Audio Essay #12: Anxiety & Depression

What are some of the useful things to know about the experience of anxiety and depression? Can psychoeducation be helpful?

What are ruminations and why might it be useful to take time to acknowledge what thoughts pass through your mind? What are some self-help steps you can take? Alongside my experience working as a psychiatry trainee and the clinicians I've learnt from, these are some books that I think can be helpful:

10 steps to positive living – a very short, easy to read, overview of some core thinking missteps that we all make that can contribute to unhappiness

School of Life – a somewhat more philosophical exploration of life lessons

The Chimp Paradox – a practical, metaphor and exercise based self-exploration  tool .

Finally, I mentioned some studies that I read in preparing for this, here they are (feel free to get in touch if you'd like the PDFs): https://pubmed.ncbi.nlm.nih.gov/30738219/ ; https://www.eif.org.uk/report/adolescent-mental-health-a-systematic-review-on-the-effectiveness-of-school-based-interventions

Audio-essay by   Dr. Anya Borissova. Dr Borissova is an academic core trainee psychiatrist in the South London and Maudsley NHS foundation trust with a special interest in psychotherapy and researching improvements in treating depression.

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Transcript

For today’s audio-essay I’d like to talk about what anxiety and depression can be like to experience, and the role of our thoughts in these conditions. 

Before I get going, I do want to underline again that these are our thoughts on how to answer these questions. We don’t expect to give a definite answer on this podcast - some of this will ring true for you, some of it won’t, but hopefully stimulate some thought and discussion. It’s in no way a replacement for seeking medical advice, but hopefully can complement any information you receive in your treatment. 

In this episode I’ll discuss: 

• What it might feel like to have anxiety/ depression 
• Spend some time thinking about ruminations, what they might be, challenging thoughts, the stickiness and clinginess of anxiety/low mood 
• Thinking about potentially helpful things like your strengths and coping mechanisms

I’ve been wondering about what might be useful to do in the early stages of illness, rather like how we now check people’s blood sugar levels and if they’re a pre-diabetes stage we tell them that things are reversible, lifestyle changes might be all they need to not develop diabetes. With respect to mental health, we talk about psychoeducation as an important intervention, so what might be important to learn with psychoeducation? Are there things that everyone should understand about their mind?

What’s the evidence base for this kind of psychoeducation? I was pleasantly surprised to find out that it exists! There have been a mixture of reviews of original studies that have found that across studies, there is good evidence for instance in young people of teaching social and emotional learning and that this reduces symptoms of depression and anxiety in the short term, as are cognitive behavioural therapy interventions, including in those with minimal but detectable signs of depression. This includes developing skills like emotional identification, articulation and regulation, communication skills, empathy and perspective taking. For young people, evidence on interventions like mindfulness training is mixed – some find a positive impact, otherwise find that there isn’t, motivation may be a key ingredient – if you’re up for doing it, it may well work better than if it’s something your school forces upon you! What seems to have the biggest impact? Active psychoeducation – so getting involved with reading a book which teaches you CBT information, having a discussion with a clinician where you can ask questions, has bigger impacts, but passive psychoeducation – like reading a leaflet – also works! 

So step 1- what kind of things might people experience when we talk about anxiety or depression? I guess an important point to make is that there is a huge range – everything from occasional flashes of feelings that are part of the range of normal human emotion - after all, sadness and worrying have their functions. Butlike many physical illnesses psychiatric conditions can occur as a result of normal processes becoming exaggerated and so these feelings can become serious, constant difficulties that are impacting on day-to-day life. 

Anxiety comes with physical and psychological symptoms. There are different flavours of anxiety – it may come out of nowhere without a clear trigger, it may be very related to being in social situations, like public speaking, or going outside. It may involve feeling hot, sweaty, clammy, heart racing, stomach discomfort, diarrhoea, constipation, feeling really sick (often in the mornings). It may involve feeling scared, like everything is awful, an intense feeling of being on edge, feeling like you’re being judged, feeling like your tongue is too big for your mouth, feeling like everyone thinks you’re stupid or that you’re boring. And it is exhausting – it doesn’t stop with some reassurance or after a bit of time has passed – it can be there all day, perhaps getting slightly better towards the evening, or feeling OK on waking but getting worse as the day goes on.  

It may get strong really quickly with a whole concoction of physical symptoms and also feeling like you’re going to die – like in a panic attack. 

Anxiety can be really closely linked with depression symptoms, or they can be totally separate. For a number of people though they do come quite hand in hand, sometimes after some days of high anxiety people notice that their mood dips, their sleep gets worse, they’ve lost their appetite, they can’t enjoy anything- even things that they used to like. This may happen in response to something stressful that’s happened, or it can come out nowhere, amidst feeling ok. People might feel like because their mind is racing, or whirring around worries, or that they’re so stuck in feeling low, that they can’t concentrate on anything, they can’t keep track of conversations with others around them. Equally, everyone might seem just really annoying and irritating – even people they got on with quite fine before. Getting out of bed may well be struggle, or having any drive to do anything. It can feel like walking through treacle, or having the flu – absolutely impossible to find energy to do anything. They might be thinking quite badly of themselves – why can’t I just focus, why can’t I get on with anyone, why can’t I do what everyone else does, I’m useless, why would anyone like me and may become a stronger more ingrained negative thought that goes round and round. This may all get so hard that actually people just don’t feel anything. They’re not even sad – they’re indifferent. Nothing matters, and sometimes it can feel like it’s not worth being alive anymore, or that everyone else would be better off without them. Sometimes harming oneself is used to try to deal with the mental pain, to distract from it, or to feel something, sometimes it’s an attempt to end life. 

At the more severe ends of both of these – receiving some explanations for the experience might help to feel less alone – but I don’t think it will in any way be enough to help treat – so always speak to a professional. 

If things aren’t at that end though, it may be helpful to have a bit more of a think on if anything rings true or seems familiar. As a first point, it might be helpful to notice what your emotions are, develop some awareness of how you feel at particular moments. Check out Alex’s Podcast on ‘Emotions’ if it feels tricky to even know what different emotions might be. No wonder- we never really learn how to be aware of our emotions or what they are. It might be helpful to notice if there are situations that bring on anxiety in particular, or patterns of negative thoughts that pass through your mind and darken your mood without you being quite aware why. This can be called ‘developing emotional literacy’, and some psychoanalytic theories say that parents naturally do this with children, but it can be disrupted for any number of reasons, and then therapy may have a role in developing this literacy. 

If there are loops of thoughts that you get into – again it might be helpful to notice, rather than them carrying you away without you being quite aware of it. You may notice on closer inspection that the thoughts occur spontaneously - rather than us actively thinking them. For instance, walking into a social situation and thinking ‘I’m ugly, I’m terrible at making conversation, I’m so boring, why would anyone want to talk to me, this’ll be awful’ might be a full movie script running at the back of your mind. If you notice – you might be able to challenge it. You might be able to say ‘Well, I may or may not be attractive to everyone, but I know unattractive people and it doesn’t have to make a difference to their life. I don’t like making conversation with new people, but sometimes I manage to make a go of it. Even when I haven’t – I’ve never died or had anything awful happen to me.’ You might get to making a joke out of it – ‘Well, I guess I’m really worried about all this because in the jungle it would be awful to be outcast from the group – but nowadays I’m not going to starve to death just because the leader of the pack doesn’t find me scintillating!’ You MAY even use it as an ice-breaker – ‘Anyone else feeling like the floor’s about to fall out from under them because they don’t know anyone?’ and discover that everyone’s a bit caught up in their own head. We can call these loops of negative, un-productive thought ‘ruminations’ – like a cow that chews grass over and over again without much movement forward. Ruminations can make us feel stuck, frustrated, and convinced that the inability to resolve the problem they’re telling us about is true, that we are worthless and hopeless and incapable of achieving what we want. But one thing that is certain in life is that there are very few certainties, and everything at some point will change or end – be it a good time or a bad time. 

One trick of anxious thought or ruminations is that they feel incredibly real and true. Fortunately, this is usually not the case. They’re up to being challenged – and this is a skill that you may develop with CBT. It’ll work with you to identify a negative thought, because the theory is that the negative thought will generate a negative feeling or an emotion, in a powerful cycle that can be equally powerfully broken down. Training yourself to distinguish between your thoughts about reality and reality itself

CBT teaches that thoughts emotional states and behaviour are all inter-related and teaches you how to change your thinking and behaviour in particular but also how to manage different emotional states.

Anxious thoughts or ruminations are also quite good at clinging to any situation you’re in. It may well be that something has just triggered some anxious emotions or some sadness. But that anxiety or sadness may avalanche and the reason you’re feeling that way is because your boss gave you some hard feedback, you’ve got lots of deadlines, your friends are being difficult, how will you ever manage to get on top of all the tasks you’ve got, you’re not going to manage to pay rent this month… these are all problems, of course, but in a good moment probably problems that you’re up to solving - in a bad moment, your mind may make them into a catastrophe. Anxiety or low mood might amplify them, or make them seem like the cause. 

A converse to identifying your negative thoughts and ruminations, may be to also spend some time reflecting on what makes you happy, what makes you who you are. What are the things that drive you, motivate you, bring you satisfaction? Are they the things you are filling your life with at the moment? Or are there changes that your life could benefit from? Covid lockdown seemed to be a real catalyst for this for some people – but for others, the stress of the whole lockdown situation, coming out of it, may have actually been a trigger for emotional difficulties. So have a think of what your strengths are, what do you believe in yourself for, what might you be grateful for? And use these as fodder for the challenging of the negative thoughts. 

Once you’ve got a bit more knowledge and understanding of yourself, your emotions, you may also think about what kind of attitude you might want to cultivate. Negative emotions are normal and part of life - often though NOT ALWAYS they can be useful and important signals from the world that can help you move forward. Life is just really really frustrating sometimes. Can you encourage yourself to accept negative emotions? To accept that sometimes things will be really rough but actually you know you CAN tolerate it, you know it will pass, and you know that your strengths are so you can do it – it isn’t all awful. Or in some cases, can you use them to inform what changes you might need to make? 
 

With time, you may also find that actually you have some choice and control of what happens with your emotions. You might find that you can take some time before yelling at your parent or your friend, or hitting them – you’ve got an awareness of being irritable or angry, so you can step out, and then avoid the aftermath of feeling even worse about yourself. Or, you might be aware that you are feeling really anxious about meeting friends – you might give yourself some compassion, you might share that with a friend, allow them to comfort and reassure you – and perhaps go to meet them after all. Paradoxically vulnerability is a sign of strength, your mind will often interpret your willingness to be vulnerable as a sign the environment is safe, particularly if your vulnerabilities are accepted by the people around you. Or even if you decide to not go – instead of going into feeling awful about yourself for this you may be allow some of their and your own compassion to fill your mind instead. 

This point about reaching out to someone or being honest about how you feel takes me into thinking about coping strategies. The reality is that no one can sort out for you how you feel. Not the best therapist in the world, not your parent or best friend. What hopefully they can do is stand by your side, and help pick you back up, whilst you go on this journey of figuring out what helps you or what doesn’t. You may find that there are particular friends who are really supportive, or help you refocus or think about situations in a refreshing way – have them on your speed-dial. Through some self-reflection, you may figure out what kind of situations are contributing to anxiety and you may then think about breaking them down into manageable chunks and exposing yourself to these situations little by little. It may be essential to identify what is contributing to your difficult emotions and attempt to change these things in a manageable, consistent way. 

You may find there’s a TV show or music or podcast that’s particularly comforting. You may find you need to get physical and give yourself some warmth – get a nice handcream and give yourself a hand or a foot massage. You might be someone who needs a really solid bedtime routine and regularity and the right amount of sleep. You may need physical activity, or art, or moments in nature. It may be impossible to fit any of these into the hecticness of your life right now – so maybe it’s 5 minutes on the tube or bus between jobs that you sit and you put your phone away and look out the window, or watch a relaxing tv show rather than scrolling. 

So in summary, the things I’ve talked about is a bit about how anxiety and depression might feel. I’ve talked about what we mean by ruminations or negative thoughts, and the idea of challenging them. I’ve also talked about taking some time to get to know yourself and identifying what is important to you. I’ve also touched on starting to think about coping mechanisms or distractions.