatry calls for the formation of a new philosophy (an immunophilosophy?), which again takes up an essential question: what is the meaning of “mental illness”, or better, what meaning can patients and therapists give together to psychicological suffering? What is this pain all about?

Sleeping constitutes around one-third of our lifetime. To put this statistic into perspective, if you live until 70 years old, around 27 years of your life would be spent sleeping. According to Maslow’s hierarchy of needs, it is one of the key physiological needs, along with breathing air and ingesting water and food. Despite the enormous amount of time we spend sleeping, as well as its vitality for our survival, it is surprising how many people suffer from sleep disorders and difficulties. According to The Sleep Council, 40% of individuals in the UK suffer from insomnia, and a quarter of all UK school children don’t get enough sleep. I myself definitely fall into the 40% statistic. Despite keeping a healthy regime, I consistently wake up feeling exhausted, and on the worst days, I lay in bed for hours not being able to fall asleep. I have done a lot of research on sleep and insomnia— both individually, and as part of my Health Psychology degree. Before we delve into benefits, risks, processes, and solutions for better sleep, it is important to clarify what sleep actually is. Being loosely defined as an “altered state of consciousness”, it divides into 4 stages, constituting 2 types of sleep: Rapid Eye Movement (REM) and non-REM sleep. The first 3 stages of your sleep cycle are non-REM sleep, during which your breathing and heartbeat get progressively slower, your muscles relax, and your body temperature drops. After this you enter REM sleep, known as a “dreaming” stage, during which your body is activated again, experiencing increased blood pressure, heart rate, and partial body paralysis. After this, the cycle repeats again, occurring several times throughout your sleep. Knowing these basics of a sleep cycle, we can now further investigate its benefits, expanding on its importance in our lives. For the purposes of this blog, I will only focus on three benefits of healthy sleep, although there are many more. Sleep plays a major function in learning and memory. This is why it is important to sleep well even during busy times, such as exams — if anything, you’re contributing to the quality of your work by allowing yourself a good night’s rest. As such, research indicates that sleep plays a role not only in encoding new memories, but also in consolidating existing long-term memories. For the former function, it is advised to sleep before the act of learning, whereas the latter function was found to be the case in sleeping after the learning. In addition to its benefits for learning, sleep is also important for forgetting. Throughout the day, your brain processes and encodes a great wealth of information, much of which will be unnecessary to remember. The capacity of human memory is limited, so it has to prioritise information that is the most relevant for normal functioning — such as your address, your partner’s name, what the colour blue looks like. However, some information doesn’t need to be stored — such as the hat colour of someone you saw on the train, or the customer support number of your phone provider. Healthy sleep ensures that irrelevant information is not stored, and that it is not in the way when you need to retrieve important memories. Lack of a good night’s rest can also affect one’s mood. A considerable amount of research has suggested that sleep, specifically its quality, duration, and latency (i.e., how long it takes you to fall asleep) are all related to the daytime affective state (i.e., your mood), depressive disorders and anxiety. This was also the case for healthy adolescents across the world, suggesting that poor sleep is a universal risk factor for affective disorders. Unfortunately, simply knowing the effects of sleep isn’t enough to actually have good sleep. Therefore, it is important to be informed of ways to avoid insomnia. As mentioned previously, this topic is very personal to me, as I have been sleeping terribly for many years now. Apart from the general methods that I will describe below, I realised that I had one very unhelpful notion that stopped me from falling asleep. It is, interestingly, performance anxiety. When I picked up that I am not sleeping well, I found myself dreading bedtime, worrying that it will be another sleepless night — which only made it worse. Interestingly, research also indicates that there is indeed a bidirectional relationship between anxiety and sleep. One of the most popular methods for treating sleeping issues is Cognitive Behavioural Therapy for Insomnia (CBT-I), which encompasses various techniques, including sleep education, sleep hygiene practices, sleep restriction, and stimulus control. You have already done a crash course in sleep education just by reading this blog up until now, so we will talk about other practices that can help you achieve healthy sleep. Sleep hygiene techniques are often the easiest to implement and are often sufficient for those with mild or occasional sleep difficulties. Sleep hygiene practices include the following: ● Avoidance of caffeine, nicotine, and alcohol ● Regular exercise ● Stress management (easy to say, isn’t it?) ● Sleep timing regularity ● Reducing bedroom noise ● Avoidance of naps. Another helpful technique is sleep restriction. It advises keeping a sleep diary for a week to identify how much time you actually spend sleeping, and then limit your time spent in bed only to that. For example, if it takes you roughly 2 hours to fall asleep and you sleep for about 6 hours, in total you spend 8 hours in bed. You then limit your time in bed only to 6 hours, continuing to keep the sleep diary, and adjusting it weekly according to the same principle. Stimulus control consists of several behavioural instructions: go to bed only when you are sleepy; don’t stay in bed when you’re unable to sleep; use the bedroom only for sleeping; wake up at the same time every day; and don’t nap during the day. These actions will help you associate bed with sleeping and develop healthy sleeping patterns. Hopefully, today you’ve learned about the basic processes of sleep, its importance for our cognitive and affective functioning, and some useful tips and techniques to nurture healthy sleeping patterns. Personally, my sleep pattern improved immensely through psychoanalytic therapy, which helped me to alleviate some of the performance anxiety I was feeling. Importantly, sleep hygiene and stimulus control techniques have also been invaluable for improving my sleep. It might take a while for your sleeping pattern to stabilise, but the main advice I can give you is to tackle the sleep-associated anxiety — this will take the pressure off and truly help you to effectively implement other, more practical techniques.

I graduated from my BSc in Psychology in 2020. At the time I was so focused on my research project which focused on trauma and psychosis-like experiences in healthy people, it made the pandemic feel thankfully distant. I started an MSc in Neuroscience in 2020 too, and during this time I received a post-traumatic stress disorder (PTSD) formulation. Totally unrelated to the above events I should add — distant memories instead for me. There are many though who will develop post-traumatic stress responses due to COVID-19, either directly through experiencing the illness, or as healthcare workers or loved ones, and indirectly through deficits in important social and support services or networks. This is why I believe traumatic stress is such an important issue to discuss —  because it is an endemic issue at all levels of our society, in the past, present and unfortunately the future. What is meant by complex trauma or complex post-traumatic stress disorder (CPTSD)? You may be wondering what is the difference between PTSD and CPTSD (complex post-traumatic stress disorder), are they not the same thing? Most of us have heard of PTSD, but CPTSD is something we come across less. Would it truly make a difference for the provisions provided to individuals seeking help? This is a hotly debated topic for researchers and clinicians in this field. CPTSD includes more symptoms than PTSD. Particularly, having trouble regulating emotions and disturbances in the sense of self, in addition to PTSD symptoms — PTSD symptoms typically include re-experiencing (flashbacks, nightmares, feeling numb, distant and avoidant, and hyperarousal symptoms (irritability, heightened vigilance, difficulty sleeping). Many people who could be diagnosed with CPTSD receive diagnoses for other disorders including PTSD, ‘personality disorders’, anxiety, or depression, amongst others. This could be due to the fact that CPTSD is only included in one of the two main diagnostic manuals, the International Classification of Disease 11 (ICD-11). Diagnostic manuals, and the ICD in particular, is a manual used internationally to classify symptoms of disorders or disease, and sometimes the causes. However, when it comes to CPTSD, knowledge is not widely distributed among medical professionals and questions remain regarding the validity of the diagnosis (is it clinically useful? Is it a label that we can measure properly and separate from others?). CPTSD was first formulated by Judith Herman (1992), citing the limitations of PTSD to describe the mental health consequences and behaviours associated with relatively brief experiences of trauma, compared to the far longer and repeated experiences of trauma that are unfortunately just as common. This includes experiences such as sexual abuse or physical abuse in childhood, sexual exploitation and human trafficking, prisoners of war or concentration camps. This is no means an exhaustive list; it is foreseeable how being in poverty, prolonged bullying or racial injustices might also produce a similar presentation. Childhood trauma, as an example, is incredibly common, 1 in 5 children experience severe maltreatment in the U.K. and adverse experiences are associated with multiple physical and mental health consequences. In my perspective, trauma is a public health crisis like obesity, a significant and prevalent risk factor for mortality and morbidity. Complex trauma in Psychiatry Herman noted that CPTSD has a capacity to almost mirror any type of personality disorder due to the severe and enduring consequences it creates that PTSD is not sufficient to describe. The ICD-11 has quite a helpful way of thinking about personality disorders, which is to have a broad core personality disorder criteria involving dysfunction around how you see yourself and/or in relationships with others. Then it specifies prominent patterns of behaviour such as having borderline, dissocial (antisocial) or Anankastia (extreme perfectionism or rigidity) traits, amongst others. The CPTSD label can imbue a sense of causality to this, yet it may lose some specificity. This I believe is both the strength and weakness of the CPTSD label. The prevalence and surprising severity of the trauma children experience would suggest complex trauma is everywhere, perhaps CPTSD is not just mirroring other mental health disorders, but for many, their diagnoses are part of the complex trauma they have experienced. For example, a review of studies conducted nearly a decade ago suggested childhood adversity was strongly associated with psychosis, accounting for 33% of cases. For many individuals with psychosis, do they not suffer from a form of complex trauma response? Complex trauma in Psychosis: The effects of trauma on the brains of those diagnosed with schizophrenia have been synthesised by a review which suggests that chronic stress hormone activity has been shown to damage cells in the brain in brain regions such as the prefrontal cortex, an area which important for appraising the processed information about our environment and valuating potential decisions and outcomes, and the hippocampus, a brain region implicated in our memory function. Hypothalamus-Pituitary-Adrenal (HPA) axis, a brain region involved in managing the body’s stress response, is also dysregulated due to this chronic stress response, which means the brain is unable to manage its response to stress in later life, locked in a very distressing feedback loop. This has been linked with some of the differences in a neurotransmitter called dopamine, found in people with psychosis, which could be involved in producing some of the acute symptoms people experience, like hallucinations. Trauma elsewhere: Trauma also appears in more common mental health complaints. The research in this area is vast and complex with seemingly contradictory findings that need to be navigated. Some key takeaway findings from a review published in the scientific journal, Neuron, include the effects of early life stress increasing the risk of depression, bipolar disorder, PTSD and suicide, and numerous health risks in a dose-response way (i.e., multiple instances of early life stress increase risk cumulatively). The experience of depression also increases the risk of developing PTSD from this early life stress. These experiences are associated with HPA-axis hyper or hypoactivity and this is associated with an increased or blunted stress hormone response and immune response. There are potentially two pathways here, one of increased function and one of decreased function, this is still an ongoing debate. I should add, I’ve noticed they would often show trauma-related imagery in many human studies — so what would be the role of dissociation here? From what I understand of dissociation, including personally, it would detach and blunt my response to such images which might mean there would not be the expected hyperactivation. Lastly, as seen in psychosis, it affects the brain as we develop, impairing brain growth and the capacity for neurons to communicate, this could point to a general effect of trauma on the developing brain. It is possible the clinical presentation, i.e., what diagnosis or formulation you might receive depends on genetic or contextual environmental factors that occurred during the early life trauma. Where does this leave complex trauma? If forms of complex trauma are everywhere in nearly all psychiatric diagnoses, it presents a significant, often key environmental risk factor to the severity of distress an individual might experience. Yet we also have a specified diagnosis of CPTSD which in the majority of incidences would relate to the very same early life trauma. So, would CPTSD reasonably explain the majority of psychiatric disorders for those with that life history, and if so, which way forward should we choose? Psychiatric classification is a little bit taxonomic — like the animal kingdom. In the past, animal specimens would be classified based on superficial characteristics (i.e., the equivalent of symptoms), but the advent of genetic sequencing has inevitably led to discoveries that some specimens do not belong to certain species, as it is the case for psychiatry as the shared bio-psycho-social causes are uncovered that are common to different disorders, even in the case of genetic risk. I found my formulation of PTSD to be validating. It is very possible to describe it as prolonged incidences as opposed to a single terrible incident, but the infrastructure to diagnose or formulate CPTSD is not widely available in the NHS. I wonder then, would such a diagnosis help that 1/3rd of psychosis cases attributable to trauma, when psychotic experiences are not included within its criteria? There is a risk of assigning an insensitive diagnosis that has none of the strengths of the previous one despite the strength of recognising the cause. Clearly, CPTSD is inadequate to be generalised beyond the scope of the initial criteria. Yet a complex post-trauma stress response seems key to many more mental health complaints than those that would be included within the CPTSD diagnosis. Is that not another way of just saying CPTSD though? Perhaps it could look like the figure below. Back to the title — Complex trauma is indeed a spectre in psychiatry, it effectively haunts the classification system by threatening to undermine it, some may see this as a good thing, and others may not. Complex trauma also haunts people and society but arguably the best window into alleviating this is through clinical recognition. It could come in the form of phenotypic stratification which is a way of classifying complaints more specifically on symptoms and inferences about causes than using often heterogenous diagnostic labels. Alternatively, multi-dimensional continuums of human distress have been suggested, in which complex trauma could be included within, which I have attempted to show with Figure 1. There is an irony perhaps that complex trauma is uncomfortably present, much in the same way it is with people who experience it.

Like many others during the early days of March’s first instalment of COVID lockdowns, I too joined the social media craze, TikTok. At the time I joined, there was no knowing how much of an influence TikTok would have on myself and my generation as a whole. Right from the start, I fell down a rabbit hole of videos which discuss topics from baking bread to social justice, to funny dogs. Initially after joining the app some of my top creators to watch were @christine_snaps, @rynnstar, @hi.this.is.tatum, and @mrs.space.cadet, but the list of my favorites has only multiplied since being on TikTok! For those who haven’t jumped onto bandwagon just yet, TikTok is essentially an app where people can make short 60–90 second long videos and view other people’s videos. TikTok runs on an algorithm which tailors your personal page to the content that you interact with most, and this algorithm is really at the heart of TikTok. Some creators find they struggle to be consistently recognized by the algorithm, but with each update to the app, it seems to get a little bit better for many creators. Through the last 9 months, TikTok has taken me around the world in a matter of minutes and helped to keep my mind busy when life seemed to stop. From cleaning TikTok to bread Tok, to laundry, witch Tok, and the news the variations are as endless as the people who create them. As with most social media, mental health has even found a home in TikTok and is a very popular community on the app. What is so interesting about TikTok is the explosion which happened during the early lockdown months, and just how global it was. In fact, in early 2020 the app had only been downloaded 315 million times, but by December that number had climbed to 2.6 billion worldwide! Of those billions of users around 60% are from GenZ and between the ages of 16–24, and this coincidentally includes me as well. In March of 2020, I was a 21-year-old college senior who had just moved back home due to the pandemic, and I was in some serious need of a new way to pass the time. So, ‘why does this all matter then?’ you might be asking yourself. Well, for starters this platform has helped to jump-start small businesses and has created an opportunity for popular content creators to earn real money through the 1 billion dollar creator fund. The creator fund was a way for popular videos to earn money and was implicated to help incentivize users to keep making original content. While the creator fund is controversial due to some potential algorithm issues, it has made some users some real money very fast. In 2020 the top three earners brought home a combined 11.9 million USD. Not everyone makes this much, but still, for many content creators, TikTok has become a reliable source of monthly income. But the economic impact of TikTok is not really the focus here. Along with financial relief for some creators, there has also been a huge impact on mental health for users throughout the pandemic. Reports are showing that the social media trends and challenges from TikTok creators have helped to keep users connected to a larger community throughout the lockdown, while also helping to keep individuals mentally stimulated in time of great uncertainty. Some of the most popular trends from TikTok have ranged from short dance routines to the new latest recipe to try. There is a wide range of content aimed towards mental health on TikTok, but by far the most prevalent on my personal page is aimed towards healthy eating and exercise. It has long been known that better diets and consistent exercise routines are key for some aspects of mental health, and TikTok has helped people share their fitness stories and build supportive communities where users are encouraged to listen to bodies. In the spirit of this message some creators have taken it upon themselves to share their personal struggles with mental health, and how food or exercise has helped them personally to cope. While some creators take a great deal of caution when posting videos, others may not realize what content like this could trigger for others dealing with similar struggles. This was a rather large issue on the app for a while and arguably still is, however, TikTok has tried to help this issue by encouraging content creators to use trigger warnings in their videos and by taking down potentially harmful videos when they are flagged by general users. Despite the efforts of TikTok, there is always a danger of harmful content being produced due to the inherent premise of the app which is to quickly gain popularity for well-liked videos. Because anyone can make a viral video there is a risk that creators may spread misinformation for many content areas including but not limited to fitness, diet, and general mental health. When the content being produced is not backed by science it becomes especially dangerous to those interacting with it. Personally, I think when taking in any form of social media it is important to be critical of the information given and to always feel comfortable asking the creators for their sources. This type of interaction is starting to become more of a common practice, but it doesn’t mean that this issue is resolved. It is most definitely in TikTok’s best interest to keep innovating ways to take down harmful videos in order to help ensure users are not impacted in negative ways, especially while we all are in general so isolated from each other. As with all social media, there are risks when consuming it, and at the end of the day, it is up to TikTok to ensure that all users are able to have good experiences while using the app. Some of my favorite creators who touch on mental health and their personal struggles are @noelmulk0 and @brittanilancaster who are champions of their own mental health and are now able to use their platforms to help open conversation with others, while also linking people to help if needed. For instance, @noelmulk0 discusses his past and present with mental health while sharing his daily life training for a triathlon, and so his content can fluctuate but often there a core message of perseverance. I think that it is really important for users to see such open and strong people creating content because it is often the case people do not see their struggle until they can relate to others going through similar things which opens the door for reflection. With this said, I also think it TikTok should be aware of this and help creators promote resources for people to connect to in their local communities. Perhaps this could look like a list of helplines within countries which would then help connect users to resources on a local level, or maybe it could look completely different, but either way, I think that social media which addresses mental health should be helping to connect users to resources whenever possible. As TikTok continues to grow and expand it will be interesting to see how they address things like mental health, and interesting to see if this social media app will help to change the standards of social media. Outside of fitness and mental health, TikTok also connects users to new ideas and hobbies. There are many different genres of videos, and some include educational themes. Whether it is to help others learn to bake or help others learn about their own implicit bias, TikTok has enabled people all over the world to learn from each other. This allows people to feel heard and to interact with like-minded people from countries or cultures they may have never imagined. It is also important to note that despite the tendency for most users to see like-minded people, there are also times when an individual’s ideas or thoughts might be challenged which is equally important. Through TikTok, international friendships are made and the coming together of minds has been able to take place which in the end helps the global community become a more understanding place. This sense of a wider global community has come at the perfect time for so many people because for so many of us life has stood still for the last year. Although TikTok is not perfect, it is through social media platforms like TikTok, that it becomes possible to stay connected to old friends and new friends. The effects of social media on mental has long been a hot topic of debate, and another viewpoint on this issue can be read in a previous InSPIre the Mind blog, here. While there still are a lot of unknowns about the overall effect of TikTok on mental health specifically, I can say my personal experience has been very good on the app. With this said, I also must recognize that I am a 22-year-old postgraduate student studying neuroscience, and in general I may have more life experience than the younger users on the app. I think as TikTok moves forward it will be imperative for the app to create better safeguards and ways to monitor what users are seeing, especially if they are minors to help ensure that people’s mental health and general wellness is taken seriously when users are on the app. It is hardly enough to leave it solely up to the content creators themselves. Personally, I think the exponential growth TikTok saw in 2020 was not a coincidence because humans are social animals. While so many people had been physically cut off from seeing family and friends, it was only natural for us all to turn to technology to bring us back together and to help people ease the hardships of isolation even if only for a few hours a day. It is really amazing how far social media can take a person without them ever leaving their home. From seeing different cities and countries to learning the latest dance trend or learning a new cleaning hack, TikTok has the ability to help many people. Although TikTok may not last forever, for now-when being used responsibly-it is having a truly amazing impact on its users. With all of that being said, it really is not a surprise that TikTok has taken off globally since March of 2020, and it has proven that in a COVID positive world, people can still come together safely to build new communities and hopefully to help strengthen the mental health of users through these communities.

Addressing doctors’ suicide and mental health in the world of medicine. The path of becoming and being a doctor is challenging. We may graduate from medical schools, enter training, and find success together, but it is strange how alone we can find ourselves when things go wrong. As a junior doctor this is something I am intent on changing. Some doctors reach out and find help, others may quietly self-medicate in different ways. Sadly, a few come to the conclusion that there is only one option left. Suicide comprises so many factors that to focus solely on one will eventually limit our understanding of what has happened. But if that factor is a workplace that is marred by stigma and fear, then it is definitely something we need to address. Clare Gerada, on preventing suicide in doctors, says: Suicide prevention means tackling the pain in the whole system, not just in individuals. Systemic change won’t come about just through compulsory mindfulness, yoga, or suicide prevention training (although these might help in bringing people together), nor indeed through creating metrics for “kindness” or “compassion.” What we need is to tackle the policies that go to the heart of the cause of distress — bullying, complaints, a culture of shaming, workload, targets, and inspection. In part 1 of When the Healer Cries, I covered the problems facing the doctor as an individual. In this part, I will discuss institutional issues that contribute to mental illness in doctors, and what prevents them from being honest. At the level of the institution(s): In one U.S study of State Medical Board (SMB) license applications, 13 of the 35 SMBs responding showed that a psychiatric condition by itself sufficed for sanctioning physicians, meaning they did it only on that basis. It was with no evidence of impairment or any specifics, onset, treatment or duration. The same states disclosed that they treat physicians receiving psychiatric care differently than they do physicians receiving care for physical illnesses. Whether in a local hospital setting or in the licensing bodies, such standards may need revision with immediacy as they hinder help-seeking by doctors. Doctors are ‘’chosen for personality traits that predict good doctoring — perfectionism, obsessiveness, and even elements of martyrdom — traits that can act against them.’’ Are our selection criteria too narrow and punitive? For entrance to medical schools and training, do we place too much emphasis on scores and intellectual achievements on paper? What about applicants’ lives beyond their CVs and certificates — early traumatic life experiences, illnesses, and genetic vulnerabilities? Should we consider those in applications — if so, how much of pre-existing conditions should we have insight to? We may not have acceptable answers to these questions. These may not even be the right questions to ask in our attempt to understand suicide in doctors. But they are important to bring forward, nonetheless. The healthcare environment is packed with pace, time pressures, birth, death, and a plethora of life-changing events in between. It is often a cauldron of intense emotion. Palliating a cancer patient, watching a trauma victim have their leg amputated or delivering a dead baby is hard. Witnessing these events can lead to burnout, something which is very common amongst doctors. Without proper funding and resources, doctors end up lacking support, overworked. The demand and complexity of health services increase as the population does, begging for more resources. This also includes Mental Health Services — despite a renewed focus on mental health in the past decade, financial help for it remains inadequate globally. Burnout in doctors is a universal dilemma. Many doctors have amazing resilience, myriad ways of coping, and a good support system, but every human has a breaking point. So what must be done to shield these doctors from experiencing chronic burnout and falling ill? The results of many burnout studies lie waiting for policymakers to put together and facilitate fruitful change. How do they walk a path of balance and well-being without straying too far? There may be support programs in universities and hospitals that invite students and doctors in a non-judgmental way. But if such programs exist, how effective have they really been? Or have we reduced them to monotonous box-ticking exercises? Many medical students and trainees, myself included, have faced at least one professor or senior doctor who has used shame, bullying, and abuse as a way of teaching. Humiliation, belittlement, and verbal abuse were the most common types of adverse treatment reported. Students would come to learn the importance of hierarchy in medicine through teaching by humiliation (‘the hidden curriculum’). Emotion can be a medium of power. Emotions like humiliation, anger, fear and shame can be used as a form of social control and rehearsal of power dynamics. As Stephen Fineman says in Emotions in Organisations: Different positions within hierarchies of power give access to different emotion scripts; and our place in this structure will influence how emotions, such as fear, anxiety or disdain can be exploited. Many doctors and students hide their feelings of discomfort and exhaustion behind a mask of competence. They are afraid of being branded as incompetent by their seniors if they do. They come to understand that their capacity to tolerate and accept humiliation and intimidation without questioning power dynamics is vital for their career progression. Then, they learn to respect and reproduce a similar work environment where opinions cannot be asserted and authority cannot be challenged. Participants (trainees) in a study described the typical work culture and hierarchy in medicine as one that led them to feel unheard, angry, oppressed, scared and humiliated. It also made them feel alienated and disillusioned. This is important to discuss and understand in mental health. Discussion must not be misunderstood as an attempt to paint the seniors as ‘bad guys’ of the field, or to negate their experience. They too are affected and may struggle like the rest. This is simply to highlight the toxicity in medical culture, and how this can all snowball into isolation and illness. And if abuse may beget abuse, how do we break that cycle? This is a call for more kindness and mutual respect in the work-place. An unfriendly working environment in medicine is a problem. While some may only feel a discouragement of sorts, the psychological damage to others may stir up substance misuse, symptoms of PTSD, depression, and ultimately suicide. Can we — or should we — change the culture of medicine? asks Dr Michael Myers in his paper on physician suicide. I am referring to the ‘‘macho’’ mystique, the normalcy and rewarding of overwork or workaholism, the ascendancy of intellectualisation and rationalism over feeling, compassion and humanism, the competition, the materialism in some sectors, and male and female sexism in our medical centres and institutions. Did Medicine fail those doctors who died by suicide? Or did we construct this culture in medicine that seems in denial that a doctor can suffer from mental illness and take their own life? The future and what we can do When a doctor dies by suicide, the reaction is absolute shock and confusion. Disbelief claws at the chests of their loved ones, leaving a heavy ‘why’ in its wake. Here are some reactions from the loved ones left behind, as presented by Michael Myers in his paper: The words of a doctor’s widow: “We have this belief that physicians have chosen that profession to continue and sustain and protect life……….and when a physician kills himself or kills herself, it is very, very confusing…….because it’s almost as if….if they’re giving up…what’s that mean for the rest of us?” The words of a doctor’s physician colleague: “Today I learned that you died and nothing will ever be the same again. I refused to believe the words I heard, that you committed suicide. Only terribly depressed people kill themselves. You weren’t terribly depressed….but then I learned that, yes, secretly you had been. How could I not know, not realize?” The individual and the institute must make a collaborative effort on challenging the issues plaguing medicine. There may be some universal models for all suicidal people that can be helpful for assessing ill doctors, but we still need one’s specifically for suicidal doctors. More evidence-based research on mood disorders, personality disorders, substance abuse and others in the medical student and doctor populations are necessary. Also, existing research on suicide risk factors may require updating with diversity into account. Prevention and postvention studies are important. As is research on medical students and doctors who have attempted suicide and did not die — so we may get an understanding of thought processes and feelings at every step leading to suicide. It would not only be helpful for the individual taking part, but also for early intervention in those like them. We should put forth results and reliable findings to health and medical directors, department chairs, college deans and professors, program coordinators, supervisors, and others so it can establish a more understanding and supportive workplace. We need to meet doctors and medical students at their level of emotional expression and work hard to create a safe space for them to share their feelings without being ridiculed or facing discrimination. In order to tackle the problems with treatment — diagnostic and therapeutic services must become available and accessible. Care must be comprehensive, advertised, and accepting. It also needs to be kind, confidential and respectful. The complexity of the illness that suicide is may encourage us to use a team that is diverse and specialised to help the doctor heal. Sometimes, their loved ones may play very important roles in their healing and should be considered. Stigma must be confronted and discussed on all fronts — overtly and covertly, in speech and in action. We could encourage those with lived experience into leadership roles so they can carve a more open, supportive and accepting workplace. The stigma-related work is a steep hill to climb in many places. But climb we shall. Critiquing this beautiful service to humanity does not equate to the condemnation of the job of being a doctor, or medicine. I have not found more fulfilment and meaning in a work I did than this. But history is full of powerful lessons for those of us who complacently row along with the current of wrongs that we are very much a part of. No matter how horrendous a state, there is always some collateral beauty and good in it, even if we may not initially perceive. There is always a better way to go about things, and always things that we can better. Perhaps what we need then is to embrace healthier notions of what it means to be a proactive, successful doctor. And to push for better, humanising institutional changes. Perhaps that is our real challenge. If the work we do today would mean tomorrow has lesser pain and disruption to society and loved ones, lesser loss of productivity and promise, then today’s work is of utmost importance. If you are struggling and in need of support, below are a few incredibly helpful organisations which provide both resources and direct help: Shout Crisis Text Line — you can text Shout to 85258 if you are experiencing a personal crisis, are unable to cope and need support. Talk to the Samaritans — they offer 24-hour emotional support in full confidence. You can call them for free on 116 123 CALM (Campaign Against Living Miserably) offers a chat and hotlines service from 5pm to midnight Papyrus (Suicide Prevention Charity) offers similar service for adolescents and young adults under the age of 35 Mind — you can call the Mind Infoline on 0300 123 3393 / info@mind.org.uk, the Mind Legal Advice service on 0300 466 6463 / legal@mind.org.uk Talk to your GP

As we make our way through lockdown 3 there is good reason to be feeling all manner of emotions. The upheaval we have all felt has come with a myriad of challenges including keeping up with the fast pace of change. As a long term youth worker, I have often been involved with young people who have really struggled with their sense of wellbeing and, in some cases, with significant mental illnesses that have emerged during their adolescence. In our teenage years, our mental health and wellbeing can be fragile, and levels of happiness among our teens here in the UK have been low for a number of years now. This then is one thing that causes me grave concern, as both a mother and a youth worker: the mental health of our young people during this most restrictive of times. A time when physical touch is restricted, when occupying the same physical space as others outside of your bubble is restricted, when hugging grandparents and other close family members might not be permitted. It’s truly mind-blowing to think that just about a year ago, your average young person probably had some kind of physical or emotional interaction with hundreds of people in a school day. Barbara Frederickson talks about micro-moments in her book Love 2.0, her overarching theory being that although we usually think about love as something that is either romantic or consists of strong connections between family members or friends who are like family, in actual fact love can be experienced in all sorts of places, with all sorts of people. A micro-moment then, is a moment of connection with another human being, two or more people who co-experience emotions in a moment are experiencing what it means to be connected into something bigger than themselves. This applies particularly with positive emotions, but also negative ones. In the middle of the first lockdown, I had a conversation with my eldest boy about this, he was really struggling with the feeling of isolation and wailed at me ‘I just want to see my friends, even if it’s Billy!’ (name has been changed for the purpose of this blog). Billy, for context, is a boy who used to call my boy names, who would stick his foot out in the corridor while my boy was passing, who routinely broke or stole new pens or pencils that my boy took into school. That my boy was so desperate to see someone, he would be happy if that was the boy who was bullying him is baffling, until you see through the lens of ‘micro-moments’. These connections with Billy were not loving, positive connections but they were, in a strange way, important. They were part of the shared experience of school life; in his school there are 1200 pupils plus a whole team of teaching and support staff. In what now feels like a pre-covid, crazy system, the bell would ring and all 1200 pupils would leave their classroom and go to another one, sometimes on the same corridor but more often than not, a room on the other side of the school. And then, in another mad move, they would have two 30 minute breaks in which all 1200 pupils would pour out of classrooms into the dining hall or into the outside spaces! Now, this school is blessed with a large playground, plus basketball courts and a large field, it is more than enough space for all 1200 of them. However, all this moving around means micro-connections with a significant chunk of the school community and this would happen 8 times a day. This is not too dissimilar to the weak-ties mentioned in this piece about working from home during the pandemic. One of the biggest consequences of the first lockdown was the complete cessation of these micro-moments for all our young people. There was a lot that was unprecedented about that first lockdown, but for my eldest boy, an extrovert who needs people, this was the biggest challenge. So how can we support our young people through these difficult times? Well, there’s no silver bullet or one-size-fits-all approach, but there are some things we can do to try make things feel a little less isolating: Have a conversation. One of the things I’ve enjoyed is the opportunity for our whole family sit at the dinner table more regularly. This gives everyone a chance to talk and to listen to each other. If you don’t think your family would talk easily then use a conversation starter game like ‘Would you rather,’ or even a quiz. You can buy table ‘games’ online easily and at low cost. The aim is not necessarily to have a deep conversation, just to begin to chat. Play a game together/do a jigsaw puzzle together. This encourages companionship without eye contact, which can be very comforting and lead to surprising conversations. Some of the deepest conversations I’ve had with teenagers have been over a jigsaw puzzle. Maybe steer away from Monopoly though! Go outdoors as often as possible, it’s truly amazing what spending a bit of time outdoors can to do help soothe the soul. If either of you is adventurous and you live in a suitable location, you might suggest cold water or wild swimming! There’s a growing body of science which shows that it is tremendously beneficial for those suffering with depression or anxiety. But if that’s not your thing then even just a stomp about the block is good. Signpost them to your local Children and Adolescent Mental Health Service online provision, spend a bit of time searching on local Facebook groups or on Google for your local CAMHS, in my area they are called i-Rock and are on Instagram posting regular Live sessions. The Young Minds website is excellent, with good information for parents as well as young people. Turn off the news, including not watching the 24/7 news channels, limit time on social media if possible and on news websites. In his book Humankind, Rutger Bregman likens the news to a drug which leads to heightened anxiety, lower mood levels, learned helplessness, contempt and hostility towards others. Limiting you and your family’s exposure to it will help to ease anxiety and stress. Look after yourself. The people around someone experiencing mental illness can find it difficult to look after themselves; it’s an anxious time when your loved ones are ill, especially when there isn’t a lot you can do to ‘make it better’. Ensuring that you are aware of how to improve your mood and taking positive steps to do this not only means you’ll be in a better frame of mind but it also models good practice to your child, they might even join you, though perhaps not if it’s having a bubble bath! Finally, if you have any serious concerns about your child’s mental health do look at the Young Minds website for advice, you might also consult your GP or find a local support group. These are difficult times we live in and we all need a bit of support to get through. Ultimately, it’s important to remember that the one thing that is constant in life is change. Things will change again and life will begin to return to something that we recognise. Hugs will return, as will micro-moments of connection and relationship. For now, we need to simply do the best we can to support our young people and children, until they are back in their regular routines, back to school, back to bustling hallways and teeming playgrounds. It will come, soon. Helplines for when things are very difficult: Childline for under 19s: 0800 111 Samaritans for anyone to call at any time about anything 116 123 Papyrus for those at risk of suicide and those concerned about them 0800 068 4141 Young Minds parents helpline 0808 802 5544 Plus a crisis messenger service for young people on 85258 Campaign Against Living Miserably (CALM) 0900 585858

This week (1st-7th Feb, 2021) is Children’s Mental Health Week. This year, the event has special significance because it falls in the context of the pandemic that, as we know, experientially and through research, has far-reaching effects on the mental health of children, adolescents and their families. Most of us have had some taste of the mental health knock-on effects of COVID-19, whether we grieved someone lost to COVID, struggled with the virus ourselves, experienced social isolation in lockdown, had anxiety, or, coped with new sources of stress. This blog will take a look at some of the science of the effects of stress on young minds. As a researcher in child and adolescent mental health and a mother, I’m passionate about understanding the effects of stress on children and young people. Over the past 6 years, I’ve been involved with a national programme called HeadStart that aims to increase children and adolescents’ wellbeing in six areas of England. My research has examined how young people experience stressors and the factors that they report to reduce their negative effects and help them cope, as well as how this changes over time. As a parent that is working and home-schooling, I’m acutely aware that COVID-19 brings in new stressors for children and families, as well as new experiences and surprises. COVID-19 Stressors The COVID-19 pandemic has ushered in new stressors for everyone, and especially children and adolescents. Parents have been under more stress which can affect their children in both subtle and direct ways. Violence towards children increases during periods of crisis. During the pandemic, children and young people have been exposed to new stressors, such as being away from the support of friends, school, teachers, extracurricular activities and community groups. Experiences of key worker children and children classified as vulnerable may be different from those that are at home with their families. In any case, children may also experience losing loved ones, worries about the risk of exposure, separation from grandparents and worrying about family health, parental employment, family poverty and uncertain futures. An increase in stressors can decrease both parents and children’s wellbeing. But what is a stressor and how does it affect the brain? A stressor is an event or an experience that triggers a stress response. Stressors can include environmental stressors (negative life events, traumatic experiences, daily hassles) and internal stressors (mental and emotional states, such as worry or trouble regulating emotions), that may be temporary, intermittent or chronic. Stressors can be highly subjective. Some people may find wearing a mask stressful, for others, it is not stressful and simply a necessary behaviour change in the context of a pandemic. Or, to take another example, one person may love to take a flight in an airplane, whereas for others it is a highly stressful, anxiety-inducing experience. Thus, there is value in considering how stressors are subjectively perceived. Stressor research often examines one stressor and its effect on mental health in isolation, such as the effects of bullying or domestic violence on health outcomes. Research often separates external stressors, such as features of the environment, from internal stressors, such as moods and states of emotions (for example, some studies only look at external stressors). However, in some qualitative research I undertook with adolescents in receipt of preventative mental health interventions, we found that stressors were not always neatly delineated in adolescent’s narratives and can be experienced in parallel. When asking adolescents about the stressors they perceived, some young people described that both external and internal stressors were perceived interact to contribute to poor wellbeing and symptoms of a mental health disorder. An external stressor in the context of lockdown might include factors such as restrictions on meeting, or losing a job. An internal stressor might include worries about the risk of catching COVID or low mood from social isolation. Stressors can stack up and overwhelm, however. What happens to the body and brain under stress? The “fight and flight” response to stress occurs when the body has a physiological reaction to either run away from or fight a stressor (or freeze). Symptoms included increased heart rate, flushed cheeks, trembling and rapid breathing. But is the fight and flight response problematic for young brains? Under normal (non-chronic) circumstances, stress is not damaging. The stress response triggers communication between the HPA (Hypothalamus-Pituitary-Adrenal) axis that increases and decreases in response to doses of stress. The stress hormone, cortisol, shuts down other systems (such as digestion) so that the body can focus on responding to a stressor. The releases of hormones enable the individual to be poised to respond to a stressor as indicated by rapid heartbeat and increased focus. After the threat has gone, the body returns to normal. However, when stress occurs repeatedly over time, its chronicity alters the body’s resting state to a higher notch. The body stays primed in a state of anticipating constant threat and the stress pathways become overactive. This serves to reduce the flexibility between an absence and presence of stress. When the load of stressors increases, a new set point is created, akin to increasing the thermostat on the body’s systems. The cumulative weight of stressors on the brain is described as Allostatic Load (AL). Such a load of stressors are understood to overwhelm the balance of the body, described as allostasis. When the allostatic load becomes too great this contributes to “wear and tear” on the regulatory systems of the body and increases the risk of disease. Researchers can measure allostatic load by measuring biomarkers such as waist circumference. The effect of stress on the brain Studies from rats and primates show that stress can alter the physical structures of the brain. Under stress, the body produces increased cortisol from the adrenal glands. The adrenal glands are triangular structures that sit on the top of the kidneys and regulate metabolism and the immune system. In the brain, raised levels of cortisol can change the size of the amygdala (an almond-shaped part of the brain linked to emotion and memory), and decrease the size of the hippocampus and specific dendrites that are part of the function of the prefrontal cortex. Studies of rodents find that prolonged stress leads rodents to exhibit anxiety and deficits in attention as well as an enhanced preference for alcohol. Adolescence is a Sensitive Period of Brain Development Research suggests that adolescence is a unique period of brain development described as a sensitive period. This means that the brain may be more influenced by the external environment during this time. “It has been proposed that neural plasticity, the way the brain adapts to internal or external changes, is heightened, rendering the adolescent brain particularly susceptible to environmental input” Research from both rodents and human studies suggests that the effects of drugs and peers are particularly strong during this time in a young person’s life. It is possible that the increased sensitivity of adolescents’ brains makes them more vulnerable to stress and developing mental health disorders. Many mental health disorders have their onset during adolescence. A review by Kessler and colleagues (2007) found that half of all lifetime mental health disorders begin by 14 years of age, but tend to be undetected and untreated. Incredibly, not all children that are exposed to a stressor will experience poor outcomes later in childhood or adulthood. Some children are resilient to the stressors they experience, they overcome them, whereas others will not. The factors that contribute to resilience are described as protective factors and include aspects such as a sense of humour and positive self-esteem. In addition to protective factors, there are other factors that result in differences in outcomes. So given the damaging nature of stressors on the brain, what can be done about it? The power of emotions Emotional support from parents and friends has the potential to counterbalance the negative effects of stress on the mind and body, research finds. The presence of emotional support from parents, friends and school can reduce the risk of mental health disorders and poor outcomes. According to the Stress Buffering Hypothesis, if individuals perceive to be supported, this can reduce the negative effects of stressors on mental health or other outcomes. A study by Brody and colleagues (2014) found that rural African American children that had grown up in an area of poverty but received emotional support from their mothers had lower allostatic load than those that did not report emotional support. When children (or adults) feel that they do not have the resources to manage a stressor that it exceeds their coping resources, this is highly problematic. Equally, if individuals feel that whilst a stressor is challenging they have the coping resources to manage it, this has found to have less of a negative effect on mental health. We need to actively counter the effects of stress Stressors have a profound influence on the minds of children and adolescents. Countering the effects of stressors on children, through interventions to reduce the negative effects of stress, are vital to protect and safeguard young people’s mental and physical health. As I understand it, it is important to put support in place for young people, that is based on evidence-based science (as not all types of support work for all young people) and it is important to understand what children and adolescents themselves report as stressor reducing and wellbeing enhancing. What makes young feel better both mentally and emotionally, can be highly individualised. Often (but fortunately not always!) one size fits all approaches don’t work to reduce the harmful effects of stress. Next steps in terms of research Some of my PhD research involved identifying patterns in a range of protective factors that adolescents themselves described as reducing the effects of stress and increasing their wellbeing. With colleagues at the Evidence Based Practice Unit, we have published a range of coping strategies described by adolescents to manage stress. Later this month, we will publish research on protective factors that are specific to children from minority ethnic groups. In the next few months of 2021, we aim to publish quantitative research examining the gender differences in trajectories of mental health and wellbeing that occur in early adolescence. What are the avenues in stress research for the wider field? Here are three directions: 1. Understanding the differential effects of stress It is vital to understand how stress affects different social groups as a precursor to putting in place measures and interventions to alleviate stress. A recent piece of research has examined the different effects of stress and patterns of self-care across Latin American countries, genders and age groups. COVID has had differential effects on a range of social groups and it is well documented that BAME groups have been disproportionately affected (BIPOC in the US context). Understanding how stress affects various groups: young children, early adolescents, teenagers and young adults and how this intersects with factors such as race, class, nationality, geography, and sexual orientation is really important. It is important to understand minority stress and the specific challenges faced by people of colour as well as the ways that within the context of the pandemic, aspects of identity might increase vulnerability to stress or conversely, confer protection against it. It is important to consider the effects of COVID on groups that are suddenly thrust into poverty such as international students as well as service industry workers and other professions badly hit. 2. To investigate the role of technology and self-care in increasing or decreasing stress in the context of lockdown A lot of support for mental health and wellbeing is mediated by technology, particularly for countries in lockdown. Children and adults spend more time on their phones and interacting with technology through online classrooms, Netflix, video games and online chat forms. Further research could examine how does technology reduce or increase stress on children and their parents during lockdown? Where there were previously clear boundaries between school and home, or work and home, what are the mental health effects of having fuzzier and looser boundaries and changed horizons as breaks in the school year are less pronounced. The family home under lockdown becomes a place of work, schooling, leisure, eating and sleeping, what does that mean for children’s mental health? Can children and teens get burnout? Self-care can mitigate the negative effects of stress but the evidence base for self-care strategies is still in its’ infancy. In a 2019 systematic review of research evidence, only few self-care strategies had a strong evidence base of effectiveness to reduce anxiety and depression. Should adopting a self-care strategy (or encouraging a child to adopt one) be based on the subjective experience of its efficacy or the evidence base? 3. The links between stress and COVID related anger Worldwide, throughout the pandemic, we have seen the rise of anger and externalising behaviours, whether in the form of resistance to masks, Americans “storming the capital”, the global rise in domestic violence, or public anger to changes and inconsistencies in COVID restrictions. It would be immensely valuable to understand what exactly this increased anger means for mental health conditions, for children, their families and the longer-term effects on brain and behaviour and how this ties together with stress. #ChildrensMentalHealthWeek is a brilliant time to get these conversations started. But it’s just as, if not more, important to keep these discussions going beyond this week, so that we can both understand and support every child as much as we can, every day.