It’s hard to build up the motivation and courage to keep trying when tension, stomach aches, lethargy, and panicky sensations get in the way of living how you want to be living.

The symptoms of your emotional disorder may challenge your courage. Your anxiety disorder itself tells you that it’s better to avoid. It says that the event isn’t worth the stress or it’s better to reassure the anxiety away than to risk it interrupting your life. The voice of depression might badger you with doubts about your own worthiness and whether it is worth it to keep trying. Anxiety and depression are exhausting to cope with and exhausting to overcome.

Viktor Frankl, the esteemed psychiatrist who survived a concentration camp during the Holocaust, believed that one who has a ‘why’ to live can endure almost any ‘how.’ Anxiety and mood disorders often result in people questioning, why did this happen to me? Another reaction to an anxiety or mood disorder can be, why will I survive and thrive with this?

To survive and thrive, you need a plan your symptoms and their triggers.

Anhedonia Anhedonia is the word for loss of interest in activities you usually find pleasurable and it is a prominent symptom of depression. It is not your fault. It isn’t a problem with your work or your loved ones. It isn’t your character and it won’t last forever. Anhedonia is the consequence of a chemical change in your brain. Your brain chemistry changes after prolonged strong, painful feelings plus secondary interpretations that you are helpless, hopeless and worthless because of them.

Understand and plan for the direction of your mood disorder. In some instances, biological factors change your mood first. Whether its sleep deprivation, hormonal factors, dietary factors, seasonal factors, or factors we don’t quite understand, biological mood symptoms can start to change your perception such that psychological, behavioral, and social factors also change. In other instances, psychological, behavioral, and social factors change first and the biological mood symptoms follow. Biological symptoms include bodily tension, headaches, stomach aches, vague pain, lethargy, and fatigue. Psychological factors include changes in focus, concentration, and motivation and painful feelings, such as guilt, despair, helplessness, irritability, anger, shame, and worthlessness. Behavioral factors include withdrawal and isolation, anger outbursts, and distraction from your internal experience. Social factors include trauma or catastrophe, discrimination, interpersonal issues, or chronic stress.

Act efficacious. Your biological symptoms of tension, headaches, stomach aches, pain, and lethargy will make it hard to do anything. Days that you feel depressed don’t need to be your best days. Just do anything that challenges your depression. Most people naturally slow down when they are physically sick and don’t feel shame about it. Your symptoms of depression are real and you don’t deserve to feel shame about them. With your behavior, you have to do enough to show your body that what its feeling isn’t true and you have to give yourself credit for whatever you do.

Try making plans like:

No matter how I feel, I get up in the morning when my alarm goes off and I make my bed.

Whenever I feel worthless, I go for a walk.

When I feel hopeless, I cook this specific nutritious meal that I enjoy.

Depression is an illness. It’s the combination of biological sensitivities plus psychological and social factors that reinforce those sensitivities. It is treatable and you can recover. Identify the symptoms of your depression, plan for it, and act efficaciously despite how you feel. I hope your process shows you strength that you didn’t know you have.

What does your depression sound and feel like? It’s important to hold onto the fact that depression isn’t the real you and it won’t last forever. If you’ve felt very depressed for a long time, it can be hard to access the real you. Listening to how other people describe depression can help you identify symptoms that you may have. Here’s an example of what depression can sound and feel like:

• I am sad, tearful, and ruminative.

• I feel unlovable, worthless, and shame about who I am and my decisions.

• I feel guilty and self-critical about past mistakes.

• I sometimes become afraid of my thoughts and memories and have panic attacks.

• I have social anxiety and fear of what others think of me.

• The only thing I can do is work and it’s hard to keep it up.

• I don’t want to socialize. I want to withdraw.

• When I’m socializing, I can’t think of anything to say and it gives me anxiety.

• I need 9+ hours of sleep.

• Food is my only source of pleasure.

• I’m not interested in sex.

• I can’t concentrate and it’s hard to work or to read.

• My mind is sticky and I have intrusive thoughts.

• My thinking is really slow.

• I don’t have new ideas or interests in new ideas.

• I’m not interested in what would usually be fun.

• I can’t stay awake, even after a full night of sleep.

• My attitude is totally serious, with no lightness to it.

• I don’t have any energy.

• I feel tired, demoralized, and hopeless about the future.

• It’s an effort to talk.

• I can’t concentrate enough to make decisions.

• I’m overly concerned for others to the point of inflated responsibility.

• I get existential and think constantly about the meaning of life and death.

• My functioning is forced.

Rumination is a repetitive negative thinking state that is triggered by pervasive negative beliefs. It is a sticky thinking pattern that shows up habitually when triggered by certain environmental or internal states.

Pervasive negative beliefs and rumination

High anxiety isn’t the consequence of lots and lots of anxiety, but rather an anxiety state plus a secondary interpretation of the state as a threat itself (also called second fear). Similarly, depression isn’t lots and lots of sadness, but rather an uncomfortable feeling (like sadness, guilt, loneliness, anger) plus an interpretation of that feeling that you are hopeless, helpless, or worthless because of it.

As an example, everyone feels lonely sometimes. Loneliness can be a clean or clear emotion if you notice it, and think, everyone feels this way sometimes. It’s painful to feel isolated and disconnected. If you don’t add any more to that, the feeling is likely to peak and pass or to give you information on an action that might be beneficial for you, like reaching out to a friend.

A more common experience of loneliness is that when the feeling of loneliness shows up, you think, what is wrong with me? why do I always feel this way? I’m such a loser for feeling like this… These thoughts are likely to trigger feelings of hopelessness, helplessness, or worthlessness. Specifically,

Helplessness – There’s nothing I can do to make this better.

Hopelessness – Things will always be this way.

Worthlessness – This is because of me. I am worthless and unlovable.

Behavioral activation is the main intervention for these types of thoughts and feelings because I want to give your body and mind the opposite experience. I want you to experience: Things in my life change. My life can change based on my actions. People like me and I feel connected to them when I take effective action.

That said, I am aware that worthlessness often feels like a blanket. If you are starting to or have lost interest in activities you usually find pleasurable, it is the feeling of worthlessness that is clouding your interest. You often have to act as though you aren’t feeling hopeless, helpless, or worthless over and over until those feelings actually fade (just like doing lots of anxiety exposures).

What can we learn about rumination from worry?

Rumination is to the past what worry is to the future. When anxious, you are prone to ask, what if? When hopeless, helpless, or worthless, you are likely prone to ask why? You will have the urge to replay past memories in an attempt to figure out why you feel the way you do, and whether or not you deserve it. This is called rumination.

Worry is a repetitive negative thinking state triggered by anxiety sensitivity and intolerance of uncertainty (and often other mechanisms too). When you perceive a threat, your body experiences fight-or-flight sensations and catastrophic future-oriented thoughts. To overcome worry, you have to predict that it is coming and then be ready to get distance from your catastrophic thoughts. If when a “what-if” thought shows up, you engage it and keep it going, you are going to fall into a worry spiral.

We want to learn to use the same skills with the urge to ruminate. That is, we want to try to predict the triggers that provoke feelings of hopelessness, helplessness, and worthlessness, and then have a plan for redirecting your attention back to the present moment, rather than ruminating about the past.

What’s the difference between rumination and introspection?

Introspection is a chosen thinking state. Like choosing to be in a conversation with a friend and choosing to either discuss a certain topic or change the topic, introspection is a chosen conversation with yourself. You can keep it going or choose to think about something else. You don’t need to figure out whatever you are thinking about at the moment. Reflective introspection starts and stops based on your decision.

Reflective introspection is different than rumination the way that problem solving is different than worrying. During both reflective introspection and problem-solving, you are choosing to bring your attention to the relevant topics and your attitude towards them is one of curiosity and hopefulness. Put differently, attempting to problem-solve or reflect assumes that your action will have positive consequences. It is an assumption of hope.

Overcoming rumination

Here’s the plan for overcoming rumination:

● Self-monitor to figure out what triggers feelings of hopelessness, helplessness, or worthlessness.

● Use behavioral activation to redirect yourself to the present moment when depression zaps your energy.

● Write out the memories that your mind often uses against you when you are ruminating.

● Make a plan to discuss content about which you actually feel hopeless, helpless, or worthless in therapy.

We can’t prevent feelings like sadness, loneliness, guilt, or anger from arising, but we can work on how we respond to those feelings. You are on your way towards overcoming depression if when you feel these feelings, you challenge the urge to ruminate in both your thoughts and your actions.