I stress, you stress, we all stress for eustress! What on earth is eustress? You may have heard this mental health buzzword bandied around lately and wondered how exactly it differs from regular old life-is-making-me-crazy stress. But believe it or not, eustress is a kind of stress that’s actually good for us. (Yep, that’s a thing.) We spoke to licensed professional counselor Amanda Ruiz, MS of Pennsylvania’s The Counseling Collective about how to identify the eustresses in life — and get the most out of them.
With all we hear about stress raising blood pressure, disturbing sleep, and even bringing on early death (yikes), it may be hard to believe there’s a kind of stress that actually boosts our mental and physical health. So to understand eustress, you may have to dismantle some preconceived notion. Simply put, eustress is any kind of pressure in our lives that actually brings positive results.
“Eustress is the normal amount of stress that you feel when doing a positive challenge, something you feel relatively capable in completing,” explains Ruiz. Happy, exhilarating events in life, like having a baby or starting a new relationship even though they feel good, create their own kind of stress on the body and brain. After all, some of the same hormones — like adrenalin and cortisol — involved in fear are also present in times of excitement. Therefore, experiencing something thrilling or challenging, such as riding a roller coaster, completing a tough project at work, or buying a new home, brings a certain kind of pressure.
The benefits of eustress
This pressure, though it may technically qualify as “stress,” is surprisingly good for us. When we undertake something difficult, it’s an opportunity for personal growth, whether we succeed or fail. And change, a common source of stress, adds a bit of spice to life. “Eustress keeps life exciting,” says Ruiz. “Without it, you might become bored, complacent, and lack motivation.”
Plenty of research has looked at the dramatic effects of positive versus negative stress. The right balance of stress has been shown to increase alertness and cognitive performance, as well as keep us more adaptable. A 2015 study found that people with high levels of good stress had less fatigue in the morning and throughout the day than those who experienced distress (AKA negative stress). And another, conducted on college students, found a connection between the level of eustress and overall life satisfaction.
When is it eustress and when is it destress?
So when is it distress and when is it eustress? Typically, distress makes us feel anxious and overwhelmed. Eustress, on the other hand, brings a feeling of excitement, accomplishment, or a challenge accepted. (The “eu” comes from a Greek word meaning “good, well, pleasant, or true,” as in “euphoria.”) Making cuts to your budget, for example, could be a distress if it’s a struggle to make ends meet — or could be a positive if it’s to save for your spring break trip to Italy. “If you feel competent to cope with the stressful event, then you are most likely experiencing eustress,” says Ruiz. “If you doubt your ability to cope with it, and instead if feels unpleasant, then it’s probably distress.”
Turning distress into eustress
Feel like most of the stressors in your life are the kind that bring you down? There’s hope! Your mindset could go a long way toward actually transforming circumstances you perceive as distress into eustress. A 2013 study found that subjects’ thoughts about their own stress had a major impact on their physical experience of it. In one module of the study, subjects were interviewed about whether they found life stressors to be “enhancing” or “debilitating.” In another, they were shown videos that framed the concept of stress as either one of these two descriptors. All told, people who were able to think of their stress as having potential benefits had less negative physical responses to it.
To get the most out of any stressful situation, try to keep an open mind to how pressures might lead to personal growth. And, regardless of the circumstances, finding a self-care practice that works for you can keep stress at manageable levels. “Learning good stress management techniques can be helpful so you are adequately equipped to cope while going through any stressor,” says Ruiz.
Today is a blah day. It isn’t that there is anything terribly wrong today. There are issues looming, yes, but there are always issues of late. There is nothing pressing, though.
It is just a blah day, a day where I lay in bed, struggling to find a reason to get up. I’ve had to pee for a couple hours now. Yet, the dull ache in my bladder is not enough to pull me from under my covers. I should probably brush my teeth. Maybe get dressed and get a bite to eat. I have been awake for more than five hours now, even before the sun rose. Yet, here I still lay.
I feel blah. While the world around me continues with its hustle and bustle, I have no motivation, no desire to do anything. Nothing seems interesting or important. Nothing is pressing enough to pull me from this funk.
I would go back to sleep if I could, call in sick from life itself. I feel like nothing, not myself. I feel numb.
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Days like this are common with depression. Those who have never struggled often assume that depression is all bouts of random sadness and tears. Yes, I have those days, too, and it is draining when everything and anything feels heart-wrenching and makes me want to cry. Yet, even worse, perhaps, than the days when I feel everything too strongly are the days I feel nothing at all.
On these days, I have trouble pulling myself up or doing anything. I’m not being lazy. I just don’t see the point. I am pulled into a gray abyss, where there’s no purpose, no joy, no motivation, no will to live. It isn’t that I’m suicidal and actively want to die, either. I just have no will to live. The emptiness is all-consuming.
People suggest I should just “try” to be happy or to be positive. If only it were this simple. Again and again, the “should be” and “could be” options roll around in my mind but I’m numb to them all. Deep down, I know I should be getting up, doing something, living life.
Yet, my brain has me in a death lock. “What’s the sense?” and “Why bother?” it parrots to me again and again. Its voice is booming and deafening. I can hear nothing else. I would love to just smile, think a happy thought and have it vanish away like a puff of smoke but it’s solid and real to me. It takes the form of four solid walls, caging me in, holding me hostage, refusing to budge or listen to reason.
Those blah days are the worst because I feel trapped in this numbness. I cannot escape. I never know whether it will last one day or one week. There is never an end in sight, never a scheduled sweet release.
Blah days drag on and on until at some point I begin to feel everything too strongly again. On blah days, I would welcome the tears, the anguish, the pain and the struggling just to feel anything at all.
It has been more than hours now, and I’ve barely managed to write a few paragraphs. Yet, those feel like a tremendous accomplishment. I call it a victory. I have done something, which is more than I am able to achieve on most blah days. I still have to pee, though the dull ache has grown into a steady cramp. Breakfast time has come and gone, and lunch time has arrived. Yet, I still don’t have any desire to eat anything, let alone get up.
There are calls I should make and things I should be doing. Yet, my depression still echoes in my head that I shouldn’t bother, that nothing is worth the effort. It tells me to stay in bed, just let this day drift on by, that it doesn’t matter.
Nothing matters. It is all I can hear. It is deafening. I am adrift in a sea of hopelessness and emptiness. I feel paralyzed.
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I swear I am not being lazy. I’m just trapped in a battle with my own mind. I feel lost and alone. I feel trapped in this emptiness. I feel nothing. I feel numb. I feel blah. This is what depression feels like.
Some nights it’s easier to fall asleep than others. But for certain people, needing over 20 minutes to fall asleep every night is a given — and sometimes others have to wait hours more. The causes of insomnia can be due to all sorts of physical and medical health conditions, so it’s important to examine all of the factors that may be creating your difficulty falling asleep.
Falling asleep can say a lot more about what’s going on with your body than just how tired you are. “The amount of time it takes to fall asleep is known as ‘sleep latency,'” Conor Heneghan, lead research scientist at Fitbit, tells Bustle. “A normal amount of sleep latency is approximately 15-25 minutes, which is considered the ‘sweet spot’ for your body to drift into light sleep stages. However, sleep latency is impacted by [a variety of] factors.” These factors can be anything from what you’ve eaten that day, or whether you’ve altered your bedtime routine, to a more serious underlying medical condition that’s making it difficult for your body to rest at night.
And while having trouble falling asleep can be caused by a myriad of health issues, falling behind on sleep can cause sleep debt and add to these problems. So if you realize you’re taking more than 20 minutes to fall asleep every night, asking your doctor about this problem may get you some relief.
Here are nine health issues that not being able to fall asleep in 20 minutes could be a sign of, according to experts.
1GERD
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GERD, or gastroesophageal reflux disease, can cause symptoms that aren’t quite apparent until you lie down to try to fall asleep.
“When lying down, it’s easier for stomach acids to flow up your esophagus, causing heartburn,” Terry Cralle, RN, clinical sleep educator and sleep consultant for Saatva, tells Bustle. “Heartburn, in turn, can disrupt falling and staying asleep. That’s why many people with GERD experience an increase in symptoms at nighttime and may have trouble finding a comfortable position for sleeping.” Avoiding GERD trigger foods like spicy food, coffee, and alcohol, in the hours before bed, may provide some relief.
2Anxiety
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Anxiety doesn’t exist solely in the mind. If you’ve been dealing with feelings of stress and nervousness in your daily life, it may be building up and causing it to be difficult for you to fall asleep.
“Those who experience anxiety have a complex relationship with sleep,” Dr. Sujay Kansagra, Mattress Firm’s sleep health expert, tells Bustle. “Anxiety can not only prevent someone from falling asleep but it can also be worsened once a person experiences the effects of sleep deprivation.” Dr. Kansagra recommends talking to your doctor if stress or anxiety may be affecting your ability to fall asleep.
3Asthma
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If falling asleep regularly takes more than 20 minutes for you, and you also experience respiratory symptoms, this could be caused by asthma.
“Asthma symptoms often worsen at night, [including symptoms of] nighttime coughing, chest tightness, wheezing and breathlessness: a condition referred to as ‘nocturnal asthma,'” Cralle says. Check in with your doctor if you realize that these sorts of symptoms tend to come along at night.
4“Social Jetlag”
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Keeping a completely different sleep schedule on weekdays and weekends can make falling asleep more difficult in general.
“Another major factor that may contribute to longer sleep latency is ‘social jetlag,’ brought on by the shift in sleep schedules that many experience on days off compared to workdays,” Heneghan says. This issue with your circadian rhythm can be addressed by keeping a more consistent bedtime and wake up time throughout the week.
5Arthritis
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If you have general aches and pains, and they worsen at night enough to make it difficult for you to fall asleep — you may have undiagnosed arthritis. And arthritis doesn’t only affect older people.
“It is estimated that as many as 80 percent of people with arthritis have difficulty sleeping,” Cralle says. “Pain makes it hard to get comfortable and to fall — and stay — asleep. Since sleep deprivation makes pain worse, it’s critical that arthritis sufferers get enough quality sleep.” So talking with your doctor both about your pain and your sleep problems can be a step in the right direction.
6Menopause
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Like arthritis, menopause is associated with aging but can show up in young peopleas well. Since you may not realize this is possible, you may not be connecting the dots between potential gynecological issues and lack of sleep.
“Women are twice as likely to suffer from insomnia than men, according to the National Sleep Foundation, and their sleepless nights have been linked with hormonal changes —especially during menopause, when hormone levels are erratic,” Dr. Kent Smith, founding director of Sleep Dallas, tells Bustle. Making sure you regularly see an OB/GYN, and always tell your doctors about changes to your health, can help you stay on top of these potential issues.
7Restless Leg Syndrome
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Tossing and turning doesn’t have to be something that you ignore. Health issues like restless leg syndrome could be seriously impacting your ability to fall and stay asleep.
“Approximately one in 10 adult Americans suffer from Restless Leg Syndrome, according to the National Sleep Foundation,” Dr. Smith says. “This sleep-related movement disorder causes overwhelming and often unpleasant urges to move the legs while at rest, often making it difficult for sufferers to drift off to sleep.” If you find it particularly hard to lie still at night, it may be best to get in touch with a doctor.
8Sleep Apnea
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While sleep apnea is known to cause disruptions during sleep, it can cause difficulties during the process of falling asleep as well. And since sleep apnea can be difficult to diagnose, you might not connect the dots on this sleep disorder immediately.
“Sleep apnea, a condition in which a person ceases to breathe multiple times per hour when they sleep, can inhibit a person’s ability to fall asleep,” Dr. Smith says. “The brain detects that it is receiving less oxygen during sleep, so, in a life-preserving attempt, it actively prevents the sufferer from falling asleep.” If you have difficulty falling asleep, plus other signs of sleep apnea, then it’s important to see a sleep specialist and seek treatment.
9Vitamin Deficiency
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Sometimes, the root cause of your difficulty falling asleep can be hard to pinpoint but relatively straightforward to treat. One of the examples of this is vitamin deficiency.
“Several common vitamin deficiencies can lead to sleep disturbance,” Arielle Levitan, M.D., co-founder of Vous Vitamin LLC, tells Bustle. “[…] Determining which vitamins to take and in which safe and proper doses is important.” Particular deficiencies like magnesium and iron can cause difficulty falling asleep, Levitan says. To find out if this is a problem, the first step is to speak with your doctor and potentially have them perform blood tests to check for deficiencies.
In order to protect your physical and mental health, it’s important not to normalize your difficulty falling asleep. Taking note of why you may be struggling to fall asleep within 20 minutes or so, and how you feel the next day, may provide you some of the data you need to discuss this issue with your doctor — and find a treatment that works for you.
I’m a counselor, and many of the introverts I see come to me because of anxiety. Some of the clients I see have diagnosable anxiety disorders, but those who don’t aren’t suffering any less. When I say anxiety, I mean “an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure,” according to the American Psychological Association.Anxiety can come in many forms and have many different causes, but in this article, I’d like to focus on social anxiety. Let’s take a look at the major signs of social anxiety, plus how you can free yourself from it by fixing “thinking errors.”
Feeling anxious or afraid in social settings. You might feel extremely self-conscious, like others are judging or scrutinizing your every move. For an adult, this might happen on a first date or a job interview, or when meeting someone for the first time, delivering an oral presentation, or speaking in a class or meeting. In children, these behaviors must occur in settings with peers — rather than adult interactions — and will be expressed in terms of age appropriate distress, such as cringing, crying, or just generally displaying obvious fear or discomfort.
Worrying quite a bit that you’ll reveal your anxiety and be rejected by others
Consistently feeling distressed during social interactions
Painfully or reluctantly enduring social interaction — or avoiding it altogether
Experiencing fear or anxiety that’s disproportionate to the actual situation
Having fear, anxiety, or other distress around social situations that persist for six months or longer
Finding that your personal life, relationships, or career are negatively affected. In other words, your anxiety makes it quite difficult for you to function in day-to-day life.
For a diagnosis of Social Anxiety Disorder, these symptoms must be present for six months or longer and not be better explained by another mental health or medical diagnosis.
Why Is Social Anxiety Common in Introverts?
If you’re an introvert who experiences social anxiety, you’re not alone. The research shows that introverts are far more likely to suffer from it than extroverts. A small study done in 2011 found that “social phobia patients” were significantly more often introverts (93.7 percent) than not (46.2 percent). Although not all introverts suffer from social anxiety, this study suggests that us “quiet ones,” by nature, may be prone to it in one form or another.
Social anxiety can be excruciating. Introverts, in my practice, struggle with it because they tend to overthink and overanalyze situations. They may find themselves caught in a cycle of planning out a conversation only to have it go differently than their script. This puts them on the spot — an introvert’s nightmare — and creates a high level of anxiety.
They then may fall into the trap of mind-reading. Mind-reading is what some therapies, like Dialectical Behavioral Therapy, call “thinking errors.” These patterns of thinking can be helpful in some situations, but when overused, can actually be quite harmful.
Many introverts (especially highly sensitive introverts) are particularly vulnerable to the “error” of mind-reading because they’re so good at attuning to others’ body language, emotions, and energy that it feels like they always know what someone else is thinking — even though they don’t actually possess telepathy.
When a conversation goes off-script and anxiety is heightened, introverts may assume others are thinking critically of them and take this assumption as fact. The thoughts of “now he thinks I’m an idiot” — though most likely false — create even more anxiety. It’s a vicious and debilitating cycle.
But you can banish social anxiety. Let’s take a look at the power of identifying and correcting thinking errors.
The Power of Fixing Thinking Errors
Let’s take an example from my practice. One young woman who came to me had a hard time making new friends. This girl was more mature than her cohort and seemed to be having trouble initiating conversation. As we talked, it came to light that her introverted trait of thinking before speaking had spiraled out of control. She’d rehearse for hours what she was going to say to a certain person, then be caught off guard when the conversation didn’t go as scripted. She then feared that people thought she was stupid or awkward (she was mind-reading) and became highly anxious.
After a conversation like this, she’d ruminate over what she should have said for days or weeks. Obviously, this left her too anxious to start any new conversations with anyone, which lead to a cycle of reinforcing her anxiety about social situations and her avoidance of them.
What did we do about it? The first step was education; we discussed both overthinking and mind-reading and how they relate to her introverted nature. She discovered that her tendency to overthink was very helpful in situations where she needed to analyze information and come to a conclusion, like schoolwork, but that with friends and family, it was creating a barrier to close relationships.
She was also able to see that while she is very attuned to others’ emotional states, she isn’t telepathic and can’t actually read others’ minds.
This education into the thought patterns that were feeding her anxiety gave her some valuable insights. For instance, she realized that the thoughts of “stupid” weren’t what she feared others would think of her, but what she thought of herself. Once we hit on this critical insight, she began to understand that her overthinking and mind-reading were actually ways to distract her from the mean things she was saying to herself.
It took quite a few sessions to help this girl become more self-compassionate and to lessen her overthinking. However, by the end of the school year, she was able to not only talk to new people, but to tackle intense, conflict-laden conversations she’d always avoided before.
If you’re an introvert who suffers from social anxiety, the first step is to do what you do best: look inside and bring awareness to the thought patterns that are no longer helping you. Some of the best ways to do this are mindfulness, yoga, and journaling. Mindfulness trains the mind to be non-judging and discerning of thoughts and feelings; yoga helps relieve stress and is a moving meditation; and journaling brings up the unconscious thoughts, feelings, and beliefs we aren’t aware of in daily life that may be holding us back.
Ask yourself if there are thinking errors that are contributing to your anxiety. Are you like the girl I described above? The next time you notice yourself committing a thinking error, don’t judge or beat yourself up for it. Instead, simply notice it — there’s power in this alone! You might go a step further and intentionally replace your thinking error with a positive thought (even if you aren’t totally feeling it yourself at the moment). Try something like, “even though I’m scared, it’s going to be okay” or “I’m a likable person, and people enjoy being around me.”
Your social anxiety won’t disappear overnight. But by stepping into mindfulness and identifying/correcting thinking errors, you can stop it from ruling your life.
When I was 15, my mother died in a car accident. Not knowing how to deal with the enormity of my loss and grief, I threw myself into homework and activities. I never missed a day of school and tried to control everything in my life. This strategy succeeded in some ways—I was able to get good grades, for example. But the inner cost of pushing away my grief and sadness showed up in other ways. I became anxious around things I couldn’t control, like unexpected changes in plans and minor injuries. And as I grew older, I started to harbor irrational worries, such as the fear of exposing my baby in utero to toxic fumes when walking past a strange smell. It was not until later, after my first child was born, that I was able to fully grieve the loss of my mother with the help of a therapist and feel all of the emotions I had spent so many years trying to ward off. As I write in my new book, “Dancing on the Tightrope,” the desire to avoid what’s unpleasant and seek what’s pleasant is part of human nature. But avoiding unpleasant emotions—rather than accepting them—only increases our psychological distress, inflexibility, anxiety, and depression, diminishing our well-being.
Research suggests that when we turn toward our cravings, we’re less likely to engage in addictive behaviors. When we turn toward our physical pain, we’re less likely to be trapped in cycles of chronic pain. When we turn toward our sadness, we’re less likely to be stuck in depression. And, when we turn toward our anxiety, we’re less likely to be paralyzed by it and can find it easier to bear.
Learning to embrace dark emotions not only reduced my anxiety but also gave me the ability to experience the joys of life more fully and trust in my ability to handle life’s challenges. As a therapist, I have also seen tremendous healing with my patients as they have learned to embrace their difficult emotions.
If we want to live more fully and be our most authentic selves, we need to turn toward our pain, not try to suppress it. But what can help us get there? The tools of mindful attention, self-compassion, and acceptance—which all come together in a practice I call “The Door.”
To do this practice yourself, make sure to start with emotions that aren’t too intense. You might want to work with a skilled therapist, especially for more intense emotions. Here’s what The Door involves.
Step 1: Develop a Willingness to Open the Door
Imagine that you’re opening the door and welcoming your emotions to come and have a seat somewhere in the room. You can picture this seat as close to or as far away from you as you like. From this perspective, you can take a gentle and curious look at what is there.
Often people will picture their emotions as having some kind of color, shape, or form. Sometimes they envision their emotions as cartoon characters or as younger parts of themselves. Part of the practice is simply to accept whatever arrives.
This is a new experience for most people. Who wants to let anxiety in the door? Who wants to welcome in sadness or anger? But when we let in whatever arrives and see it from a bit of a distance, we can take a curious look and explore what is there.
Step 2: Take a Curious Look at Whatever Walks in the Door
Mindfully observing what we’re feeling can help us cope with whatever is before us. It can be useful to name our feelings—”Oh, that’s hurt; that’s jealousy; that’s anger”—because, as simple as this sounds, we often don’t pay attention to the nuances of what we’re feeling. Consequently, important information gets lost along the way. Labeling our distressing emotions gives us a way of validating our inner experience, but it has the added benefit of dialing down their intensity.
It can also be beneficial to see our emotional “visitors” as temporary guests. Adding the phrase “in this moment” to a statement like “I am feeling stress, anger, or hurt” can help us be with what is there without feeling overwhelmed. Other things you might say to yourself include:
Can I allow myself to notice how this is showing up in my body and in my thoughts?
If this feeling or part of me could talk, what might it say?
What might it want or need?
Being curious rather than fearful or rejecting your emotions provides a better lens for understanding them.
Step 3: Give Yourself the Gift of Compassion
Besides pushing away uncomfortable feelings, many of us have been conditioned to judge our emotions in negative ways. We’ve learned that if we show sadness, it’s a sign of weakness, that we’re a bad person if we feel anger or jealousy, and that we should “move on” when we experience loss. When we come face-to-face with difficult emotions, we often tell ourselves to buck up and stop being silly or that there’s something wrong with us.
When we practice mindfulness in combination with self-kindness and a recognition of our common humanity—the fact that we all suffer as human beings—we cultivate self-compassion, a quality that’s been linked to psychological well-being.
To practice self-compassion, imagine sitting with a good friend who is suffering and think about how you might extend a gesture of compassion. What would your body language be like? How might you listen? What sensations would you feel around your heart?
Now picture that person extending compassion towards you. What might they say or do? What words would you find comforting or soothing?
Chances are, they wouldn’t be telling you to cut it out or that you shouldn’t be feeling this way. They might say, “That sounds really hard. I’m here for you.” Or perhaps they would simply extend a hand.
When we can learn to sit mindfully with our own emotions and bring compassion to whatever we’re experiencing, it’s as if we have become that caring friend, sitting with ourselves. Learning to be there for ourselves, through the positive moments—and the painful ones—can be tremendously healing.
While embracing our dark emotions takes courage and practice, using The Door technique allows us to open to a gift on the other side. Each time we practice being with our difficult emotions, we grow inner resources, learn to trust in our capacity to handle our experiences, develop resilience to move through life’s challenges, and find ways to pursue what truly matters. Each of us has the power to face what is hard if we only open the door.
Beth Kurland is a clinical psychologist, public speaker, and author of three books, including “Dancing on the Tightrope: Transcending the Habits of Your Mind and Awakening to Your Fullest Life,” from which this essay was adapted. This article was republished from Healthline.com
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The term “smiling depression” – appearing happy to others while internally suffering depressive symptoms – has become increasingly popular. Articles on the topic have crept up in the popular literature, and the number of Google searches for the condition has increased dramatically this year. Some may question, however, whether this is actually a real, pathological condition.
While smiling depression is not a technical term that psychologists use, it is certainly possible to be depressed and manage to successfully mask the symptoms. The closest technical term for this condition is “atypical depression”. In fact, a significant proportion of people who experience a low mood and a loss of pleasure in activities manage to hide their condition in this way. And these people might be particularly vulnerable to suicide.
It can be very hard to spot people suffering from smiling depression. They may seem like they don’t have a reason to be sad – they have a job, an apartment and maybe even children or a partner. They smile when you greet them and can carry pleasant conversations. In short, they put on a mask to the outside world while leading seemingly normal and active lives.
Mental Health Awareness: Facts and figures
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Inside, however, they feel hopeless and down, sometimes even having thoughts about ending it all. The strength that they have to go on with their daily lives can make them especially vulnerable to carrying out suicide plans. This is in contrast to other forms of depression, in which people might have suicide ideation but not enough energy to act on their intentions.
Although people with smiling depression put on a “happy face” to the outside world, they can experience a genuine lift in their mood as a result of positive occurrences in their lives. For example, getting a text message from someone they’ve been craving to hear from or being praised at work can make them feel better for a few moments before going back to feeling low.
Other symptoms of this condition include overeating, feeling a sense of heaviness in the arms and legs and being easily hurt by criticism or rejection. People with smiling depression are also more likely to feel depressed in the evening and feel the need to sleep longer than usual. With other forms of depression, however, your mood might be worse in the morning and you might feel the need for less sleep than you’re normally used to.
Smiling depression seems to be more common in people with certain temperaments. In particular, it is linked to being more prone to anticipate failure, having a hard time getting over embarrassing or humiliating situations and tending to ruminate or excessively think about negative situations that have taken place.
Women’s Health magazine captured the essence of smiling depression – the façade – when it asked women to share pictures from their social media and then to recaption them on Instagram with how they really felt in the moment they were taking the picture. Here are some of their posts .
It is difficult to determine exactly what causes smiling depression, but low mood can stem from a number of things, such as work problems, relationship breakdown and feeling as if your life doesn’t have purpose and meaning.
If you suffer from smiling depression it is therefore particularly important to get help. Sadly, though, people suffering from this condition usually don’t, because they might not think that they have a problem in the first place – this is particularly the case if they appear to be carrying on with their tasks and daily routines as before. They may also feel guilty and rationalise that they don’t have anything to be sad about. So they don’t tell anybody about their problems and end up feeling ashamed of their feelings.
So how can you break this cycle? A starting point is knowing that this condition actually exists and that it’s serious. Only when we stop rationalising away our problems because we think they’re not serious enough can we start making an actual difference. For some, this insight may be enough to turn things around, because it puts them on a path to seeking help and breaking free from the shackles of depression that have been holding them back.
Meditation and physical activity have also been shown to have tremendous mental health benefits. In fact, a study done by Rutgers University in the US showed that people who had done meditation and physical activity twice a week experienced a drop of almost 40 per cent in their depression levels only eight weeks into the study. Cognitive behavioural therapy, learning to change your thinking patterns and behaviour, is another option for those affected by this condition.
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And finding meaning in life is of utmost importance. The Austrian neurologist Viktor Frankl wrote that the cornerstone of good mental health is having purpose in life. He said that we shouldn’t aim to be in a “tensionless state”, free of responsibility and challenges, but rather we should be striving for something in life. We can find purpose by taking the attention away from ourselves and placing it onto something else. So find a worthwhile goal and try to make regular progress on it, even if it’s for a small amount each day, because this can really have a positive impact.
We can also find purpose by caring for someone else. When we take the spotlight off of us and start to think about someone else’s needs and wants, we begin to feel that our lives matter. This can be achieved by volunteering, or taking care of a family member or even an animal. Feeling that our lives matter is ultimately what gives us purpose and meaning – and this can make a significant difference for our mental health and well-being.
Many people tend to blame others for their issues. Prime candidates are parents, partners, friends, bosses, and kids. Perhaps these examples sound familiar?
“The reason I don’t have a social life is that my husband is an introvert. If he were more outgoing, I could really get out more.”
“My kids are so difficult, it is impossible to have people over the house. They just run wild and I wouldn’t be able to enjoy myself.”
“If my dad hadn’t cheated on my mom, I would have a healthy view of relationships now and I wouldn’t keep going for these jerks that treat me poorly.”
It is very tempting to blame others for things going wrong in your life, even personal habits you dislike or your own dysfunctional thought patterns.
However, if you rely on blaming others for your own current emotional and mental issues, you are doing yourself a disservice in a multitude of ways. Here’s why blaming others can sabotage your ability to be happy.
1. Blame keeps you in a negative headspace
Focusing on what others are doing “wrong” keeps you in a negative, pessimistic frame of mind. Instead of looking for solutions, you are lingering on problems. Instead of recognizing what people are doing well, you are looking at their flaws.
In the first example above, the woman is blaming her husband for her own lack of a social life, which makes her see him in a fairly negative and uncharitable way. You can see how this would contribute to feelings of depression and marital discord. If she blames her husband openly for his introversion, he likely will feel attacked and attack her back, which will lead to marital issues both short and long term.
2.Blame stops you from looking at your own contribution to issues
As long as others are “the problem,” you don’t have to do the challenging, but ultimately rewarding, work of examining your own behavior. Your thought patterns and expectations influence the things in your life that you wish were different.
For instance, the parent in the second example above could be exploring ways to work with her kids on improving their behavior, or exploring why it may be familiar or easy for her to limit her socializing. As long as she characterizes the kids as the problem, though, she doesn’t need to do any of this deeper introspection, which would likely be very useful in moving her out of this stuck place.
3.Blame keeps you tethered to the past
Instead of looking for ways that you can work on negative behavior patterns, blame allows you to stay mired in the past.
In the last example above, thinking about your dad’s impact on how your relationship functions may be useful. But continuing to actively blame him may prevent you from digging deep into what’s causing your unfulfilling intimate relationships.
It helps to talk through blame
Of course, this in no way means you should ignore or minimize the ways that others impact you. It is extraordinarily useful to discuss your relationships — past and present — with a therapist, or to introspect about them on your own.
However, it is essential to move from a “blame” stance to an “understanding” stance, which can give you the mental and emotional space you need to get out of old patterns and move forward in more flexible and liberating ways.
Expressing love for your nearest and dearest is a hallmark of Valentine’s Day, but research suggests that you may want to save some of that love and compassion for yourself.
A study published in Clinical Psychological Science shows that university students who engaged in exercises focused on self-compassion had lower physiological arousal relative to peers who engaged in other exercises.
“These findings suggest that being kind to oneself switches off the threat response and puts the body in a state of safety and relaxation that is important for regeneration and healing,” says Hans Kirschner of the University of Exeter, first author on the research.
“Previous research has found that self-compassion was related to higher levels of well-being and better mental health, but we didn’t know why,” explains lead researcher Anke Karl, also of the University of Exeter.
“Our study is helping us understand the mechanism of how being kind to yourself when things go wrong could be beneficial in psychological treatments,” Karl says. “By switching off our threat response, we boost our immune systems and give ourselves the best chance of healing. We hope future research can use our method to investigate this in people with mental health problems such as recurrent depression.”
For the study, the researchers recruited 135 university students and assigned them to one of five experimental groups. Each group completed an exercise in which they listened to an 11-minute audio recording and engaged with a specific scenario.
The researchers monitored participants’ physiological arousal during the exercise, measuring their heart rate and sweat response. Participants also answered questions about how safe they felt, how likely they were to be kind to themselves, and how connected they felt to others.
As expected, the two groups that engaged in self-compassion exercises — either a body scan meditation or a loving-kindness meditation — reported feeling more self-compassion and connection with others as a result of the exercises. And they also showed reduced physiological arousal, with a drop in heart rate and diminished sweat response. They also showed an increase in heart rate variability, a sign of being able to flexibly adapt to different situations.
Importantly, participants who engaged in positive thinking by focusing on an event or situation that was going well also reported increased self-compassion and decreased self-criticism, but they did not show the same physiological response.
In contrast, the group that engaged in self-critical thinking, contemplating something they hadn’t managed or achieved as they had hoped, showed an increase in heart rate and sweat response — physiological signs consistent with feelings of stress.
“These findings help us to further understand some of our clinical trials research findings, where we show that individuals with recurrent depression benefit particularly from mindfulness-based cognitive therapy when they learn to become more self-compassionate,” says coauthor Willem Kuyken of the University of Oxford.
Future research will need to explore whether the one-time self-compassion exercises used in this study have similar effects for people with depression.
Overall, the findings suggest that showing yourself a little love and compassion may help you feel more connected and less stressed.
Reference
Kirschner, H., Kuyken, W., Wright, K., Roberts, H., Brejcha, & Karl, A. (2019). Soothing your heart and feeling connected: A new experimental paradigm to study the benefits of self-compassion. Psychological Science. doi:10.1177/2167702618812438
This question came up in conversation when I was speaking with someone who has experienced severe panic attacks to the point of calling them “debilitating”, requiring inpatient care. As they were sharing about the ordeal, they told me that when they contemplate the time spent seeking treatment and the aftermath, it ramped up both the anxiety and PTSD symptoms. Even as a career therapist with decades of experience treating people with stand-alone anxiety, with no overt PTSD symptoms, I had not considered that remembering the anxiety was re-traumatizing. I have heard clients share that anticipating panic attacks was in and of itself anxiety provoking. For this person and so many others, it is hard to determine the line between the two.
As is the case for many who struggle with this condition, they experienced body memory, flashbacks and tremors, as if the events of the past were recurring. Reminding themselves, “I am here and now, not there and then,” alleviated some of the more intense indicators.
This person is also intent on taking on challenges and resilience is one of their superpowers. Overcoming life changing physical conditions were part of the symbolic exercise equipment that helped them to become stronger and more flexible. They were aware that life events happen, unbidden at times and all they can do is ride the waves, sometimes treading water, until things settle back into place. Having solid support from family, friends and professionals keeps them afloat.
Although it might be hard to acknowledge an upside to anxiety or trauma, this person and others I have encountered in both personal and professional realms have been grateful for accompanying lessons. Keep in mind, that no one is sugar-coating it, nor are they denying the pain. They are making a conscious decision to face what comes their way. Paradoxically, the one certainty of life is uncertainty. A catch-22, since anxiety thrives on unpredictability.
The field of Positive Psychology, which offers a strengths-focused perspective to recovery from traumatic experiences, was pioneered by psychologist Martin Seligman, who directs the Positive Psychology Center at the University of Pennsylvania. One concept in this approach is post-traumatic growth, which reflects counterintuitive responses to horrific circumstances. Research from Lawrence G. Calhoun and Richard G. Tedeschi of the University of North Carolina Charlotte found that survivors of trauma often experienced profound healing, a stronger spiritual faith and philosophical grounding. One powerful reframing is referring to the outcome as Post Traumatic Growth.
When survivors view themselves in that light and additionally as thrivers who give back or pay it forward, rather than as victims who have no choice but to feel as they do, healing is possible. One such thriver is Michele Rosenthal, a keynote speaker, award-winning blogger, award-nominated author, workshop/seminar leader and certified professional coach. Michele is also a trauma survivor who struggled with posttraumatic stress disorder (PTSD) for over twenty-five years. She calls herself Chief Hope Officer (CHO) of Your Life After Trauma, LLC.
Her trauma came in the form of a condition called, ToxicEpidermal Necrolysis Syndrome (TENS), which she describes as “a freak allergy to a medication that turned me into a full-body burn victim almost overnight.” This horror was followed by a series of physiological and psychological conditions that would flatten even the strongest of people. It took years of determination to recover that led her to be symptom free and now she guides others to overcome their own trauma-trials.
What helped her see her way clear to the other side of suffering is what she refers to as a “healing rampage.”
Rosenthal says, “It is an approach to recovery that is, 1) committed — we keep going no matter what; 2) consistent — we work at it every day; 3) creative — we look for new options and healing opportunities; and, 4) complex — we do the deep work rather than skim the surface as we seek relief.
These are important resiliency building skills regardless of diagnosis or symptomology, whether it falls under the umbrella of anxiety or PTSD.
Learn relaxation and breathing techniques to center yourself in the here and now.
Do grounding exercises such as walking barefoot on the grass or sand or tapping the bottoms of your feet.
If possible, avoid people, places or things that may overtly trigger reaction. Some PTSD survivors may steer clear of fireworks or large numbers of people if loud noises or crowds are related to the initial events.
Contemplate an exit strategy if you get inadvertently triggered.
Breathe in relaxing aromas, such as lavender, chamomile, vanilla or bergamot.
Listen to music that is soul soothing.
Seek support from family and friends who may understand your situation and if not, offer a listening presence.
Engage in therapy with a licensed professional.
If medications are indicated, work with a Psychiatrist or CRNP (Certified Registered Nurse Practitioner) who can prescribe.
Attend a self-help group.
Utilize the therapeutic modality of EMDR (Eye Movement Desensitization and Reprocessing).
Exercise, whether it is in a gym, or a dance floor or basketball court assists in moving the energy. I think of emotion as ‘e-motion’ or ‘energy in motion’.
Spend time in nature which is restorative.
Dig in the dirt, and plant seeds for new beginnings.
Avoid self-medicating with drugs, alcohol, gambling, work, shopping or food.
Indulge in healthy hobbies, such as reading, crafts, music, playing board games, putting together puzzles or models.
Volunteer your time in your community.
If you have a spiritual practice, use it as an additional therapeutic modality.
Determine your passion and live it as fully as you can.
Spend time with children and learn how to be silly from them.
The first sign that something is happening is Angelina’s hands. As she chats to the nurse in Italian, she begins to gesticulate, jabbing, moulding and circling the air with her fingers. As the minutes pass and Angelina becomes increasingly animated, I notice a musicality to her voice that I’m sure wasn’t there earlier. The lines in her forehead seem to be softening, and the pursing and stretching of her lips and the crinkling of her eyes tell me as much about her mental state as any interpreter could.Angelina is coming to life, precisely as my body is beginning to shut down. It’s 2am, and we’re sat in the brightly lit kitchen of a Milanese psychiatric ward, eating spaghetti. There’s a dull ache behind my eyes, and I keep on zoning out, but Angelina won’t be going to bed for at least another 17 hours, so I’m steeling myself for a long night. In case I doubted her resolve, Angelina removes her glasses, looks directly at me, and uses her thumbs and forefingers to pull open the wrinkled, grey-tinged skin around her eyes. “Occhi aperti,” she says. Eyes open.This is the second night in three that Angelina has been deliberately deprived of sleep. For a person with bipolar disorder who has spent the past two years in a deep and crippling depression, it may sound like the last thing she needs, but Angelina – and the doctors treating her – hope it will be her salvation. For two decades, Francesco Benedetti, who heads the psychiatry and clinical psychobiology unit at San Raffaele Hospital in Milan, has been investigating so-called wake therapy, in combination with bright light exposure and lithium, as a means of treating depression where drugs have often failed. As a result, psychiatrists in the USA, the UK and other European countries are starting to take notice, launching variations of it in their own clinics. These ‘chronotherapies’ seem to work by kick-starting a sluggish biological clock; in doing so, they’re also shedding new light on the underlying pathology of depression, and on the function of sleep more generally.“Sleep deprivation really has opposite effects in healthy people and those with depression,” says Benedetti. If you’re healthy and you don’t sleep, you’ll feel in a bad mood. But if you’re depressed, it can prompt an immediate improvement in mood, and in cognitive abilities. But, Benedetti adds, there’s a catch: once you go to sleep and catch up on those missed hours of sleep, you’ll have a 95 per cent chance of relapse.The antidepressant effect of sleep deprivation was first published in a report in Germany in 1959. This captured the imagination of a young researcher from Tübingen in Germany, Burkhard Pflug, who investigated the effect in his doctoral thesis and in subsequent studies during the 1970s. By systematically depriving depressed people of sleep, he confirmed that spending a single night awake could jolt them out of depression.
Benedetti became interested in this idea as a young psychiatrist in the early 1990s. Prozac had been launched just a few years earlier, hailing a revolution in the treatment of depression. But such drugs were rarely tested on people with bipolar disorder. Bitter experience has since taught Benedetti that antidepressants are largely ineffective for people with bipolar depression anyway.
His patients were in desperate need of an alternative, and his supervisor, Enrico Smeraldi, had an idea up his sleeve. Having read some of the early papers on wake therapy, he tested their theories on his own patients, with positive results. “We knew it worked,” says Benedetti. “Patients with these terrible histories were getting well immediately. My task was finding a way of making them stay well.”
So he and his colleagues turned to the scientific literature for ideas. A handful of American studies had suggested that lithium might prolong the effect of sleep deprivation, so they investigated that. They found that 65 per cent of patients taking lithium showed a sustained response to sleep deprivation when assessed after three months, compared to just 10 per cent of those not taking the drug.
Since even a short nap could undermine the efficacy of the treatment, they also started searching for new ways of keeping patients awake at night, and drew inspiration from aviation medicine, where bright light was being used to keep pilots alert. This too extended the effects of sleep deprivation, to a similar extent as lithium.
“We decided to give them the whole package, and the effect was brilliant,” says Benedetti. By the late 1990s, they were routinely treating patients with triple chronotherapy: sleep deprivation, lithium and light. The sleep deprivations would occur every other night for a week, and bright light exposure for 30 minutes each morning would be continued for a further two weeks – a protocol they continue to use to this day. “We can think of it not as sleep-depriving people, but as modifying or enlarging the period of the sleep–wake cycle from 24 to 48 hours,” says Benedetti. “People go to bed every two nights, but when they go to bed, they can sleep for as long as they want.”
San Raffaele Hospital first introduced triple chronotherapy in 1996. Since then, it has treated close to a thousand patients with bipolar depression – many of whom had failed to respond to antidepressant drugs. The results speak for themselves: according to the most recent data, 70 per cent of people with drug-resistant bipolar depression responded to triple chronotherapy within the first week, and 55 per cent had a sustained improvement in their depression one month later.
And whereas antidepressants – if they work – can take over a month to have an effect, and can increase the risk of suicide in the meantime, chronotherapy usually produces an immediate and persistent decrease in suicidal thoughts, even after just one night of sleep deprivation.
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Angelina was first diagnosed with bipolar disorder 30 years ago, when she was in her late 30s. The diagnosis followed a period of intense stress: her husband was facing a tribunal at work, and they were worried about having enough money to support themselves and the kids. Angelina fell into a depression that lasted nearly three years. Since then, her mood has oscillated, but she’s down more often than not. She takes an arsenal of drugs – antidepressants, mood stabilisers, anti-anxiety drugs and sleeping tablets – which she dislikes because they make her feel like a patient, even though she acknowledges this is what she is.
If I’d met her three days ago, she says, it’s unlikely I would have recognised her. She didn’t want to do anything, she’d stopped washing her hair or wearing make-up, and she stank. She also felt very pessimistic about the future. After her first night of sleep deprivation, she’d felt more energetic, but this largely subsided after her recovery sleep. Even so, today she felt motivated enough to visit a hairdresser in anticipation of my visit. I compliment her appearance, and she pats her dyed, golden waves, thanking me for noticing.
At 3am, we move to the light room, and entering is like being transported forward to midday. Bright sunlight streams in through the skylights overhead, falling on five armchairs, which are lined up against the wall. This is an illusion, of course – the blue sky and brilliant sun are nothing more than coloured plastic and a very bright light – but the effect is exhilarating nonetheless. I could be sitting on a sun lounger at midday; the only thing missing is the heat.
When I’d interviewed her seven hours earlier, with the help of an interpreter, Angelina’s face had remained expressionless as she’d replied. Now, at 3.20am, she is smiling, and even beginning to initiate a conversation with me in English, which she’d claimed not to speak. By dawn, Angelina’s telling me about the family history she’s started writing, which she’d like to pick up again, and inviting me to stay with her in Sicily.
How could something as simple as staying awake overnight bring about such a transformation? Unpicking the mechanism isn’t straightforward: we still don’t fully understand the nature of depression or the function of sleep, both of which involve multiple areas of the brain. But recent studies have started to yield some insights.
The brain activity of people with depression looks different during sleep and wakefulness than that of healthy people. During the day, wake-promoting signals coming from the circadian system – our internal 24-hour biological clock – are thought to help us resist sleep, with these signals being replaced by sleep-promoting ones at night. Our brain cells work in cycles too, becoming increasingly excitable in response to stimuli during wakefulness, with this excitability dissipating when we sleep. But in people with depression and bipolar disorder, these fluctuations appear dampened or absent.
Depression is also associated with altered daily rhythms of hormone secretion and body temperature, and the more severe the illness, the greater the degree of disruption. Like the sleep signals, these rhythms are also driven by the body’s circadian system, which itself is driven by a set of interacting proteins, encoded by ‘clock genes’ that are expressed in a rhythmic pattern throughout the day. They drive hundreds of different cellular processes, enabling them to keep time with one another and turn on and off. A circadian clock ticks in every cell of your body, including your brain cells, and they are coordinated by an area of the brain called the suprachiasmatic nucleus, which responds to light.
“When people are seriously depressed, their circadian rhythms tend to be very flat; they don’t get the usual response of melatonin rising in the evening, and the cortisol levels are consistently high rather than falling in the evening and the night,” says Steinn Steingrimsson, a psychiatrist at Sahlgrenska University Hospital in Gothenburg, Sweden, who is currently running a trial of wake therapy.
Recovery from depression is associated with a normalisation of these cycles. “I think depression may be one of the consequences of this basic flattening of circadian rhythms and homeostasis in the brain,” says Benedetti. “When we sleep-deprive depressed people, we restore this cyclical process.”
But how does this restoration come about? One possibility is that depressed people simply need added sleep pressure to jump-start a sluggish system. Sleep pressure – our urge to sleep – is thought to arise because of the gradual release of adenosine in the brain. It builds up throughout the day and attaches to adenosine receptors on neurons, making us feel drowsy. Drugs that trigger these receptors have the same effect, whereas drugs that block them – such as caffeine – make us feel more awake.
To investigate whether this process might underpin the antidepressant effects of prolonged wakefulness, researchers at Tufts University in Massachusetts took mice with depression-like symptoms and administered high doses of a compound that triggers adenosine receptors, mimicking what happens during sleep deprivation. After 12 hours, the mice had improved, measured by how long they spent trying to escape when forced to swim or when suspended by their tails.
We also know sleep deprivation does other things to the depressed brain. It prompts changes in the balance of neurotransmitters in areas that help to regulate mood, and it restores normal activity in emotion-processing areas of the brain, strengthening connections between them.
And as Benedetti and his team discovered, if wake therapy kick-starts a sluggish circadian rhythm, lithium and light therapy seem to help maintain it. Lithium has been used as a mood stabiliser for years without anyone really understanding how it works, but we know it boosts the expression of a protein, called Per2, that drives the molecular clock in cells.
Bright light, meanwhile, is known to alter the rhythms of the suprachiasmatic nucleus, as well as boosting activity in emotion-processing areas of the brain more directly. Indeed, the American Psychiatric Association states that light therapy is as effective as most antidepressants in treating non-seasonal depression.
In spite of its promising results against bipolar disorder, wake therapy has been slow to catch on in other countries. “You could be cynical and say it’s because you can’t patent it,” says David Veale, a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust.
Certainly, Benedetti has never been offered pharmaceutical funding to carry out his trials of chronotherapy. Instead, he has – until recently – been reliant on government funding, which is often in short supply. His current research is being funded by the EU. Had he followed the conventional route of accepting industry money to run drug trials with his patients, he quips, he probably wouldn’t be living in a two-bedroom apartment and driving a 1998 Honda Civic.
The bias towards pharmaceutical solutions has kept chronotherapy below the radar for many psychiatrists. “A lot of people just don’t know about it,” says Veale.
It’s also difficult to find a suitable placebo for sleep deprivation or bright light exposure, which means that large, randomised placebo-controlled trials of chronotherapy haven’t been done. Because of this, there’s some scepticism about how well it really works. “While there is increasing interest, I don’t think many treatments based on this approach are yet routinely used – the evidence needs to be better and there are some practical difficulties in implementing things like sleep deprivation,” says John Geddes, a professor of epidemiological psychiatry at the University of Oxford.
Even so, interest in the processes underpinning chronotherapy is beginning to spread. “Insights into the biology of sleep and circadian systems are now providing promising targets for treatment development,” says Geddes. “It goes beyond pharmaceuticals – targeting sleep with psychological treatments might also help or even prevent mental disorders.”
In the UK, the USA, Denmark and Sweden, psychiatrists are investigating chronotherapy as a treatment for general depression. “A lot of the studies that have been done so far have been very small,” says Veale, who is currently planning a feasibility study at Maudsley Hospital in London. “We need to demonstrate that it is feasible and that people can adhere to it.”
So far, what studies there have been have produced mixed results. Klaus Martiny, who researches non-drug methods for treating depression at the University of Copenhagen in Denmark, has published two trials looking at the effects of sleep deprivation, together with daily morning bright light and regular bedtimes, on general depression. In the first study, 75 patients were given the antidepressant duloxetine, in combination with either chronotherapy or daily exercise. After the first week, 41 per cent of the chronotherapy group had experienced a halving of their symptoms, compared to 13 per cent of the exercise group. And at 29 weeks, 62 per cent of the wake therapy patients were symptom-free, compared to 38 per cent of those in the exercise group.
In Martiny’s second study, severely depressed hospital inpatients who had failed to respond to antidepressant drugs were offered the same chronotherapy package as an add-on to the drugs and psychotherapy they were undergoing. After one week, those in the chronotherapy group improved significantly more than the group receiving standard treatment, although in subsequent weeks the control group caught up.
No one has yet compared wake therapy head-to-head with antidepressants; neither has it been tested against bright light therapy and lithium alone. But even if it’s only effective for a minority, many people with depression – and indeed psychiatrists – may find the idea of a drug-free treatment attractive.
“I’m a pill pusher for a living, and it still appeals to me to do something that doesn’t involve pills,” says Jonathan Stewart, a professor of clinical psychiatry at Columbia University in New York, who is currently running a wake therapy trial at New York State Psychiatric Institute.
Unlike Benedetti, Stewart only keeps patients awake for one night: “I couldn’t see a lot of people agreeing to stay in hospital for three nights, and it also requires a lot of nursing and resources,” he says. Instead, he uses something called sleep phase advance, where on the days after a night of sleep deprivation, the time the patient goes to sleep and wakes up is systematically brought forward. So far, Stewart has treated around 20 patients with this protocol, and 12 have shown a response – most of them during the first week.
It may also work as a prophylactic: recent studies suggest that teenagers whose parents set – and manage to enforce – earlier bedtimes are less at risk of depression and suicidal thinking. Like light therapy and sleep deprivation, the precise mechanism is unclear, but researchers suspect a closer fit between sleep time and the natural light–dark cycle is important.
But sleep phase advance has so far failed to hit the mainstream. And, Stewart accepts, it’s not for everybody. “For those for whom it works, it’s a miracle cure. But just as Prozac doesn’t get everyone better who takes it, neither does this,” he says. “My problem is that I have no idea ahead of time who it’s going to help.”
§
Depression can strike anyone, but there’s mounting evidence that genetic variations can disrupt the circadian system to make certain people more vulnerable. Several clock gene variations have been associated with an elevated risk of developing mood disorders.
Stress can then compound the problem. Our response to it is largely mediated through the hormone cortisol, which is under strong circadian control, but cortisol itself also directly influences the timing of our circadian clocks. So if you have a weak clock, the added burden of stress could be enough to tip your system over the edge.
Indeed, you can trigger depressive symptoms in mice by repeatedly exposing them to a noxious stimulus, such as an electric shock, from which they can’t escape – a phenomenon called learned helplessness. In the face of this ongoing stress, the animals eventually just give up and exhibit depression-like behaviours. When David Welsh, a psychiatrist at the University of California, San Diego, analysed the brains of mice that had depressive symptoms, he found disrupted circadian rhythms in two critical areas of the brain’s reward circuit – a system that’s strongly implicated in depression.
But Welsh has also shown that a disturbed circadian system itself can cause depression-like symptoms. When he took healthy mice and knocked out a key clock gene in the brain’s master clock, they looked just like the depressed mice he’d been studying earlier. “They don’t need to learn to be helpless, they are already helpless,” Welsh says.
So if disrupted circadian rhythms are a likely cause of depression, what can be done to prevent rather than treat them? Is it possible to strengthen your circadian clock to increase psychological resilience, rather than remedy depressive symptoms by forgoing sleep?
Martiny thinks so. He is currently testing whether keeping a more regular daily schedule could prevent his depressed inpatients from relapsing once they’ve recovered and are released from the psychiatric ward. “That’s when the trouble usually comes,” he says. “Once they’re discharged their depression gets worse again.”
Peter is a 45-year-old care assistant from Copenhagen who has battled with depression since his early teens. Like Angelina and many others with depression, his first episode followed a period of intense stress and upheaval. His sister, who more or less brought him up, left home when he was 13, leaving him with an uninterested mother and a father who also suffered from severe depression. Soon after that, his father died of cancer – another shock, as he’d kept his prognosis hidden until the week before his death.
Peter’s depression has seen him hospitalised six times, including for a month last April. “In some ways being in hospital is a relief,” he says. However, he feels guilty about the effect it has on his sons, aged seven and nine. “My youngest boy said he cried every night I was in hospital, because I wasn’t there to hug him.”
So when Martiny told Peter about the study he had just started recruiting for, he readily agreed to participate. Dubbed ‘circadian-reinforcement therapy’, the idea is to strengthen people’s circadian rhythms by encouraging regularity in their sleep, wake, meal and exercise times, and pushing them to spend more time outdoors, exposed to daylight.
For four weeks after leaving the psychiatric ward in May, Peter wore a device that tracked his activity and sleep, and he completed regular mood questionnaires. If there was any deviation in his routine, he would receive a phone call to find out what had happened.
When I meet Peter, we joke about the tan lines around his eyes; obviously, he’s been taking the advice seriously. He laughs: “Yes, I’m getting outdoors to the park, and if it’s nice weather, I take my children to the beach, for walks, or to the playground, because then I will get some light, and that improves my mood.”
Those aren’t the only changes he’s made. He now gets up at 6 every morning to help his wife with the children. Even if he’s not hungry he eats breakfast: typically, yoghurt with muesli. He doesn’t take naps and tries to be in bed by 10pm. If Peter does wake up at night, he practises mindfulness – a technique he picked up in hospital.
Martiny pulls up Peter’s data on his computer. It confirms the shift towards earlier sleep and wake times, and shows an improvement in the quality of his sleep, which is mirrored by his mood scores. Immediately after his release from hospital, these averaged around 6 out of 10. But after two weeks they’d risen to consistent 8s or 9s, and one day, he even managed a 10. At the beginning of June, he returned to his job at the care home, where he works 35 hours a week. “Having a routine has really helped me,” he says.
So far, Martiny has recruited 20 patients to his trial, but his target is 120; it’s therefore too soon to know how many will respond the same way as Peter, or indeed, if his psychological health will be maintained. Even so, there’s mounting evidence that good sleep routine can help our mental wellbeing. According to a study published in Lancet Psychiatry in September 2017 – the largest randomised trial of a psychological intervention to date – insomniacs who underwent a ten-week course of cognitive behavioural therapy to address their sleep problems showed sustained reductions in paranoia and hallucinatory experiences as a result. They also experienced improvements in symptoms of depression and anxiety, fewer nightmares, better psychological wellbeing and day-to-day functioning, and they were less likely to experience a depressive episode or anxiety disorder during the course of the trial.
Sleep, routine and daylight. It’s a simple formula, and easy to take for granted. But imagine if it really could reduce the incidence of depression and help people to recover from it more quickly. Not only would it improve the quality of countless lives, it would save health systems money.
In the case of wake therapy, Benedetti cautions that it isn’t something people should try to administer to themselves at home. Particularly for anyone who has bipolar disorder, there’s a risk of it triggering a switch into mania – although in his experience, the risk is smaller than that posed by taking antidepressants. Keeping yourself awake overnight is also difficult, and some patients temporarily slip back into depression or enter a mixed mood state, which can be dangerous. “I want to be there to speak about it to them when it happens,” Benedetti says. Mixed states often precede suicide attempts.
A week after spending the night awake with Angelina, I call Benedetti to check her progress. He tells me that after the third sleep deprivation, she experienced a full remission in her symptoms and returned to Sicily with her husband. That week, they were due to be marking their 50th wedding anniversary. When I’d asked her if she thought her husband would notice any change in her symptoms, she’d said she hoped he’d notice the change in her physical appearance.
Hope. After she has spent more than half her life without it, I suspect its return is the most precious golden anniversary gift of all.
This article first appeared on Mosaic and is republished here under a Creative Commons licence.
