Inside Anorexia: Understanding the Mental & Physical Impacts

Anorexia’s Grip on the Mind & Body 

Anorexia nervosa, more commonly known as anorexia, is an eating disorder marked by significantly low body weight, an extreme fear of weight gain, and a distorted perception of one’s body weight.[1] There are two main subtypes of anorexia: the first includes a restricted diet with extensive weight loss and lack of energy intake, while the second includes binge-purge eating behaviors where the person will combine episodes of excessive eating and self-induced vomiting. Nevertheless, both subtypes are driven by the individual’s motivation to control their weight and shape.[2,3]  

Due to the drastically decreased intake of nutrients of those with anorexia people suffering from the eating disorder can experience a wide range of physical, emotional, and behavioral symptoms including:[4]

• An unrealistic perception of body image or weight

• Fear of becoming fat 

• Thin appearance 

• Frequently skipping meals 

• Irritability 

• Social withdrawal 

• Abnormal blood count 

• Dry and/or yellowing skin 

• Fatigue 

• Eroding teeth from vomiting 

• Excessive exercise 

• Frequently checking mirrors or reflections for perceived flaws  

In recent years, research on the biological causes of anorexia has sharply increased. Researchers have begun focusing on possible genetic factors that may explain why certain individuals are at higher risk for developing anorexia than others. Additionally, certain personality characteristics have been linked to the development of anorexia including those that exhibit obsessive-compulsive tendencies, or those suffering from additional mental illnesses, such as anxiety or depression.[5,6] While males also suffer from anorexia, young girls are increasingly at risk of becoming anorexic due to the emphasis on thinness being equated to beauty, especially within Western culture.[7]

Physiological Effects 

Anorexia can have considerable effects on the human body, and may even become fatal. The major concern for those struggling with this eating disorder is the effects it has on the cardiovascular system, as heart damage is the most common reason for hospitalization in those with anorexia.[8] Moreover, for those suffering from the subtype of anorexia that includes purging, there is a greater risk of depleting the body of electrolytes which are essential in muscle contractions, notably the heartbeat.[9,10] With the restricted consumption of calories, the body is forced to break down its own tissue as fuel, with muscles being some of the first organs to go once fat has already been utilized. The heart also receives less energy leading to a drop in pulse and blood pressure from the lack of expendable energy. Hence there is a major risk for heart failure and mitral valve prolapse, a heart disease that affects the efficacy of the valve between the left heart chambers.[11] 

Another system that comes under concern is the gastrointestinal (GI) tract, especially concerning purging (i.e., forced vomiting or bowel movements). When an individual purges, it can interfere with the normal functioning of the stomach; the constant vomiting can lead to stomach pain and bloating, block the intestines from masses of undigested foods, and lead to nausea, thus perpetuating the feeling of needing to vomit.[12] Additionally, the stomach and esophagus can become worn down by the acid within the stomach, and in some cases rupture. The additional use of laxatives can also cause the individual to be constipated as the long-term restriction of food causes their body to no longer be able to digest food properly. It can also cause the body to become dependent on laxatives to have normal bowel movements.[13]

Many women will lose their menstrual cycle during severe cases of anorexia; this loss is due to the decrease in thyroid hormones that can both stop a woman’s cycle but also lead to bone loss, and a reduction in resting metabolic rate.[14,15] Furthermore, the effects of starvation can lead to high cholesterol levels and a drop in body temperature due to a lack of energy. Malnutrition can also decrease infection-fighting white blood cells making the individual more prone to sickness.[16] These combined factors have led eating disorders to be categorized as one of the deadliest disorders that currently exist.  

Neuropsychological Effects 

A major concern for those suffering from an eating disorder is the prevalence of suicide - roughly one-quarter to one-third of those with an eating disorder have attempted suicide, with 80% of those attempts occurring during depressive episodes.[17] In fact, depression and anxiety are two of the most common comorbid disorders related to anorexia. In a review by Calvo-River et al. (2022) the prevalence rate for depression and anorexia has been reported between 30 and 80%; such a large rate has been proposed due to the lack of studies investigating the relationship between the two pathologies.[18] Anxiety has also been found to have a large prevalence rate as Swinbourne et al. (2012) reported that from the 100 women presenting symptoms of disordered eating, 69% of them reported the onset of anxiety which proceeded to the onset of the eating disorder. From that, the most common anxiety diagnosed was social phobia (42%) and post-traumatic stress disorder (26%).[19] 

In addition, significant effects of anorexia nervosa have also been detected in numerous cognitive and neurological abilities. Due to the decrease in calories consumed by the individual, a person becomes unable to concentrate and often becomes obsessed with food. Additionally, the lack of nutrient intake damages the layer of lipids that are responsible for insulating neurons and allowing for more effective and rapid electrical conduction, thus slowing down signals being sent between neural connections between the brain and the body.[20]

The decrease in neurological function has led to the investigation into the effects anorexia has on numerous neuropsychological variables including:[21-23] 

• Executive Functioning: attention, planning, cognitive flexibility, set shift, mental flexibility 

• Learning: new rule learning, visual learning, verbal learning 

• Memory: verbal memory and nonverbal memory, working memory  

• Verbal Functioning: verbal fluency, verbal inhibition, verbal reasoning 

• Visuospatial Ability: spatial planning, visuospatial representation

• Speed of information processing

Executive functioning has been one of the most well-researched cognitive functions studied concerning anorexia as the effects of starvation have been shown to impair attention, mental flexibility, cognitive function, and decision-making.[24,25] In fact, papers such as Stedal et al (2021), Zakzanis et al. (2010), Grau et al. (2019), and Weider et al. (2014) all highlighted or found significant effects in individual executive functioning. Most notable were those found in Stedal et al. (2021) which discussed the possibility that the duration of illness may be linked to how severe the deficits in neuropsychological functioning are. Young individuals with a shorter duration of illness showed little difference in their performance compared to the typical control group.[26] However, this is in contrast to what has been previously found within adult groups. There is typically an overall low performance in all domains tested, including executive functioning, compared to the control group. Thus, the evidence seems to show that the duration of the eating disorder may be directly related to the negative effects on the brain.[27] Nevertheless, this idea is not the dominant one, as it was found in only four studies analyzed by Stedal et al. (2021) and so more investigation needs to be made into the relationship between the two variables.[28] 

Additionally, the lack of cognitive flexibility in individuals who suffer from anorexia poses a challenge once placed in therapy. Stedal et al. (2021) notes that patients' lack of willingness to change their thinking patterns, paired with increased compulsive behaviors for those who may purge, create reluctance to modify their thinking and eating patterns.[29] Thus, cognitive inflexibility and set cognitive shift can make key parts of therapy such as goal setting, collaboration, and thought experiences a challenge.

Memory has also been shown to be greatly impacted by anorexia nervosa. Zankzanis et al (2010), analyzed 36 different studies comparing the cognitive impairments between those suffering from anorexia nervosa and bulimia nervosa, a type of eating disorder characterized by episodes of binge eating followed by purging. From the 36 studies, a large effect size was found for deficits in decision-making, verbal memory, immediate and long-delay visual memory, and psychomotor speed.[30] The memory deficits were consistent with those highlighted by Aspen, et al. (2014) as eating disorder patients seemed to have a bias for memory of words that related to the body and body shape.[31] 

Misperceptions of body image in the mind constitute another pivotal focus in research on the effects of anorexia. Distortion of body image has been attributed to difficulties in visual perception and may even be linked to alterations in visual memory.[32] As Grau et al. (2019) propose individuals with eating disorders may process and organize information in less time and less efficiently.[33] Additionally, impairments in spatial perception and representation may affect the individual’s idea of what their body truly looks like. Typically, those with anorexia will rate their ideal body figure and figures they think others find more attractive as thinner than their current figure, and also thinner than what they believe they currently look like.[34]

Treatment 

There are multiple forms of treating anorexia nervosa, however, the most widely used for the treatment of eating disorders is Cognitive Behavioral Therapy (CBT). Mainly used with adults suffering from anorexia, the main goal of CBT is to specifically focus on returning the client to regular eating habits and challenging ideals that continue the overvaluation of their shape and weight.[35] CBT pushes the client to challenge their unrealistic thoughts about their appearance, encourages them to stop excessively exercising, and brings them into a space that can reinforce healthier eating habits. 

Conversely, the use of family-based treatment has shown exceptional improvements in adolescents suffering from anorexia, with Lock et al. (2010) citing a full or partial remission rate of 89% for individuals who used this form of therapy to recover from their eating disorder.[36] The gold standard for treating young adults with anorexia,[37] family-based therapy can be conducted with the individual's entire family or just their parents/guardians. Families must be involved in the recovery process of minors due to the fact their support can form as a short-term catalyst to help the recovery process. Additionally, bringing in the family can bring about the implementation of family meal patterns, allowing them and the clinician to suggest and try out methods to return the child’s eating patterns to normal.[38] Muratore & Attia (2021) note that more recently, developments have been made to hold sessions with parents only, as studies have indicated holding parent-focused treatment brings out better remission rates in adolescents.[39]

In addition to predominant methods, acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT) are two new forms of treatment for anorexia on the rise. Both of these treatments emphasize the importance of mindfulness and acceptance during recovery as a way to reduce maladaptive behaviors. A recent pilot study conducted using acceptance and commitment therapy shows improvements in both weight and eating disorder symptoms, which may reduce rehospitalizations after individuals are discharged.[40] 

In more severe cases, individuals may need to attend multiple-day treatment programs typically held in hospitals allowing them access to medical care, individual or group therapy, and nutritional education. Some individuals may choose residential treatment. This treatment option allows individuals to temporarily live in the facilities which can assist those who have been to the hospital many times or show no signs of improvement through conventional avenues or rehabilitation.[41] 

Future Steps

A main issue with investigating the effects of anorexia, and other eating disorders, on individuals is the high rates of comorbid disorders.[42] Grau et al. (2019) reported that in their group of long-duration eating disorder patients, approximately 54-58% presented comorbidities, such as anxiety, depression, personality disorders, or substance use disorders.[43] Thus, more investigation must be made into how these comorbid effects may contribute to or worsen both physiological and neuropsychological effects on individuals with eating disorders. 

Another issue is that many studies have only investigated the effects on adult populations and neglect those of adolescents. Additionally, tests typically used to measure test performance are developed using an adult population, making it more difficult to get an accurate representation when using them on adolescents.[44] Thus, given the high rate of anorexia within youth populations, more accurate research must be done into the effects of eating disorders on adolescent populations and whether those changes in the brain and body can be reversed with time. 

Furthermore, more strides must be taken to diversify the population pool as many studies on this topic have been produced by overlapping authors and/or laboratories.[45] Nevertheless, these findings pose a great insight into the long-lasting changes to the human brain and body for those suffering from anorexia nervosa. 

If you or someone you know is struggling with extreme body shame and/or a difficult relationship with food, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist, or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 Stedal, K., Scherer, R., Touyz, S., Hay, P., & Broomfield, C. (2021). Research Review: Neuropsychological functioning in young anorexia nervosa: A meta‐analysis. Journal of Child Psychology and Psychiatry, 63(6), 616–625. https://doi.org/10.1111/jcpp.13562 

2 Anorexia nervosa - Symptoms and causes - Mayo Clinic. (2018, February 20). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591 

3 National Eating Disorders Association. (2018, February 22). Health consequences. https://www.nationaleatingdisorders.org/health-consequences

4 “Anorexia Nervosa” Mayo Clinic

5 Ibid. 

6 Zakzanis, K. K., Campbell, Z., & Polsinelli, A. J. (2010). Quantitative evidence for distinct cognitive impairment in anorexia nervosa and bulimia nervosa. Journal of Neuropsychology, 4(1), 89–106. https://doi.org/10.1348/174866409x459674

7 “Anorexia Nervosa” Mayo Clinic

8 Northwestern Medicine. (2016). Disordered eating and your heart. Northwestern Medicine. https://www.nm.org/healthbeat/healthy-tips/anorexia-and-your-heart 

9 National Eating Disorders Association. (2018)

10 Northwestern Medicine. (2016)

11 “Anorexia Nervosa” Mayo Clinic

12 National Eating Disorders Association (2018)

13 Ibid. 

14 “Anorexia Nervosa” Mayo Clinic

15 National Eating Disorders Association (2018)

16 Ibid. 

17 Smith, A. R., Zuromski, K. L., & Dodd, D. R. (2018). Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Current Opinion in Psychology, 22, 63–67. https://doi.org/10.1016/j.copsyc.2017.08.023

18 Calvo-Rivera, M. P., Navarrete-Páez, M. I., Bodoano, I., & Gutiérrez-Rojas, L. (2022). Comorbidity between anorexia nervosa and Depressive Disorder: A Narrative review. Psychiatry Investigation, 19(3), 155–163. https://doi.org/10.30773/pi.2021.0188

19 Swinbourne, J., Hunt, C., Abbott, M. J., Russell, J., St Clare, T., & Touyz, S. (2012). The comorbidity between eating disorders and anxiety disorders: Prevalence in an eating disorder sample and anxiety disorder sample. Australian and New Zealand Journal of Psychiatry, 46(2), 118–131. https://doi.org/10.1177/0004867411432071

20 National Eating Disorders Association (2018)

21 Weider, S., Indredavik, M. S., Lydersen, S., & Hestad, K. (2014). Neuropsychological function in patients with anorexia nervosa or bulimia nervosa. International Journal of Eating Disorders, 48(4), 397–405. https://doi.org/10.1002/eat.22283

22 Grau, A., Magallón-Neri, E., Faus, G., & Feixas, G. (2019). Cognitive impairment in eating disorder patients of short and long-term duration: a case-control study. Neuropsychiatric disease and treatment, 15, 1329–1341. https://doi.org/10.2147/NDT.S199927 

23 Ibid.

24 Weider, et al., (2014)

25 Grau et al., (2019)

26 Stedal et al., (2021) 

27 Ibid. 

28 Ibid. 

29 Ibid. 

30 Zakzanis et al., (2010)

31 Aspen, V., Darcy, A., & Lock, J. (2013). A review of attention biases in women with eating disorders. Cognition & Emotion, 27(5), 820–838. https://doi.org/10.1080/02699931.2012.749777

32 Grau et al., (2019)

33 Ibid. 

34 Zakzanis et al., (2010)

35 Muratore, A. F., & Attia, E. (2021). Current therapeutic approaches to anorexia nervosa: state of the art. Clinical Therapeutics, 43(1), 85–94. https://doi.org/10.1016/j.clinthera.2020.11.006 

36 Lock, J., Grange, D. L., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing Family-Based Treatment with Adolescent-Focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025. https://doi.org/10.1001/archgenpsychiatry.2010.128 

37 Muratore & Attia (2021)

38 Ibid. 

39 Ibid. 

40 Ibid. 

41 Eating disorder treatment: Know your options. (2017, July 14). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/eating-disorders/in-depth/eating-disorder-treatment/art-20046234

42 Weider et al., (2014)

43 Grau et al., (2019) 

44 Stedal et al., (2021) 

45 Ibid. 

The Unseen Wounds of Dating Violence on Mental Health

Silent Scars

Dating violence is a pervasive issue that inflicts profound wounds on victims, both visible and hidden. The National Coalition Against Domestic Violence reports that 1 in 3 women and 1 in 4 men have experienced intimate partner physical violence such as slapping, injury and sexual abuse.[1] These issues can be difficult to notice from the outside of a relationship, allowing abuse to continue while mental scars shape victims' psychological and physical well-being. The connections between dating violence, abuse, and mental health shed light on the silent struggles endured by survivors.

The Spectrum of Abuse

Abuse in dating relationships takes on various forms - from physical violence to emotional manipulation, coercion, and even digital harassment. The dynamic that leads to violence in a relationship is a power imbalance when one person gains power and control over the other.[2] This may take the forms of threats, intimidation, financial abuse, stalking and isolation[3] and this multifaceted spectrum of dating violence can leave victims feeling trapped in a cycle of abuse. Dating violence shatters victims' sense of security, trust, and self-worth, planting the seeds for lasting mental health challenges. 

Examples of the warning signs of abusive behaviors include:[4]

• Using force or coercion to initiate sexual activity

• Attempting to isolate one from their family or friends

• Using threats

• Breaking objects, creating noise or yelling to establish intimidation 

• Having a history of abuse in past relationships 

• Expressing control financially (refusing for a partner to work)

• Expressing control over where a partner goes, what they wear, who they speak to...

• Frequent mood swings and shifts when in public compared to in private

• Constant jealousy 

Erosion of Emotional Well-being

The emotional toll inflicted by dating violence relates to poor mental health outcomes. Adolescent dating violence is particularly prevalent (i.e., 1 in 3 adolescents have experienced an abusive or unhealthy relationship) and is a predictor of partner violence as an adult.[5,6] Pérez-Marco et al. (2020) note that adolescents characterized dating violence as psychological, sexist, and verbal types of violence.[7] For example, blackmailing or damaging a partner’s dignity are examples of psychological violence.[8] Further, Piolanti et al. (2023) note that adolescent dating violence contributes to increased risk-taking behaviors such as marijuana and alcohol use, and negative mental health such as victimization, a common result of physical or emotional abuse.[9] These poor outcomes were more common among females when compared to males. Additionally, among 116 married women experiencing domestic abuse, Malik et al. (2021) found that abuse was associated positively with depression, anxiety and stress.[10] Domestic abuse was also related to a decreased quality of life.[11] The constant undercurrent of fear, anxiety, and uncertainty from degradation and physical attacks can erode victims' emotional well-being and even skew the perception of their relationship as being “normal” amidst high psychological distress.

Emotional abuse is related to:[12]

• Social anxiety

• Depression 

• Eating disorders

• Post Traumatic Stress Disorder (PTSD)

• Chronic pain

• Shame

• Self-doubt

• Low self-esteem

• Codependency 

Complex Trauma & Misconceptions of Dating Violence

Exposure to dating violence often inflicts complex trauma, or unique forms of psychological injury that can lead to enduring emotional and mental turmoil. The patterns of abuse – the relentless cycle of tension, explosion, and reconciliation – carve a pattern of fear in victims' minds. Complex trauma can manifest as post-traumatic stress disorder (PTSD), anxiety disorders and depression.[13] From an external perspective, relationship violence is commonly misunderstood as bystanders may question why a victim stays in their violent relationship if they are being abused. It is so easy to ask, “Why don’t they just leave?”[14] However, there is a deep manipulative aspect to dating violence that maintains a harmful cycle.

De Sousa et al. (2023) found that among participants ages 15-22 in relationships, control tactics were predominantly isolation, domination, and emotional manipulation.[15] These controlling dynamics establish heavy power imbalances that lead to both a bystander's and a victim's blindness to the harm of a relationship. For example, an abusive partner may conceal their violent tendencies when in public or around peers, but when in private with their partner, inflict abuse. The victim may even develop learned helplessness, in which they have repeatedly experienced violence and eventually stop resisting or trying to change the uncontrollable circumstance. Additionally, it is common for victims to find comfort in their abusive relationship, as they are manipulated to believe that they abuse because their partner “loves them,” as Shawn Guy writes for Genesis Women’s Shelter in an article about teen dating violence.[16] This occurrence is sometimes referred to as Stockholm syndrome, or the psychological response of a positive connection to an abuser.[17]

The Path to Recovery: Empowerment and Support

Victims of dating violence find it challenging to escape their abusers. Feelings of shame, guilt, and societal stigma can create barriers to seeking help. Additionally, financial dependence and isolation enforced by abusers can make it difficult for victims to end relationships.

Professional help through therapy can help survivors regain a sense of agency and control over their lives to minimize the long-term effects of abuse and trauma. For example, Karakurt et al. (2022) found that cognitive-behavioral therapy (CBT), mindfulness, motivational interviewing and expressive writing have led to successful results in increasing empowerment among women who had experienced intimate partner violence.[18] These modalities lowered stress and depressive symptoms, as well.[19]

Empowerment becomes a sign of hope as victims rebuild their self-worth as Pérez-Marco et al. found that empowerment skills were an effective resource to combat negative outcomes of abuse.[20] Treatment for perpetrators of domestic violence is less researched, but also integral to preventing relationship violence and subsequent mental health challenges. Taking into consideration social, societal and developmental contexts may be involved in methods to address high levels of violence exhibited by abusers as well as equitable access to treatment.[21,22]

Dating violence and abuse result in devastating impacts on victims' mental health, inflicting trauma that may never fully fade without proper intervention. By amplifying awareness, education, and access to mental health resources, society can stand against the silent scars left by dating violence and empower survivors on their journey toward recovery.

If one is experiencing any form of abuse or mental health challenges due to a relationship, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 National Coalition Against Domestic Violence. National Statistics. https://ncadv.org/STATISTICS#:~:text=NATIONAL%20STATISTICS&text=On%20average%2C%20nearly%2020%20people,10%20million%20women%20and%20men.

2 Washington University in St. Louis. (2023). What is Relationship and Dating Violence? https://students.wustl.edu/relationship-dating-violence/

3 Ibid.

4 Ibid.

5 Liz Claiborne Inc and The Family Fund. Teen Dating Abuse 2009 Key Topline Findings. http://nomore.org/wp-content/uploads/2014/12/teen_dating_abuse_2009_key_topline_findings-1.pdf 

6 Piolanti, A., Waller, F., Schmid, I. E., & Foran, H. M. (2023). Long-term Adverse Outcomes Associated With Teen Dating Violence: A Systematic Review. Pediatrics, 151(6), e2022059654. https://doi.org/10.1542/peds.2022-059654 

7 Pérez-Marco, A., Soares, P., Davó-Blanes, M. C., & Vives-Cases, C. (2020). Identifying Types of Dating Violence and Protective Factors among Adolescents in Spain: A Qualitative Analysis of Lights4Violence Materials. International journal of environmental research and public health, 17(7), 2443. https://doi.org/10.3390/ijerph17072443

8 Ibid.

9 Polanti et al. (2023)

10 Malik, M., Munir, N., Ghani, M. U., & Ahmad, N. (2021). Domestic violence and its relationship with depression, anxiety and quality of life: A hidden dilemma of Pakistani women. Pakistan journal of medical sciences, 37(1), 191–194. https://doi.org/10.12669/pjms.37.1.2893

11 Ibid.

12 Telloian, C. (2023, March 23). What Are the Effects of Emotional Abuse? https://psychcentral.com/health/effects-of-emotional-abuse#relationship-impacts 

13 PTSDuk. (2023). Causes of PTSD: Domestic Abuse. https://www.ptsduk.org/what-is-ptsd/causes-of-ptsd/domestic-abuse/

14 Ibid.

15 De Sousa, D., Paradis, A., Fernet, M., Couture, S., & Fortin, A. (2023). "I felt imprisoned": A qualitative exploration of controlling behaviors in adolescent and emerging adult dating relationships. Journal of adolescence, 95(5), 907–921. https://doi.org/10.1002/jad.12163

16 Guy, S. (2020, October 19). When Love is Blind: What Teens Don’t See in an Abusive Relationship. https://www.genesisshelter.org/when-love-is-blind-what-teens-dont-see-in-an-abusive-relationship/

17 Cleveland Clinic. (2022, February 14). Stockholm Syndrome. https://my.clevelandclinic.org/health/diseases/22387-stockholm-syndrome

18 Karakurt, G., Koç, E., Katta, P., Jones, N., & Bolen, S. D. (2022). Treatments for Female Victims of Intimate Partner Violence: Systematic Review and Meta-Analysis. Frontiers in psychology, 13, 793021. https://doi.org/10.3389/fpsyg.2022.793021

19 Ibid.

20 Pérez-Marco, et al. (2020)

21 Oğuztüzün, Ç., Koyutürk, M., & Karakurt, G. (2023). Characterizing Disparities in the Treatment of Intimate Partner Violence. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science, 2023, 408–417. 

22 Wexler D. B. (1999). The broken mirror. A self psychological treatment perspective for relationship violence. The Journal of psychotherapy practice and research, 8(2), 129–141. 

Traumatic Brain Injuries: Why Survivors Face an Increased Risk of Developing Depression and Anxiety

Alleviating the Aftermath of a TBI

Each year, approximately 2.5 million individuals suffer from a traumatic brain injury (TBI) in the United States.[1] As a result of suffering a TBI, individuals can experience a multitude of physical effects, including: mood changes, memory or concentration problems, difficulty sleeping, headaches and fatigue.[2] In addition, individuals who experience a TBI are also more susceptible to developing a mental health disorder. A study conducted by Fann and colleagues in 2004 found that 49% of individuals who suffered a moderate to severe TBI and 36% of those with mild TBI also received a psychiatric diagnosis within a year following their injury. The prevalent comorbidity of traumatic brain injuries and mental health disorders is one that must not be overlooked by physicians and mental health care providers.[3] 

Depression after a TBI: a distinct disease

Depression is one of the most common mental health disorders that TBI survivors face. The heightened risk for depression is largely due to the stress that occurs on the brain following a traumatic injury, such as a TBI. The brain’s neural pathways can become altered with a TBI, causing formally strong and functional pathways within the brain to no longer work properly.[4] How this relates to depression is we rely heavily on these pathways to understand and communicate our own emotions. With damage to these pathways, it becomes difficult to carry out these crucial functions, subsequently leading to an inability to process emotions.[5]

Common symptoms of depression that an individual may face following a traumatic brain injury include:[6]

• Feelings of sadness, emptiness, or hopelessness

• Angry outbursts, irritability or frustration 

• Sleep disturbances

• Tiredness and lack of energy, with small tasks taking extra effort

• Feelings of worthlessness or guilt

• Trouble thinking, concentrating, or decision-making

Anxiety after a TBI

In addition to depression, anxiety is a common problem individuals face after experiencing a traumatic brain injury. Due to the changes that can occur to an individual following their accident, they may feel overwhelmed more easily in situations that previously did not bother them. This can be due to the fact that individuals may struggle to focus, think fast, or process information quickly - so in situations where these tools must be used, they can become easily anxious.[7] It's also important to note that individuals who suffered from anxiety prior to their TBI may find their symptoms have worsened following their accident and more difficult to manage.[8] Common symptoms of anxiety that an individual may experience after a TBI include:[9]

• Feeling nervous, restless, or tense

• Having a sense of impending danger or doom

• Having an increased heart rate

• Breathing rapidly 

• Having trouble sleeping

• Having difficulty controlling worry

Targeted treatments

In order to effectively help treat the depression and anxiety that can occur following a TBI, combination therapy should be used. However, these therapies must be targeted directly to an individual’s TBI. The first treatment course that is often considered when attempting to alleviate the symptoms of depression and anxiety are SSRIs. This class of antidepressants are often used in the treatment of anxiety and depression, and work to increase the amount of serotonin in the brain.[10] The reason why they work so well in the treatment of depression and anxiety after a traumatic brain injury is their dopaminergic effects can help improve cognition in individuals who have suffered a TBI, while also improving their mental state.[11]

In addition to pharmacological interventions, cognitive behavioral therapy (CBT) is extremely effective at helping depression and anxiety in TBI survivors. Cognitive behavioral therapy may be tailored to utilize two things: cognitive restructuring and behavioral activation. Cognitive restructuring helps survivors address and redirect irrational thoughts following their accident, which allows an individual to shift to a more positive mental space.[12] Behavioral activation is a tool used when treating TBI survivors to encourage them to plan activities to improve their mood. This could be as simple as planning a daily walk or as extravagant as a trip away; using this technique allows survivors to look forward to their life again.[13]

Another extremely important treatment in addressing depression and anxiety following a TBI is positive psychology. Positive psychology helps to rewire a survivor's brain and encourage them to use forward, optimistic thinking. This could include simply writing in a journal a gratitude list for the day, or expressing positive thoughts out loud to another individual, daily. This practice has been extremely helpful with survivors' neuroplasticity - the ability of the brain to reform and strengthen neural pathways in the brain. Following a TBI, these pathways can be lost, which is why rewiring these pathways with positive thinking can help alleviate feelings of anxiety and depression.

Overall, it is essential that TBI survivors understand the risk factors for and key signs of anxiety and depression. If you or someone you know would like to learn more about how to seek help alleviating the symptoms of anxiety and depression following a TBI, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. 

Contributed by: Daphne Lasher

Editor: Jennifer (Ghahari) Smith, Ph.D.

references

1 Brain Trauma Foundation. (n.d.). Frequently asked questions (FAQ). Brain Trauma Foundation. https://braintrauma.org/info/faq#:~:text=Each%20year%20about%202.5%20million,Falls%20(28%25)

2 The Mayo Clinic. (2021, February 4). Traumatic brain injury. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557

3 Fann, J. R., Burington, B., Leonetti, A., Jaffe, K., Katon, W. J., & Thompson, R. S. (2004). Psychiatric illness following traumatic brain injury in an adult HealthMaintenance organization population. Archives of General Psychiatry, 61(1), 53. https://doi.org/10.1001/archpsyc.61.1.53

4 Cooney, E. (2023, July 6). Why depression after traumatic brain injury is distinct - and less likely to respond to standard treatment. STAT. https://www.statnews.com/2023/07/06/depression-after-traumatic-brain-injury/

5 Ibid. 

6 The Mayo Clinic. (2022, October 14). Depression (major depressive disorder). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

7 Model System Knowledge Translation Center

8 Ibid.

9 The Mayo Clinic. (2018, May 4). Anxiety disorders. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-20350961

10 The Mayo Clinic. (2019, September 17). The most commonly prescribed type of antidepressant. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825

11 Fann, J. R., Hart, T., & Schomer, K. G. (2009). Treatment for depression after Traumatic Brain Injury: A systematic review. Journal of Neurotrauma, 26(12), 2383–2402. https://doi.org/10.1089/neu.2009.1091

12 Flint Rehab. (2023, January 6). Brain injury and depression: Causes, symptoms, & treatments. Flint Rehab. https://www.flintrehab.com/brain-injury-and-depression/ 

13 Ibid.

The Role of Gratitude in Improving Mental Health

Focusing on the Good 

Gratitude has its foundational roots in the humanities, from ancient philosophical studies, to religious conceptualizations, and evolutionary theories. Though gratitude has traditionally been understood and studied in this way, novel insights, questions, and understandings are being developed under the lens of contemporary scientific research today. In the past few decades gratitude has been studied in increasingly precise contexts, from early childhood education, to prosocial behavior in the workplace and potential for chronic disease treatment. Nevertheless, gratitude is still quite difficult to define. Is it an emotion, a virtue or a behavior? The APA gives a general description of gratitude as part of a wider outlook on life that involves noticing and appreciating the positive aspects of life.[1] Though there are many conceptualizations of gratitude, Emmons & McCullough (2003) defined gratitude in two parts: 1) recognizing that one has obtained a positive outcome and 2) recognizing that there is an external source for this positive outcome.[2]

In general, gratitude has been shown to present a plethora of benefits for one’s mental and physical health. It may foster a more positive mood, induce better sleep, and even lower disease markers and inflammation in the body.[3] Additionally, depressive symptoms, substance abuse, anxiety, chronic pain, and risk of disease may be lowered with the implementation of daily gratitude practices.[4] Cultivating feelings of gratitude through practices of mindfulness and daily journaling can fortify relationships with others as well as increase empathy and prosocial behavior. Overall, expressions and practices of gratitude have been extensively studied for its ability to increase well-being, longevity, and happiness. 

The origins of gratitude 

Though gratitude has often been thought of as merely an intuitive emotion or feeling, there have been key developments in various fields that have led to our increased understanding of gratitude and the ways it can be qualitatively and quantitatively measured. 

Evolutionary: 

The questions surrounding gratitude and its origins can be traced back centuries to evolutionist Darwin. In The Descent of Man (1871), he offers the possibility that humans and other animals share collective emotions, “even the more complex ones such as jealousy, suspicion, emulation, gratitude, and magnanimity.”[5] With this, gratitude may have played a unique role in human social evolution. It has been posited that gratitude is an adaptation for what Robert Trivers first coined as “Reciprocal Altruism” in 1971, or the sequential exchange of costly benefits between non relatives.[6] This is supported by a series of studies by prominent gratitude researchers Mccullough et al. (2008) which explain that a positive feeling of gratitude can alert us to the benefits we’ve received from others and inspire us to show appreciation, which will in turn make others more likely to help us again in the future.[7] The evolutionary advantage is that we become more interconnected and collectively stronger as a society, as strangers become friends and new allyships are created. 

Neurobiological: 

There have also been more recent studies which incorporate systematic ways of studying and measuring the biological origins of gratitude. In one key fMRI based study by Fox et al. (2015), higher ratings of gratitude correlated with increased brain activity in participants’ anterior cingulate cortex and medial prefrontal cortex. Activity in these regions has been linked to moral cognitive processes, social reward and interpersonal bonding, as well as emotion perception and theory of mind. Previously, it was unknown how the brain generated the range of feelings associated with gratitude; however, this study provides a window into gratitudes origins, as well as its relationship to mental health and resilience.[8]   

Factors that contribute to gratitude

Multiple studies have honed in on certain individual factors that may contribute to increased or decreased expressions of gratitude including personality, cognitive factors, and gender. 

1. Personality Traits: Recently, Szcześniak et al. (2020) studied the interaction among personality traits, emotional intelligence, and a grateful disposition. They found that both gratitude and emotional intelligence correlated positively and significantly with extraversion, openness to experience, agreeableness, and conscientiousness. Conversely, gratitude and emotional intelligence correlated negatively and significantly with neuroticism.[9]

2. Cognitive Factors: Certain cognitive factors may also influence the amount of gratitude one feels in a particular situation. Some examples include the perceived intention of the benefactor, the apparent cost to the benefactor, or the value of the gift which vary based on the situation.[10] This differs based on personal experience and background, perception of the situation, and even some larger cultural norms.   

3. Gender: In particular, Kashdan et al. (2009) hypothesized that women possess an advantage over men in experiencing and benefiting from gratitude. In this comparative study of reaction to gift appraisals, women viewed gratitude expression to be exciting and interesting while men were less likely to feel and express gratitude, made more critical evaluations of gratitude, and derived fewer benefits.[11]   

Along with the numerous individual factors which show variance in either lending to or inhibiting expressions of gratitude, there is also a wider discussion on gratitude as it relates to the complex interplay of religion, culture, and social norms. 

1. Religion: Gratitude has often been associated with and studied in conjunction with religion and spirituality. Specifically looking at the United States, a study by Krause (2009) found that more frequent church attendance and stronger God-mediated control beliefs are associated with positive changes in gratitude over time.[12] In accordance with these findings, a more generalized study of intergroup differences conducted by Ferenczi et al. (2021) examined religiousness, gratitude, and well-being over time and found that religiousness is linked to higher gratitude and moreover, an increase in gratitude can result in an increase in subjective well-being.[13] 

2. Culture: Cross cultural research often looks at the difference between individualist and collectivist cultures in the context of behavior, values, practices, and more. Srirangarajan et al. (2020) found evidence that across East Asian and Western cultures, being grateful generally seems to have a similar relationship with a wide variety of psychological variables including but not limited to life-satisfaction, stress and social anxiety, and anger.[14] Another more recent study carried out by Freitas et al. (2022) sampled a participant pool with diverse cultural backgrounds ranging from countries such as China, Brazil, Russia, and Turkey to investigate gratitude as a moral virtue. The main findings indicated that despite the broad array of cultures represented, gratitude as a virtue develops during childhood and is influenced by one's cultural group.[15] 

3. Parenting Style: As gratitude has been shown to have developmental roots, parenting styles and gratitude in children has also been examined. Obeldobel & Kerns (2021) conducted a literature review that showed how children’s gratitude was higher when parents modeled gratitude, there was a more secure parent–child attachment, and parents employed more supportive, autonomy granting, and warm parenting styles. These findings align with attachment theory, social learning and emotion socialization theories, and the find-remind-and-bind theory.[16] 

Individual Benefits 

Researchers have been interested in gratitude particularly in regard to its potential for improving one’s mental and emotional health for decades. Many key mechanisms and rationales for significant findings have been identified and discussed throughout the existing literature. More recent studies, though, have also begun to incorporate physical health and well-being into experimental design. 

1. Improving Physical Health: UCLA Health notes that gratitude supports heart health through the improvement of depression symptoms, increased sleep, improved diet and more frequent exercise - which all reduce the risk of heart disease.[17] Additionally, several studies show that a grateful mindset positively affects biomarkers associated with the risk for heart disease. One recent study by Jans-Beken et al. (2021) sought to provide an updated overview of the literature on the connection of gratitude to human health, specifically focusing on experimental study findings. The researchers state that gratitude interventions appear to positively affect a number of cardiovascular and inflammatory parameters, (e.g., a decrease in diastolic blood pressure with daily gratitude journaling) as well as improving sleep quality.[18] In addition, not only has gratitude journaling been shown to lessen depressive symptoms related to chronic illness, but has been shown to lessen inflammatory chronic disease biomarkers such as HbA1c (which is involved in blood sugar control). This is especially important given that high levels of HbA1c have been associated with chronic kidney disease, a number of cancers, and diabetes.[19] 

2. Improving Well-being: In addition to the evidence of improvements to physical health, many more studies support the idea that a grateful disposition is associated with greater life satisfaction, optimism, subjective well-being, positive affect, and overall happiness.[20] Some mechanisms by which gratitude can positively intervene in one’s life to improve general well-being include counteracting materialism and protecting against burnout. Specifically looking at student culture, Tsang et al. (2014) found that undergraduate students reported less life satisfaction, which could be explained by their lowered levels of gratitude. The study concluded that gratitude played an important mediating role for the negative relationship between materialism and life satisfaction. Grateful people may be less materialistic because they feel more satisfied with their lives - and thus, don’t feel much of a need to acquire new things in order to feel more satisfied.[21] 

3. Treating Mental Illness: While there is clearly strong evidence for gratitude’s role in improving both mental and physical health, several more studies are concentrating on gratitude interventions for specific psychological challenges and the related mechanisms by which these may elicit significant positive changes. 

   Through various meta-analysis and literature review studies, it is now commonly accepted that gratitude can play a key role in improving depressive symptoms. One recent development, though, comes from a study carried out by Tomczyk et al. (2022), examining gratitude and acceptance of illness for women who were at risk for clinical depression. They identified that women with elevated depressive symptoms who were more grateful (compared to those who were less grateful) were more accepting of their condition, which was related to increased well-being and decreased feelings of depression and anxiety.[22] 

   Gratitude can help promote long-term recovery from substance misuse. In particular, the Narcotic Anonymous (NA) program has adopted gratitude as a key component of recovery and urges members to practice gratitude on a daily basis on their journey toward successful recovery.[23] 

   Several more studies have been conducted under the topic of gratitude’s effect on mitigating stress and anxiety disorders, PTSD, and suicidal ideation. For example, Vieselmeyer et al. (2017) looked at the role that gratitude and resilience played in post-traumatic stress. Particularly relevant to contemporary events and the dramatic increase in the prevalence of community trauma like school shootings, these researchers found that people with high trait gratitude four months following the 2014 Seattle Pacific University shooting showed a stronger relationship between post-traumatic stress and post-traumatic growth, implying that very grateful people are also more resilient and willing to adopt a growth mindset post-trauma.[24] Another study by Li et al. (2015) examined the relationship between suicide ideation and gratitude, finding that the odds of suicidal ideation and suicide attempts were lower among adolescents who scored higher on gratitude, and furthermore, these results were mediated by both prevalence of stressful life events and self-esteem.[25]

   Perhaps one of the most widely studied and supported topics related to mental health and gratitude, though, is its effect on stress and depression. A comprehensive study by Wood et al. 2008 examined the direction of the relationships between trait gratitude, perceived social support, stress, and depression during a life transition. The key findings from this study is that gratitude seems to directly foster social support, and to protect people from stress and depression, which has major implications for clinical interventions.[26] 

4. Child/Adolescent Health: The Anxiety and Depression Association of America outlines the mental health benefits of gratitude for kids and teens including improving mood, increasing social connection, reducing suicide risk, and improving sleep. Many of the existing studies on child/adolescent gratitude and mental health examine a specific type of intervention (e.g., gratitude journaling) and its longitudinal effects. For example, one study by Tara et al. (2016) sought out to promote positive psychology evidence-based interventions for use in schools. They found that students who completed the gratitude intervention demonstrated enhanced school belonging and gratitude relative to the control group. Thus, a link was established between gratitude, sense of belonging and well-being for school-aged children.[27] The generalizability of this result, however, may not be definitive. In one gratitude article featured in the Journal of Positive Psychology, Hussong et al. (2018) states that children and adolescents often display wider variance in ways of expressing gratitude. In other words, there are different aspects of gratitude moments (i.e., awareness, thoughts, feelings, and actions) and the way that these facets appear in children.[28]

Social Benefits

A major implication of gratitude is in its social benefits. Studies have looked at how gratitude improves relationships between individuals, enhances productivity in the workplace, boosts well-being among students, and stimulates more helping behavior within collective spaces. Especially relevant to the demanding and highly stressful work environment of healthcare since the Covid-19 pandemic, Kersten et al. (2021) was motivated to investigate the effect of gratitude in mitigating and alleviating the effects of burnout in the workplace. They carried out a study, surveying an international sample of employees, showing a clear negative relationship between work-specific gratitude and disengagement, mediated by Interpersonal Helping Behavior (IHB).[29] 

Similarly, other studies have been interested in the relationship between gratitude and prosocial behavior. Prosocial behavior refers to a range of positive behaviors including positive interactions (e.g., friendly play or peaceful conflict resolutions), altruism (e.g., sharing, offering help), and behaviors that reduce stereotypes.[30]

Zhang (2022) was able to identify a positive relationship between gratitude and adolescents’ prosocial behavior as well as further clarify the mechanism by which the effect operates. Two factors in particular were identified as important to cultivating greater prosocial behavior: the sense of meaning in life and self-esteem. Researchers rationalized that the sense of meaning in life generally refers to an awareness of life goals, tasks, and missions, and hence is intertwined with positive physical and mental health, improved mood, and life satisfaction to promote gratitude and prosocial behavior. Moreover, higher self-esteem is recognized as a key factor in adolescents being more attuned to the behavior of others to then form a positive cognition of themself and others.[31]

Gratitude interventions 

It’s clear that gratitude has been conceptualized in many different ways throughout history and utilized within various disciplines and subfields of psychological study. Because of its applicability, gratitude is extremely well-studied and universally accepted as an intervention which can aid mental health struggles and increase life-satisfaction. From maintaining and improving relationships, fostering a more secure sense of self and well-being, as well as being more attuned to others around us, gratitude is an economical, effective, and comprehensive intervention. What are some ways, then, to cultivate a gratitude practice? 

1. Noting the Positive: One relatively simple practice is “counting blessings” or gratitude journaling (e.g., writing down things one is grateful for either daily or weekly). Another gratitude practice under the same paradigm as journaling is,“mental subtraction.” This activity involves imagining what life would be like if a positive event had not occurred and has been shown to greatly improve mood.[32] 

2. Mindfulness: According to Ochsner Health, mindfulness is defined as paying attention, on purpose, in the present moment, non-judgmentally. To practice mindfulness is simply to invite yourself to where you already are and to experience and acknowledge that moment without judgment or expectation.[33] Mindfulness has been shown to bring emotional regulation, steady attention, and physical healing over the past few decades with the emergence of modern neuroscience and numerous evidence-based studies.[34] While gratitude is central to happiness, mindfulness can help us cultivate it as it enables us to be present with the feelings and sensations of goodness in our life. Like gratitude, mindfulness is a practice which can be practiced daily and refined over time. 

3. Acceptance and Commitment Therapy (ACT): This psychotherapeutic intervention integrates the principles of both acceptance and mindfulness in order to increase flexibility in thinking and outcomes. In addition, this therapy hones in on defusion, engagement with emotions, articulation of life values, self-compassion, mindful gratitude, and stepwise movement in accord with one’s life values.[35] An article from positivepsychology.com states “gratitude is about feeling the right way, about the right things, and at the right time. It is inseparably linked with self-discipline and motivation.” Commitment to action and mindful behavior are both tenets of ACT and will also contribute to a stronger, more consistent gratitude practice.[36] 

Though both mindfulness and ACT are well studied and relatively easy to implement in daily life, there are some factors and limitations that have hindered one’s willingness to adopt practices and express gratitude. These include narcissism, gratitude turning into indebtedness or obligation, and cultural differences and cultural contexts which all affect the way we may experience and perceive gratitude. Generally though, gratitude has been posited as social glue which fortifies relationships. At its most effective, gratitude interventions have been shown to elicit positive changes behaviorally, mentally, and physically. It provides a wealth of benefits to those who commit to this principle as a daily practice and lens through which to view life rather than a short term solution. 

If you or someone you know would like to learn more about how to incorporate gratitude in daily life, learn about mindfulness and ACT, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.  

Contributed by: Kaylin Ong

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 American Psychological Association. (2015, April 9). A grateful heart is a healthier heart [Press release]. https://www.apa.org/news/press/releases/2015/04/grateful-heart 

2 Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377–389. https://doi.org/10.1037/0022-3514.84.2.377 

3 APA (2015) 

4 American Psychological Association. (2012, August 5). Growing up grateful gives teens multiple mental health benefits, new research shows [Press release]. https://www.apa.org/news/press/releases/2012/08/health-benefits 

5 Trivers, R. L. (1971). The Evolution of Reciprocal Altruism. The Quarterly Review of Biology, 46(1), 35–57. http://www.jstor.org/stable/2822435 

6 McCullough, M. E., Kimeldorf, M. B., & Cohen, A. D. (2008). An Adaptation for Altruism: The Social Causes, Social Effects, and Social Evolution of Gratitude. Current Directions in Psychological Science, 17(4), 281–285. https://doi.org/10.1111/j.1467-8721.2008.00590.x

7 Suchak, M. (2017, February 1). The Evolution of Gratitude [Review of The Evolution of Gratitude]. Greater Good Magazine. https://greatergood.berkeley.edu/article/item/the_evolution_of_gratitude 

8 Fox, G. R., Kaplan, J., Damasio, H., & Damasio, A. (2015). Neural correlates of gratitude. Frontiers in psychology, 6, 1491. https://doi.org/10.3389/fpsyg.2015.01491 

9 Szcześniak, M., Rodzeń, W., Malinowska, A., & Kroplewski, Z. (2020). Big Five Personality Traits and Gratitude: The Role of Emotional Intelligence. Psychology Research and Behavior Management, Volume 13, 977–988. https://doi.org/10.2147/prbm.s268643 

10 Allen, S. (2018). The Science of Gratitude. https://ggsc.berkeley.edu/images/uploads/GGSC-JTF_White_Paper-Gratitude-FINAL.pdf?_ga=2.82610261.2142947331.1637096170-1362583773.1634590861 

11 Kashdan, T. B., Mishra, A., Breen, W. E., & Froh, J. J. (2009). Gender Differences in Gratitude: Examining Appraisals, Narratives, the Willingness to Express Emotions, and Changes in Psychological Needs. Journal of Personality, 77(3), 691–730. https://doi.org/10.1111/j.1467-6494.2009.00562.x 

12 Krause, N. (2009). Religious Involvement, Gratitude, and Change in Depressive Symptoms Over Time. International Journal for the Psychology of Religion, 19(3), 155–172. https://doi.org/10.1080/10508610902880204 

13 Ferenczi, A., Tanyi, Z., Mirnics, Z., Kovács, D., Mészáros, V., Hübner, A., & Kövi, Z. (2021). Gratitude, Religiousness and Well-Being. Psychiatria Danubina, 33(Suppl 4), 827–832.https://pubmed.ncbi.nlm.nih.gov/35026809/ 

14 Srirangarajan, T., Oshio, A., Yamaguchi, A., & Akutsu, S. (2020). Cross-Cultural Nomological Network of Gratitude: Findings From Midlife in the United States (MIDUS) and Japan (MIDJA). Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.00571 

15 Freitas, L. B. L., Palhares, F., Cao, H., Liang, Y., Zhou, N., Mokrova, I. L., Lee, S., Payir, A., Kiang, L., Mendonça, S. E., Merçon-Vargas, E. A., O’Brien, L., & Tudge, J. R. H. (2022). How weird is the development of children’s gratitude in the United States? Cross-cultural comparisons. Developmental Psychology. https://doi.org/10.1037/dev0001383 

16 Obeldobel, C. A., & Kerns, K. A. (2021). A literature review of gratitude, parent–child relationships, and well-being in children. Developmental Review, 61, 100948. https://doi.org/10.1016/j.dr.2021.100948 

17 Health benefits of Gratitude. UCLA Health System. (n.d.). https://www.uclahealth.org/news/health-benefits-gratitude   

18 Jans-Beken, L., Jacobs, N., Janssens, M., Peeters, S., Reijnders, J., Lechner, L., & Lataster, J. (2019). Gratitude and health: An updated review. The Journal of Positive Psychology, 15(6), 1–40. https://doi.org/10.1080/17439760.2019.1651888 

19 Allen, S. (2018). The Science of Gratitude. https://ggsc.berkeley.edu/images/uploads/GGSC-JTF_White_Paper-Gratitude-FINAL.pdf?_ga=2.82610261.2142947331.1637096170-1362583773.1634590861 

20 Ibid. 

21 Tsang, J.-A., Carpenter, T. P., Roberts, J. A., Frisch, M. B., & Carlisle, R. D. (2014). Why are materialists less happy? The role of gratitude and need satisfaction in the relationship between materialism and life satisfaction. Personality and Individual Differences, 64, 62–66. https://doi.org/10.1016/j.paid.2014.02.009 

22 Tomczyk, J., Nezlek, J. B., & Krejtz, I. (2022). Gratitude Can Help Women At-Risk for Depression Accept Their Depressive Symptoms, Which Leads to Improved Mental Health. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.878819 

23 Chen, G. (2016). Does gratitude promote recovery from substance misuse? Addiction Research & Theory, 25(2), 121–128. https://doi.org/10.1080/16066359.2016.1212337 

24 Vieselmeyer, J., Holguin, J., & Mezulis, A. (2017). The role of resilience and gratitude in posttraumatic stress and growth following a campus shooting. Psychological Trauma: Theory, Research, Practice, and Policy, 9(1), 62–69. https://doi.org/10.1037/tra0000149 

25 Li, D., Zhang, W., Li, X., Li, N., & Ye, B. (2012). Gratitude and suicidal ideation and suicide attempts among Chinese Adolescents: Direct, mediated, and moderated effects. Journal of Adolescence, 35(1), 55–66. https://doi.org/10.1016/j.adolescence.2011.06.005 

26 Wood, A. M., Maltby, J., Gillett, R., Linley, P. A., & Joseph, S. (2008). The role of gratitude in the development of social support, stress, and depression: Two longitudinal studies. Journal of Research in Personality, 42(4), 854–871. https://doi.org/10.1016/j.jrp.2007.11.003 

27 Diebel, T., Woodcock, C., Cooper, C., & Brignell, C. (2016). Establishing the effectiveness of a gratitude diary intervention on children’s sense of school belonging. Educational and Child Psychology, 33(2), 117–129. https://doi.org/10.53841/bpsecp.2016.33.2.117 

28 Hussong, A. M., Langley, H. A., Thomas, T. E., Coffman, J. L., Halberstadt, A. G., Costanzo, P. R., & Rothenberg, W. A. (2018). Measuring gratitude in children. The Journal of Positive Psychology, 14(5), 563–575. https://doi.org/10.1080/17439760.2018.1497692 

29 Kersten, A., van Woerkom, M., Kooij, D. T. A. M., & Bauwens, R. (2021). Paying Gratitude Forward at Work. Journal of Personnel Psychology. https://doi.org/10.1027/1866-5888/a000296

30 Wright, J. D. (2015). International Encyclopedia of the Social & Behavioral Sciences |ScienceDirect. Sciencedirect.com. https://www.sciencedirect.com/referencework/9780080970875/international-encyclopedia-of-the-social-and-behavioral-sciences 

31 Zhang, D. (2022). The relationship between gratitude and adolescents’ prosocial behavior: A moderated mediation model. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.1024312 

32 Allen (2018) 

33 How Mindfulness and Gratitude Can Improve Your Well-Being | Ochsner Health. Ochsner Health System. https://blog.ochsner.org/articles/giving-thanks-how-mindfulness-and-gratitude-can-improve-your-well-being 

34 Gregoire, C. (2014, March 19). Mind and Body: Jack Kornfield on Gratitude and Mindfulness [Review of Mind and Body: Jack Kornfield on Gratitude and Mindfulness]. Greater Good Magazine. https://greatergood.berkeley.edu/article/item/jack_kornfield_on_gratitude_and_mindfulness 

35 Fradkin, C. (2017). Janina Scarlet: Superhero Therapy: A Hero’s Journey Through Acceptance and Commitment Therapy. Journal of Youth and Adolescence, 46(7), 1629–1632. https://doi.org/10.1007/s10964-017-0658-8 

36 The Neuroscience of Gratitude and How It Affects Anxiety & Grief. (2019, April 9). PositivePsychology.com. https://positivepsychology.com/neuroscience-of-gratitude/#brain-changes 

Understanding Anxious Depression

Double Trouble

Illnesses are considered “comorbid” when a person experiences two or more conditions simultaneously.[1] One of the most common comorbid conditions is anxious depression (i.e., anxiety and depression) where roughly 45-67% of patients with major depressive disorder (MDD) meet criteria for at least one comorbid anxiety disorder and 30-63% of patients with anxiety disorder meet criteria for comorbid MDD.[2] The American Psychiatric Association defines someone as having MDD with anxious distress if they meet the criteria of major depressive disorder plus at least two of five anxiety symptoms (e.g., feeling keyed up or tense, being unusually restless, having trouble concentrating because of worry, having fear that something awful may happen, or feeling that one might lose control of oneself).[3]

How Is Anxious Depression Different?

Anxious depression has a few distinguishing factors from non-anxious depression. A study by Rajkumar R.P. (2022) found that people with comorbid depression and anxiety tend to have an earlier age at the onset of either illness, higher rates of childhood trauma, higher levels of neuroticism, more severe functional impairment, and poorer treatment response.[4] Additionally, people with anxious depression were found to have more frequent episodes of major depression, a higher risk of suicide ideation and previous suicide attempts.[5] Demographically, patients with anxious depression are significantly more likely to be in a primary care setting, female gender, non-single, unemployed, and less educated, according to the NIMH-funded “Sequenced Treatment Alternatives to Relieve Depression” project (STAR*D).[6] Physiologically, a study by Inkster et al. (2011) found that patients with anxious depression had more gray matter in their temporal gyrus compared to those with non-anxious depression.[7]

Reasons For Comorbidity 

Multiple theories explain why the two illnesses co-occur so frequently. One view holds that the two conditions have similar biological mechanisms in the brain, making them more likely to appear together.[8] Another theory states that dysregulation of biological mechanisms (e.g., immune-inflammatory pathways, amygdala, hypothalamic-pituitary-adrenal axis) is the cause.[9] A developmental approach finds that insecure attachment in childhood creates a predisposition to the development of anxious depression.[10] Regarding the environment, theory states that the conditions often present simultaneously when an external stressor or stressors trigger a person.[11] Lastly, there is a diagnostic theory that states since anxiety and depression have many overlapping symptoms (e.g., problems with sleep), people frequently meet the criteria for both diagnoses.[12]

Treatment for Anxious Depression 

The National Alliance on Mental Illness (NAMI) notes that anxious depression is often more challenging to treat due to the illnesses “working together” to cause more intense and persistent symptoms.[13] Thus, individuals may need more specialized treatments to combat their symptoms.[14] For example, if antidepressants prescribed by a psychiatrist improve a person’s mood but not their anxiety, the next step would be to seek a therapist for cognitive behavioral therapy (CBT).[15] 

Various drug therapies are available to help treat anxious depression. An analysis by Choi et al. (2020) revealed that SSRIs were effective in treating anxious depression, benzodiazepines can be used to augment SSRI and treat baseline anxiety, and atypical antipsychotics can be used as augmentation agents for treating major depressive disorder.[16]

If you think you or someone you know may have Anxious Depression, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Salcedo, B. (2018, January 19). The comorbidity of anxiety and depression. NAMI. https://www.nami.org/Blogs/NAMI-Blog/January-2018/The-Comorbidity-of-Anxiety-and-Depression  

2 Choi, K. W., Kim, Y. K., & Jeon, H. J. (2020). Comorbid Anxiety and Depression: Clinical and Conceptual Consideration and Transdiagnostic Treatment. Advances in experimental medicine and biology, 1191, 219–235. https://doi.org/10.1007/978-981-32-9705-0_14

3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

4 Rajkumar R. P. (2022). Comorbid depression and anxiety: Integration of insights from attachment theory and cognitive neuroscience, and their implications for research and treatment. Frontiers in behavioral neuroscience, 16, 1104928. https://doi.org/10.3389/fnbeh.2022.1104928

5 Choi et al., (2020)

6 Fava M, Rush AJ, Alpert JE, Carmin CN, Balasubramani GK, Wisniewski SR, et al. What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: a replication and extension. Can J Psychiatry. 2006;51(13):823–35.

7 Inkster B, Rao AW, Ridler K, Nichols TE, Saemann PG, Auer DP, et al. Structural brain changes in patients with recurrent major depressive disorder presenting with anxiety symptoms. J Neuroimaging. 2011;21(4):375–82

8 Salcedo (2018)

9 Rajkumar (2022)

10 Ibid. 

11 Salcedo (2018)

12 Ibid. 

13 Ibid. 

14 Ibid.

15 Ibid.

16 Choi et al., (2020)

Climate Anxiety: The Psychological Impacts of Climate Change

Are We Doomed?

Climate change refers to long-term changes in the Earth’s weather pattern and temperatures due to increased fossil fuel emissions. Studies have shown that humans have become the leading cause of climate change as the Earth’s surface is now around 1.1°C (2°F) warmer than in the 1800s. While that may not sound like a significant rise, the United Nations notes that it can lead to major environmental changes with catastrophic consequences including water scarcity, flooding, declining biodiversity, severe fires and storms.[1] Such dire warnings and predictions have led to psychological distress about what the future may hold. 

Climate Anxiety

Ecological anxiety (i.e., eco-anxiety) is the psychological discomfort arising from the threat of an ecological disaster, which itself is seen as uncertain or difficult to control. Climate change anxiety falls under the category of eco-anxiety and is explained as “the distress caused by climate change as people become anxious about their future.”[2] Nadarajah et al. (2022) note that climate change has become a source of concern for many international organizations including the United Nations and the World Health Organization (WHO) as they now consider this ecological threat to be the greatest danger to mental health within the next century.[3]  

The consequences humanity is already facing have been shown to have effects on their mental health and well-being. For example, excessive heat has been associated with increased aggression, suicide, and hospitalizations for mental illness. Air pollution caused by fine air particulate matter can lead to cognitive impairment and behavioral problems in vulnerable populations. Extreme heat and severe weather events also pose a greater risk to children’s development due to their thermoregulation not being fully developed and their greater dependency on adults and social support.[4] 

Climate anxiety can be caused due to either direct causes (e.g., trauma resulting from extreme weather events) or indirect causes (e.g., trauma from a perceived threat to the future). These causes can have different impacts on an individual’s symptoms of climate anxiety.  Cognitive-emotional impairments include difficulty sleeping, crying, nightmares, and rumination. Functional-impairments of climate anxiety include the inability to work or socialize with others.[5] Other mental health disorders have been associated with climate-related trauma such as post-traumatic stress disorder (PTSD), depression, anxiety, suicidal thoughts, and survivor guilt. Some individuals can even develop mood disorders or maladaptive eating due to the great uncertainty the future can hold and the intense fear that comes from questioning the future of their existence.[6]

Cross-National Investigation of Climate Anxiety 

While climate anxiety is just beginning to be studied, most research conducted has been done in Western, Educated, Industrialized, Rich Democracies (WEIRD). However, more emphasis is being drawn on the need for worldwide research on how global warming is affecting global populations psychologically. A 2021 study conducted in 50 different countries by Peoples’ Climate Vote found 64% of 1.2 million respondents believed climate change to be a global threat. Additionally, a survey conducted by Yale University in 2021 noted that the majority of people from over 30 countries felt climate change would affect them by either a “moderate amount” or a “great deal”.[7] Further, a 2021 poll conducted by Hickman et al., in the Global South found that Brazil (86%), India (80%), Nigeria (70%), and the Philippines (92%) all indicated high levels of fear for the future. Adversely, Russia reported some of the lowest concerns at 9.6%,[8] but this may be attributed to that population’s lack of climate-related information due to extreme internet/information censorship enacted by their government.[9] 

Due to the great fear of climate change, many studies, such as Ogunbode et al., (2022), have shown a direct relationship between climate anxiety and pro-environmental behaviors, such as supporting climate policies and climate activism. This is especially prominent among European, democratic, affluent countries - as their citizens are likely to have fewer political or financial barriers to expressing their concerns and have more opportunities to learn about global warming and its consequences. Additionally, pro-environmental behaviors are linked with individualist countries, as people feel a greater need to act on their personal beliefs.[10]

Generation Z &the Fear for Their Future 

While most climate anxiety research involves WEIRD countries, a global trend is beginning to emerge in cross-national data: Generation Z (i.e., those born 1997-2012) is more concerned with climate change than the generations before them. The Lancet Planetary Health (2021) conducted a global survey in 10 different countries asking young people (16 to 25 y/o) about their climate anxiety and their reaction to governmental response.[11] From this study, 83% of young people reported they were at least “moderately worried” and 59% reported they were “very worried” about global warming and its threat to the future. Additionally, 45% expressed that their worry affected their daily functioning such as concentrating, working, socializing, eating, and spending time in nature. The study also reveals respondents' fear for their future, with 75% indicating that the “future is frightening” and 56% feeling “humanity is doomed”.[12]

These pessimistic views are understandable, as Generation Z and those after will bear the harsh burden of climate change. A 2021 review by Hickman et al., found Gen-Z and future generations will face extremely high disease risk due to environmental changes. Hickman’s study also examined young people’s view on government response to climate change, and found respondents felt “frustrated by unequal power, betrayed and angry, and disillusioned with authority, drawing battle lines”.[13] The ecological crisis has gotten to the heart of younger populations, with one 16-year-old noting, “I think it’s different for young people. For us the destruction of the planet is personal.”[14] 

Young people have even turned to legal action in the hope of pushing the government to take action on the climate crisis. The case of Juliana v. United States was filed in 2015 after 21 children and young adults (8-19 y/o) asserted the government’s inaction on climate change was violating their right to life, liberty, and property. Additionally, the youth plaintiffs argued it was the government’s duty to protect public groups, which they failed to do as they permitted and encouraged fossil fuel usage.[15] However, in 2020 the case was thrown out stating the issue needed to be raised with the executive and legislative branches of government versus the courts.[16]

Many factors play into why this generation feels more strongly about climate change - the most prominent is media exposure. Younger generations are becoming more exposed to news, images, and reports of environmental disasters due to constant access to the internet and social media from their smartphones, and thus frequently witness the consequences of global warming.[17] Moreover, repeated exposure to negative news on climate change increases their awareness of the threat and increases their anticipation of the consequences. This then leads to additional information-seeking as a reactive behavior to the uncertainty of the future.[18] Finally, the social norms around climate change within younger generations are more pro-environmental, thus giving them a sense of security in their feelings. Ogunbode et al., (2022) add that when people around an individual react to the consequences in a similar way, they feel justified in their behaviors.[19]

Mitigating Climate Anxiety 

While the threat from climate change is a grave concern for many people, there are steps individuals can take to lower their anxiety as well as combat the crisis. Individuals can also decrease their climate anxiety as well as make a difference by supporting pro-environmental behaviors (e.g., saving energy at home, avoiding food waste, and using public transportation) and promoting policies and organizations that push to help the environment.[20] Taking pauses or meditating can also calm certain anxieties people may have about the climate crisis. Mindfulness can allow people to focus on the present moment and learn compassion for themselves and nature. Further, individuals can use contemplative time to reflect on the complexity of climate change, understand change cannot come overnight and can allow them to reflect on the power they hold to enact change and help make a difference. Psychotherapy, particularly cognitive behavioral therapy (CBT), can be useful for people to employ and work through their concerns with a mental health professional.[21] Particular components of CBT that can be useful in combating climate anxiety include:[22] 

• Using problem-solving skills to cope with difficult situations

• Learning to develop a greater sense of confidence in one’s own abilities

• Facing one’s fears instead of avoiding them

• Learning to calm one’s mind and relax one’s body

Additionally, individuals can seek clinicians who practice ecotherapy, or nature therapy, as these practitioners may have a greater awareness of current climate concerns. This is especially useful as ecotherapy focuses on reconnecting with nature and exploring how people’s lives are part of a greater system. If conducted in a group format, ecotherapy allows people to explore their personal relationships with nature as well as share with others their emotions and worries,[23] which can further validate their feelings and help someone feel less alone.

Future Steps 

Although climate anxiety is a relatively new concept, more emphasis needs to be placed on investigating the impacts of climate anxiety on non-WEIRD populations. Additionally, focusing on how different international factors such as education, religion, and region affects people’s feelings towards global warming will allow a better way to educate and create more effective strategies to help slow climate change.[24,25] Moving forward, it is imperative for mental health professionals to continue to develop strategies that allow clients to feel their concerns are being heard, as this phenomenon will only worsen as the consequences of climate change continue to rise. 

If you or someone you know is struggling with depression, hopelessness and/or anxiety regarding climate concerns, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

references

1 United Nations. (n.d.). What is climate change? | United Nations. https://www.un.org/en/climatechange/what-is-climate-change

2 Nadarajah, K., David, J., Brun, L., Bordel, S., Moyon, L., Foll, D. L., Delouvée, S., & Somat, A. (2022b). “We Are Running Out of Time”: Temporal Orientation and Information Seeking as Explanatory Factors of Climate Anxiety among Young People. Psych, 4(3), 560–573. https://doi.org/10.3390/psych4030043

3 Nadarajah et al., (2022)

4 Clayton, S. (2020). Climate anxiety: Psychological responses to climate change. Journal of Anxiety Disorders, 74. https://doi.org/10.1016/j.janxdis.2020.102263

5  Nadarajah et al., (2022)

6 Reyes, M. E. S., Carmen, B. P. B., Luminarias, M. E. P., Mangulabnan, S. a. N. B., & Ogunbode, C. A. (2021). An investigation into the relationship between climate change anxiety and mental health among Gen Z Filipinos. Current Psychology, 42(9), 7448–7456. https://doi.org/10.1007/s12144-021-02099-3 

7 Tam, K., Chan, H., & Clayton, S. (2023b). Climate change anxiety in China, India, Japan, and the United States. Journal of Environmental Psychology, 87, 101991. https://doi.org/10.1016/j.jenvp.2023.101991 

8 Hickman, C., Marks, E., Pihkala, P. P., Clayton, S., Lewandowski, R. J., Mayall, E. E., Wray, B., Mellor, C., & Van Susteren, L. (2021). Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey. The Lancet Planetary Health, 5(12), e863–e873. https://doi.org/10.1016/s2542-5196(21)00278-3

9 Litvinova, D. (2023, May 24). The cyber gulag: How Russia tracks, censors and controls its citizens | AP News. AP News. https://apnews.com/article/russia-crackdown-surveillance-censorship-war-ukraine-internet-dab3663774feb666d6d0025bcd082fba 

10 Ogunbode, C. A., Doran, R., Hanss, D., Ojala, M., Salmela-Aro, K., Van Den Broek, K. L., Bhullar, N., De Aquino, S. D., Marot, T. A., Schermer, J. A., Wlodarczyk, A., Lu, S. L., Jiang, F., Maran, D. A., Yadav, R., Ardi, R., Chegeni, R., Ghanbarian, E., Z and, S., . . . Karasu, M. (2022). Climate anxiety, wellbeing and pro-environmental action: correlates of negative emotional responses to climate change in 32 countries. Journal of Environmental Psychology, 84, 101887. https://doi.org/10.1016/j.jenvp.2022.101887

11 Hickman et al., (2021) 

12 Ibid. 

13 Ibid. 

14 Ibid. 

15 Salas, R. N., Jacobs, W., & Perera, F. P. (2019). The Case of Juliana v. U.S. — Children and the Health Burdens of Climate Change. The New England Journal of Medicine, 380(22), 2085–2087. https://doi.org/10.1056/nejmp1905504

16 Youth climate lawsuit against federal government headed for trial. (2023). Yale E360. https://e360.yale.edu/digest/juliana-youth-climate-lawsuit-trial 

17 Nadarajah et al., (2022)

18 Ibid. 

19 Ogunbode et al., (2022) 

20 Ibid. 

21 Reyes et al., (2021) 

22 What is Cognitive Behavioral Therapy? (2017, July 31). https://www.apa.org. https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral  

23 GoodTherapy Editor Team. (2018, August 15). Ecotherapy/nature therapy. https://www.goodtherapy.org/learn-about-therapy/types/econature-therapy 

24 Tam et al., (2023)

25 Reyes et al., (2021) 

Imposter Syndrome: Mirror, Mirror On the Wall… Am I Worthy of This All?

Drowning in Self-Doubt

 I don’t belong here. I don’t deserve this. I only got this far because I got lucky.  I’m going to fail one day, and then people are going to finally realize what a fraud I am. 

Imposter phenomenon, commonly termed as “Imposter Syndrome,” can drown a person’s mind with self-doubt, fear of failure, and feeling unworthy of their successes. This is a condition that typically affects high-achieving individuals who are unable to internalize their accomplishments, and constantly think of themselves as an “imposter,” or fraud. Instead of attributing their accomplishments to their own efforts and intelligence, they attribute their accomplishments to external factors, such as luck or social support. Despite their objective successes, they focus more heavily on their setbacks, and use those to internally justify the belief that they are a fraud. Currently, there is no formal accepted medical definition for the phenomenon in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or clinical diagnosis for this phenomenon.[1,2]

Competitive environments naturally bring a sense of self-doubt for many, and this often manifests as a healthy amount of stress that allows an individual to adapt and accomplish their goals appropriately. However, what distinguishes those with imposter phenomenon is excessive self-doubt and worry that significantly interferes with mental health and overall well-being. Some levels of stress can drive success and achievement, but it is important to recognize when the cost of one’s mental health becomes too great. 

Prevalence and Notable Characteristics 

Those who suffer from the imposter phenomenon can range across all ages and genders.[3] However, there it has been found to disproportionately affect students, those in the healthcare field, and minority racial/ethnic groups. High pressure and high stake environments tend to reveal and accentuate imposter phenomena in individuals. Minority groups may be predisposed to the imposter phenomenon due to higher psychological stress in educational and workplace experiences compared to their majority counterparts. In particular, minority individuals may face greater financial stress, racial discrimination, and the pressure to pursue higher education as a first-generation student - all of which contribute to the development of the imposter phenomenon.[4] For instance, minority individuals who work or study in predominantly Caucasian environments may already feel as if they do not belong or deserve a place there, leading them to compensate by working much harder than peers to achieve the same goals.

The idea of self-fulfilling prophecy also comes into play in this situation, as a minority individual who is stereotyped as less intelligent or less capable, and is expected to achieve less, is led to act in a certain way that confirms these expectations despite being perfectly capable to surpass expectations.[5] Children from minority families are also often taught they need to work much harder than their White counterparts to reach the same level of success due to systemic discrimination and racism. This familial and societal pressure to achieve contributes heavily to an individual’s development of imposter phenomena, as self-worth becomes internally contingent on external successes.[6] 

The inability to internalize one's successes is also associated with multiple comorbidities, including depression, anxiety, and other psychological health issues. The phenomenon has been commonly researched in population-based evaluations, but there is an unknown true prevalence due to differences in recruitment strategies for these studies. Bravata et al. (2020) note that the prevalence across studies has ranged from 9%-82%.[7] Common characteristics that may be present in those who suffer from imposter phenomenon include:[8]

• Perfectionism

• Super-heroism (e.g., the need to be the best)

• Atychiphobia (e.g., fear of failure)  

• Denial of competence

• Achievemephobia (e.g., fear of success)

• Burnout

• Low self-esteem 

• Excessive comparison to peers 

• Maladaptive personality

To evaluate for imposter phenomenon, the Clance Imposter Phenomenon Scale is highly utilized as a diagnostic tool. The tool contains 20 Likert-scale agree/disagree questions, which have not been externally validated.[9] Examples of some of these questions include:[10]

• “I can give the impression that I’m more competent than I really am.”

• “It’s hard for me to accept compliments or praise about my intelligence or accomplishments.”

• “I’m often afraid that I may fail at a new assignment or undertaking even though I generally do well at what I attempt.”

The Imposter Cycle 

The classic cycle that an individual with imposter phenomenon faces starts with an assignment, duty, obstacle, or another task which requires reaching a certain level of achievement. The individual will then choose one of two paths: over-preparation or procrastination. Those who over-prepare will feel as if they have to work excessively hard, especially harder than those around them, to achieve that goal. Those who procrastinate will feel as if they are an imposter because they are rushed in preparation, and worry that their rushed efforts portray them as a fraud. After the task is completed, and the goal is achieved, they will experience a short sense of success, which is quickly diminished by overwhelming feelings of fear, anxiety, and fraudulence that leads them to repeat the cycle when presented with a new task.[11] This cycle may end up sabotaging their own success, creating an obsession over any small mistake, and working intensely hard to prove they are not a fraud to themselves.[12]

Conquering The Voice in Your Head

Building resilience and overcoming imposter feelings requires active efforts on both the individual’s part, and the environment in which they work or study. For an individual, the medical and behavioral health treatments involve careful evaluation to determine how to target these feelings. Such treatments can include:[13]

• Self-reflection

• Counseling

• Cognitive Behavioral Therapy (CBT)

• Psychotherapy

Individuals must also actively practice gratitude strategies to appreciate their own achievements and work ethic. One way to start is by learning about imposter feelings, and where these negative feelings can derive from. Then, the practice of self-reflection can be used to identify the imposter-related negative feelings. Sharing these feelings with a counselor or therapist, or even trusted friends and family, can help a person gain a better appreciation for their achievements and abilities. Additionally, finding others that share these feelings can bring more solace and safety in one's workplace or academic environment, as building a support network can reduce isolation and loneliness while facing these negative feelings. It is also important to ask for help when needed, especially since many people suffering from imposter feelings believe they are completely alone in their pursuits, and in order to avoid fraudulent feelings, they steer clear from external support.[14] 

Genuinely celebrating each success, instead of simply brushing them off and moving ahead, can help one practice gratitude and internalize their successes, breaking down barriers of self-doubt in the future. Instead of focusing on perfectionism, and aiming for the achievement, take the time to appreciate any progress and efforts to get there. Track your success and remind yourself of your abilities when self-doubt becomes overwhelming. This serves as a way to increase your internal validation.[15] Practice mindfulness, and build a sense of self-worth outside of academic or professional accomplishments. Positive qualities about character and personality are also triumphs to be celebrated and appreciated. Doing so can help build self-compassion, and lean away from basing one's self-worth on how high a test score was achieved or how big of a promotion was obtained. Take time to learn from failures and mistakes, but also remember that behind every large success there is a series of setbacks.[16] Making an organized plan for success is another way to avoid overwhelming yourself and more strategically reaching your goals, one step at a time. Managing anxious imposter feelings can be done by breaking down a larger goal into smaller attainable goals/tasks that allow you to practice consistency in your work and confidence in yourself.[17]

Institutions can also actively reduce imposter feelings for their employees or students by generating a more inclusive and diverse community. This will help encourage minorities to feel more encouraged and comfortable in their environment, leading them to feel more confident with their successes and attempts for success.[18]

The imposter phenomenon can overwhelm a person’s mind and body. Developing healthy coping mechanisms is crucial to maintain a positive psychological state of well-being. After acknowledging one's feelings and practicing self-reflection, a person may make efforts to change their lifestyle to accommodate for such high levels of stress and anxiety due to impostor feelings. This may involve setting new reasonable goals or expectations, rather than aiming for the highest achievement at all times. Unreasonably high goals can hurt chances of success, leaving one feeling more discouraged. Instead, build a momentum for success by making reasonable and attainable goals, and build off of these goals more and more as they continue to be reached. In other words, take it one step at a time. One may choose to find a mentor that can guide them towards their goals, eliminating the feeling of isolation that frequently pairs with imposter feelings. Teaching others what you have learned through your accomplishments can also help internalize your own successes, building confidence in yourself while simultaneously encouraging others.[19]

If one has been feeling increasing symptoms of the imposter phenomenon, and it is impacting daily life and overall mental or physical health, it is recommended to contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance on reducing anxiety and impostor feelings.

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Bravata, D. M., Madhusudhan, D. K., Boroff, M., & Cokley, K. O. (2020, August 24). Commentary: Prevalence, Predictors, and Treatment of Imposter Syndrome: A Systematic Review. Journal of Mental Health and Clinical Psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7174434/ 

2 Huecker, M. R., Shreffler, J., McKeny, P. T., & Davis, D. (2023, April 9). Imposter Phenomenon - statpearls - NCBI Bookshelf. Imposter Phenomenon. https://www.ncbi.nlm.nih.gov/books/NBK585058/  

3 Ibid.

4 Ibid.

5 Palmer, C. (2021, June 1). How to overcome impostor phenomenon. Monitor on Psychology, 52(4). https://www.apa.org/monitor/2021/06/cover-impostor-phenomenon 

6 Weir, K. (n.d.). Feel like a fraud?. American Psychological Association. https://www.apa.org/gradpsych/2013/11/fraud  

7 Bravata, et al. (2020) 

8 Huecker, et al. (2023)

9 Ibid.

10 Clance, P. R., & O'Toole, M. A. (1987). The Imposter Phenomenon: An internal barrier to empowerment and achievement. Women & Therapy, 6(3), 51–64. https://doi.org/10.1300/J015V06N03_05 

11 Ibid. 

12 Munley, K. (2020, December 2). Expert or poser? debunking the psychology behind Imposter Syndrome. ScIU. https://blogs.iu.edu/sciu/2020/11/21/expert-or-poser/  

13 Huecker, et al. (2023)

14 Weir, K. (n.d.). Feel like a fraud?. American Psychological Association. https://www.apa.org/gradpsych/2013/11/fraud  

15 Jaqua, E. E., Nguyen, V., Park, S., & Hanna, M. (2021). Coping With Impostor Syndrome. Family practice management, 28(3), 40. https://pubmed.ncbi.nlm.nih.gov/33973753/ 

16 Palmer (2021) 

17 Munley (2020)

18 Eruteya, K. (2022, January 5). You’re not an imposter. you’re actually pretty amazing. Harvard Business Review. https://hbr.org/2022/01/youre-not-an-imposter-youre-actually-pretty-amazing   

19 Jaqua, et al. (2021) 

Wounds Outside of Combat: Sexual Trauma in the Military

Sexual Violence: A Prevailing Issue

Sexual violence persists within all branches of the armed forces and in recent years, reports of sexual assault and harassment have garnered national attention. Sexual harassment and assault are also more prevalent within the military than in the majority of civilian organizations. While the armed forces progress in addressing this challenging issue, understanding sexual violence in a military context offers a lesser-known perspective on sexual trauma’s challenges.

In 2020, Fort Hood specialist Vanessa Guillen was assaulted and killed by a fellow soldier within her chain-of-command. This event was one of many that year that increased visibility on issues in the armed forces’ efforts against sexual violation. Even before Vanessa Guillen’s murder, the military was under pressure to improve their culture and overcome rampant reports of sexual assault. In 2004, a Department of Defense (DOD) task force aiming to provide resources to sexual assault survivors made recommendations for systematic changes to better support soldiers who experience sexual violence.[1] Those recommendations included developing a central point of accountability and a unified response system.[2] A year later, the military acknowledged that mandating commanders to be notified of crimes of sexual violence was a deterrent to soldiers who feared retaliation from their supervisors, peers, assailant (all of whom have the potential to be the same person) after reporting and removed this requirement.[3] The task force concluded their investigation by creating training on Sexual Assault Prevention and Response (SAPR) that has been led by the SAPR office, headquartered at the Pentagon. In the subsequent decades, the DOD and Department of Veteran Affairs have continued implemented several policies to improve treatment, clarify reporting procedures and provide long-term support to sexual assault victims.[4]

In 2022, public backlash over the discovery of murdered soldiers at Fort Cavazos, Texas spurred the military to add sexual harassment as a crime under the Uniform Code of Military Justice (UCMJ).[5] Still, despite decades of efforts against sexual violence, in the last two fiscal years research conducted by the Department of Veterans’ Affairs reported an increase of soldiers who filed unrestricted reports after being sexual assaulted and/or harassed. According to a fiscal year 2022 report submitted by the Pentagon, the rate of sexual assaults had risen 1% from the previous year.[6] Officials maintain that the increase of sexual assault reports is a positive step toward addressing the cultural problem because it implies that soldiers have less of a fear of retaliation or ostracization.[7] However, for service members, their families and future recruits, this increase potentially signals that the military is still searching for an enduring solution to the corrosive issue of sexual violence.[8] 

Defining Military Sexual Trauma (MST)

Military sexual trauma (MST) is a term used by the armed forces and Veterans Affairs (VA) to refer to sexual harassment and/or sexual assault that occurs in the military. According to the Department of Veterans Affairs, MST is specifically defined as: physical assault of a sexual nature, battery of a sexual nature, or sexual harassment (unsolicited verbal or physical contact of a sexual nature which is threatening in character) which occurred while the former member of the Armed Forces was serving on duty, regardless of duty status or line of duty determination.[9] Unlike other organizations, the VA extends the definition of MST to sexual harassment to encompass both physical and verbal instances of sexual encounters to which service members did not consent.

Specific examples include, but are not limited to:[10]

• Being coerced or pressured into any kind of sexual activity (with the potential fear of negative repercussions if an individual does not consent, or promises any kind of advantage if they engage) 

• Any form of physical contact or action without consent, including when a person is in a state that renders them completely incapable of communicating (e.g., sleeping, sick, intoxicated)

• Being forced to engage in sexual activity through physical harm such as slapping, kicking, punching or assault with any form of a weapon

• Being touched or grabbed in a sexual way during hazing or training

• Any unwanted comments about a person’s body or sexual activities that they perceive to violate a personal boundary

• Sexual advances that are spoken, gestured, sent through the phone or online

Like the DOD, the VA acknowledges sexual harassment with similar gravity to sexual assault, implementing resources such a hotline, victim advocates, and VA police for any individual who seeks resources or wishes to file a report.[11]

Common Symptoms Post-Trauma

After a sexually traumatizing event, veterans experience elevated rates of mental disorders, physical ailments, and difficulty building interpersonal relationships.

Specific impacts on health include:

Mental  

MST survivors have a high lifetime rate of post-traumatic stress disorder (PTSD) for both men at women, at 65% and 45% respectively.[12] Veterans who report MST and have PTSD are also likely to have comorbid major depression, anxiety, eating disorders, and substance use disorders. MST also exacerbates pre-existing mental health conditions, worsening the symptoms of conditions prior to the trauma-inducing event.[13]

Physical

Sexual difficulties, chronic pain and/or gastrointestinal disease are common physical health problems for service members recovering from sexual assault and/or harassment. [14] Survivors’ cognitive function is also impaired - many recovering service members report reduced ability to pay attention, concentrate and remember details.[15]

Interpersonal Relationships  

In some cases, veterans who experienced sexual abuse harbor trust issues and have problems engaging in social activities and intimacy. Struggling to progress out of isolation, many survivors also report difficulties finding or maintaining work after their military service.[16]

Prevalence of MST in Different Groups

Regardless of a person’s socioeconomic gender, ethnicity or identity there is still a chance that they are vulnerable to predatory behavior and sexual violence. Surveys indicate that 1% of active duty men and nearly 5% of active duty women are victimized in any given 12-month period.[17] In another study conducted in 2016, researchers from the University of Mary Washington compiled statistics on veterans reporting military sexual trauma across the following databases: PsycINFO, PubMed, and PILOTS.[18] The results revealed that 15.7% of current military personnel and veterans report MST when the measure includes both harassment and assault.[19] Additionally, 13.9% report MST when the measure assesses only assault and 31.2% report MST when the measure assesses only harassment.[20] Across all military branches MST was significantly higher among veterans who reported using VA healthcare services.[21]

Women

Women are significantly more likely to experience and report MST than their male counterparts.[22] Roughly one-in-three women veterans have told their VA health care provider they experienced sexual harassment or assault while in the military.[23] Women with MST also have higher rates of PTSD than those with other traumas: 60% and 43%, respectfully.[24]

Men

Contrary to common misconceptions, men are also victims of sexual violence. Male service members have a 3.9% likelihood of reporting abuse when the measure includes both harassment and assault, and a 1.9% likelihood when the measure assesses only assault. Fearing judgment and alienation, male victims underreport sexual assault and/or harasment; Rossellini et al. (2017) note the true number of such men might exceed that of women, as men have a much lower rate of reporting to authorities than their female counterparts.[25] 

Ethnic Minorities

Ethnic minorities (particularly women of color) experience MST at greater levels than their Caucasian counterparts, with research conducted in 2023 at Washington University in St. Louis revealing that 21% of ethnic minority female veterans compared with 1% of ethnic minority male veterans have experienced MST.[26] Black women are also the most-likely to delay disclosure of MST.[27]

LGBTQ+

Research at Washington University in St. Louis also discovered that while non-LGBTQ service members report MST at a rate of 14%, those identifying as sexual minorities report MST at nearly twice the rate at 26%.[28] Experiencing the greatest rate of sexual harassment/assault, nearly 1-in-3 transgender service members (30%) report MST. 

Other Demographics

In a 2022 study conducted at Pennsylvania University, researchers found that those who experienced adversity or trauma during childhood were more likely to experience Military Sexual Trauma (MST) during their service (Auman-Bauer 2022).[29]

Other factors that exacerbate a person’s potential to be sexually assaulted or harassed in the military include:

• Age/young adults

• Having a low level of education

• Being unmarried

• Having a lower rank

• Being within their first contract of recently entered service         

Post-Trauma Care & Recovery

Peer support has emerged as a form of treatment that mitigates symptoms of loneliness and isolation, and is a common example of clinical care and support during an MST survivor’s journey through recovery. Organizations like the Women Veterans Network (WoVeN) and Veterans Sisters are examples of peer support with the mission to increase community and connection and provide resources for women veterans.

Penn State University researchers who identified the connection between MST and previous combat experience and childhood trauma propose screening service members prior to leaving the military in order to try to determine how to best treat them.[30] Under this proposal, the military hands the patients’ information off to the VA, to then provide specific trauma-informed care to service members who have experienced trauma as they transition out of active-duty.[31]

The mobile app Beyond MST provides self-help tips, assessments, and skills-based tools to support the health and well-being of MST survivors. Designed by the VA, this app comes at no cost, does not disclose a person’s personal information, and helps service members regain hope and heal.[32]

Post-MST Psychotherapy

The Veterans Affairs Office of Research and Development conducted a study in 2006 to determine which treatment methods were most effective in treating post-MST symptoms.[33] As the researchers determined, treating sexual violence in military settings is unique and departs from clinical approaches to civilian sexual trauma for two reasons: veterans with MST are likely violated by trusted military personnel and victims are often without access to immediate treatment.[34] Although MST treatments continue to evolve, effective therapies include Cognitive Behavorial Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR), and narrative therapy. In certain instances, psychiatrists also prescribe anti-anxiety medication and/or anti-depressants.[35]

Brothers in Arms? Regaining Trust in the Military

As the armed forces continue to work to appeal to a younger generation, the slow improvement with addressing sexual assault has the potential to impact the number and diversity of recruits. In 2021 Secretary of Defense General (Gen.) Lloyd Austin established the Independent Review Commission on Sexual Assault in the Military to improve efforts in accountability, prevention, and victim care.[36] After receiving the commission’s results, Gen. Austin accepted every proposed policy change, and later remarked, “These investments are pivotal to restore the trust of our service members, as well as those considering military service.”[37] The accepted changes include increasing workers within the sexual assault response workforce, including victim advocates and sexual assault response coordinators.

Still, the military has added work to do before it fully controls the sexual assault and harassment within its ranks. In 2013, the investigative documentary The Invisible War earned critical and commercial success for shedding light on the pervasive issue of sexual assault in every military branch.[38] Featuring stories from over 25 soldiers, the documentary was groundbreaking in its final message: a female soldier in combat zones is more likely to be raped by a fellow soldier than killed by enemy fire.[39]

Although the film was made over a decade ago, this statistic still stands, and the victims of sexual assault carry symptoms of PTSD, agoraphobia, and depression - much like their counterparts who endured combat. According to the Rape, Abuse and Incest National Network, these destructive long-term physical, psychological, and social effects of sexual violence on the victims cannot be underestimated, and as veterans integrate into the civilian world, mental illnesses put them at higher risks of homelessness, unemployment, and suicide.[40] Leaders in and outside of the military continue to gain awareness into the emotional and mental impacts of sexual violence. However, the military must not only attempt to eliminate sexual violence by developing new policies and regulations - it must also address the intangible part of its culture that has allowed this violence to persist.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Department of Defense. Task Force Report on Care for Victims of Sexual Assault. National Center on Domestic and Sexual Violence Website. http://www.ncdsv.org/images/DOD_TaskForceReportOnCareForVictimsOfSexualAssault_4-2004.pdf

2 National Resource Center on Domestic Violence (NRCDV). (2021). Sexual violence in the military. NRCDV Website. https://vawnet.org/sc/sexual-violence-military-0

3 Ibid.

4 Ibid.

5 Chappell, B. (2022, January 27). Vanessa Guillen’s murder led the U.S. to deem military sexual harassment a crime. National Public Radio Website. https://www.npr.org/2022/01/27/1076143481/vanessa-guillen-murder-military-sexual-harassment-crime

6 Ware, D. (2023, April 28). Reports of sexual assaults increased in the Navy, Air Force, and Marines in 2022; Army saw a decline. American Legion Website. https://www.legion.org/news/258848/reports-sexual-assaults-increased-navy-air-force-and-marines-2022-army-saw-decline#:~:text=There%20were%208%2C942%20reports%20of,slight%20increase%20from%20last%20year

7 Ibid.

8 U.S. Department of Defense. (2022, September 2). DOD takes measures as sexual assault annual report numbers released. U.S. Department of Defense Website.https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

9  U.S. Congress. (2004). United States Code: Uniform Code of Military Justice, 38 USC 1720D: Counseling and treatment for sexual trauma. Retrieved from the Library of Congress, https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section1720D&num=0&edition=prelim

10 U.S. Department of Veterans Affairs. (2023, May 18). Military Sexual Trauma. U.S. Department of Veterans Affairs Website. https://www.mentalhealth.va.gov/msthome/index.asp

11 U.S. Department of Veterans Affairs. (2022, December 12). VA’s Anti-Harassment and Anti-Sexual Assault Policy. U.S. Department of Affairs Website. https://www.va.gov/stop-harassment/policy/

12 Disabled American Veterans (DAV). (2023). What is Military Sexual Trauma? DAV Website. https://www.dav.org/get-help-now/veteran-topics-resources/military-sexual-trauma-mst/

13 Ibid.

14 Ibid. 

15 Ibid.

16 Ibid.

17 Bicksler, B., Farris, C., Ghosh-Dastidar, B., Jaycox, L.H., Kilpatrick, D., Kistler, S., Street, A., Tanielian, T., Williams, K.H. (2014).Sexual Assault and Sexual Harassment in the U.S. Military. Rand Corporation Website. https://www.rand.org/pubs/research_reports/RR870z2-1.html

18 Wilson L. C. (2018). The Prevalence of Military Sexual Trauma: A Meta-Analysis. Trauma, violence & abuse, 19(5), 584–597. https://doi.org/10.1177/1524838016683459

19 Ibid.

20 Ibid.

21 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

22 Wilson (2018)

23 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

24 Yaeger, D., Himmelfarb, N., Cammack, A., & Mintz, J. (2006). DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. Journal of general internal medicine, 21 Suppl 3(Suppl 3), S65–S69. https://doi.org/10.1111/j.1525-1497.2006.00377.x

25 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

26 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

27 Goldbach, J. T., Schrager, S. M., Mamey, M. R., Klemmer, C., Holloway, I. W., & Castro, C. A. (2023). Development and Validation of the Military Minority Stress Scale. International journal of environmental research and public health, 20(12), 6184. https://doi.org/10.3390/ijerph20126184

28 Ibid.

29 Ibid.

30 Bauer, K.A. (2022, August 24). Military sexual trauma more likely among veterans with prior adversity, trauma. Social Science Research Institute at the University of Pennsylvania Website. https://www.psu.edu/news/social-science-research-institute/story/military-sexual-trauma-more-likely-among-veterans-prior/

31 Ibid.

32 Galovski, T. E., Street, A. E., Creech, S., Lehavot, K., Kelly, U. A., & Yano, E. M. (2022). State of the Knowledge of VA Military Sexual Trauma Research. Journal of general internal medicine, 37(Suppl 3), 825–832. https://doi.org/10.1007/s11606-022-07580-8

33 Goldbach et. al (2023)

34 Suris, A.M. (2006). Treatment for veterans with military sexual trauma. VA Office of Research and Development. https://classic.clinicaltrials.gov/ct2/show/NCT00371644#contactlocation

35 Ibid.

36 U.S. Department of Defense. (2022, September 2). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. Department of Defense Website. https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

37 United States Air Force. (2022, September 5). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. United States Air Force Website. https://www.aflcmc.af.mil/NEWS/Article-Display/Article/3149016/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

38 Huval, R.I. (2013, May 10). Sen Kristen Gillibrand credits The Invisible War with shaping new bill. Public Broadcasting Station Website. https://www.pbs.org/independentlens/blog/sen-gillibrand-credits-the-invisible-war-in-shaping-new-bill/

39 Ibid.

40 Thurston, A. (2022, November 9). Why veterans remain at greater risk of homelessness. The Brink, pioneering research from Boston University Website. https://www.bu.edu/articles/2022/why-veterans-remain-at-greater-risk-of-homelessness/