Author: NeuroAffective-CBT by Daniel Mirea

Daniel Mirea is an accredited CBT psychotherapist, a senior lecturer and a clinical supervisor who trained and also trains in different cognitive and behavioural approaches including traditional-CBT, Compassion Focused Therapy, Cognitive-Behavioural Hypnosis, EMDR, Schema Therapy, Mindfulness (MBCT), Dialectical Behaviour Therapy or ACT. With a career spanning over 35 years in the mental health field, Daniel dotted many 'i's and crossed many 't's in the fields of mental health, forensic psychology or substance misuse clinics as a clinical head, clinical supervisor or trainer. Daniel Mirea always felt drawn towards complex cases of low self-esteem and childhood trauma but also at the other end of the spectrum by the prospect of enhancing performance and abilities through a positive mindset. As such, over the years he developed a few behavioural approaches including and especially Neuroaffective-CBT for chronic feelings of shame, Emotion-Focused CBT for interpersonal problems and Sports-CBT for enhancing performance in sports. Through this website Daniel Mirea will attempt to share some of his clinical experience, research findings with you but also his passion for the human mind in general, his findings will never cease to surprise...

The Transdiagnostic Application of NeuroAffective-CBT: A Case Study of Chronic Stress and Burnout

NeuroAffective-CBT by Daniel Mirea

Dr Marco Cortez (UKCP, MBACP)

Abstract

This case report describes the application of NeuroAffective-CBT® (NA-CBT®) with a single working mother, Susan, presenting with chronic stress, shame-organised self-criticism, affective instability, and fluctuating anxiety and low mood. The article may be relevant for clinicians working with clients who ‘understand their patterns’ cognitively but struggle to sustain regulation under stress.

Although Susan demonstrated motivation and cognitive insight consistent with traditional CBT, therapeutic progress was initially constrained by physiological dysregulation and entrenched affective patterns. NA-CBT was therefore selected for its neurobiologically informed, transdiagnostic framework (Mirea, 2018). Central to the intervention were the Pendulum-Effect formulation and the TED (Tired–Exercise–Diet) module, which supported affect regulation and consolidation of learning. Outcomes indicate improvements in emotional stability, behavioural consistency, and self-compassion. The case highlights both the clinical utility and the limitations of NA-CBT within a time-limited therapeutic context characterised by ongoing psychosocial stress.

This case offers a clinically grounded illustration of how an affect-regulation-first, transdiagnostic approach may be applied to chronic stress and burnout-adjacent presentations, where cognitive insight is present but sustained behavioural change is constrained by physiological and shame-organised responding.

Keywords: NeuroAffective-CBT; affect regulation; shame; behavioural experiments; Pendulum Effect; TED model; psychological flexibility; embodied cognition; transdiagnostic psychotherapy; lifestyle interventions; affective neuroscience; case study

Introduction

Cognitive Behavioural Therapy (CBT) is an established evidence-based treatment for anxiety and depressive disorders (Beck, 1976; Hofmann et al., 2012). However, CBT may be less effective for clients whose difficulties are dominated by chronic shame, affective dysregulation, and embodied stress responses, rather than by explicit cognitive distortions alone (Gilbert, 2010; Panksepp, 2011).

NeuroAffective-CBT extends traditional CBT by explicitly integrating findings from affective neuroscience, attachment theory, and psychophysiology (Mirea, 2018). NA-CBT proposes that durable cognitive and behavioural change depends on the regulation of subcortical affective systems and bodily states, particularly in individuals experiencing persistent emotional volatility and shame-organised responding (Mirea, 2018; Schore, 2012).

This paper presents a detailed, practice-based case study illustrating the application of NA-CBT with a single working mother whose presenting difficulties were coherently conceptualised using the Pendulum-Effect formulation. As a single-case report, the aim is not to necessarily establish efficacy but rather to provide a clinically grounded illustration of how affect-regulation-focused interventions may support therapeutic engagement and change in complex, non-diagnostic presentations.

Client Information

The client, referred to as Susan, is a 42-year-old single mother of two children, one of whom has significant additional needs. She works part-time in a professional role and experiences ongoing financial strain, chronic fatigue, and emotional overwhelm. Susan self-referred for therapy due to persistent anxiety, low mood, bodily tension, and difficulty initiating and sustaining work-related tasks.

She reported no previous experience of psychological therapy and denied suicidal ideation or risk to others. Her difficulties were longstanding and had intensified in the context of prolonged caregiving demands and occupational disruption. Although Susan did not meet formal criteria for occupational burnout, her presentation reflected core burnout features including emotional exhaustion, reduced task initiation, and shame-organised overcompensation.

Presenting Difficulties

Susan reported the following difficulties:

  • persistent tiredness and bodily pain
  • anxiety related to finances and perceived competence
  • fluctuating mood states rather than sustained depression
  • strong self-criticism and pervasive shame
  • cycles of overworking followed by avoidance and emotional shutdown

Despite insight into her thinking patterns, Susan struggled to implement consistent behavioural change. Emotional reactions were often rapid, intense, and disproportionate to present-day triggers, suggesting affective processes operating beneath conscious cognition and outside deliberate control (LeDoux, 1996; Mirea, 2025).

Rationale for NeuroAffective-CBT®

Although Susan met many criteria for standard CBT suitability (Safran et al., 1993), her difficulties were better explained by affective and physiological dysregulation rather than faulty beliefs alone or a discrete diagnostic category. Instead, her presentation reflected a cluster of symptoms common across common mental health presentations, organised around shame-dominant affective responding and chronic stress exposure.

NA-CBT was therefore selected to:

  1. Address emotional reactivity at a neuroaffective level
  2. Reduce shame-organised responding
  3. Stabilise physiological states that interfered with learning
  4. Support belief change through emotionally salient experience

When affective systems are chronically activated, cognitive techniques may inadvertently intensify self-criticism or compensatory over-effort (Mirea, 2018). This pattern was observed during the early phase of Susan’s therapy, further supporting the need for a regulation-first approach.

Pendulum-Effect Formulation

A core feature of NA-CBT is the Pendulum-Effect formulation, which conceptualises psychological distress as oscillation between opposing coping strategies driven by unresolved core affect (Mirea, 2018). These oscillations occur largely outside conscious awareness and function to maintain dominant affects such as shame, guilt, fear, or self-criticism.

In Susan’s case, this oscillation was pronounced. She alternated between procrastination (intentional delay) and avoidance (withdrawal) until tasks became unavoidable. These phases were then followed by periods of overcompensation marked by excessive responsibility-taking, urgency, and perfectionistic standards. Such efforts were typically unsustainable and culminated in collapse, accompanied by intensified self-blame, hopelessness, and emotional withdrawal (or capitulation). A similar pendulum pattern was observed in her eating behaviour, in which episodes of overeating (overcompensation) were followed by periods of restriction (avoidance) and harsh self-reproach (capitulation), further reinforcing shame and loss of self-trust.

Within the Pendulum-Effect formulation, these patterns reflect the complex and dynamic oscillation between avoidant, overcompensatory, and capitulating strategies rather than a linear sequence of behaviours. Shame-based core affect was conceptualised as occupying the functional centre of the system, with oscillating strategies serving as complex self-sabotage, to temporarily manage distress while simultaneously reinforcing negative self-evaluative beliefs such as “I am inadequate” or “I am failing.” Importantly, these strategies were understood not as pathology, but as historically adaptive survival responses shaped by cumulative relational, developmental, and contextual stress (Mirea, 2018; Porges, 2011).

Therapeutic work therefore focused on reducing the amplitude of oscillation rather than eliminating emotional experience, while gradually introducing adaptive coping strategies aligned with authentic personal values that promote psychological health and functional independence. Intervention emphasised affect regulation, increased awareness of pendulum dynamics, and the cultivation of compassionate choice at moments of activation, thereby supporting greater stability and flexibility in emotional and behavioural responding.

Pendulum Poles Identified

Susan oscillated between the following coping poles:

  • Overcompensation: excessive responsibility, perfectionism, overworking
  • Avoidance: procrastination, emotional numbing, withdrawal
  • Capitulation: resignation, hopelessness, self-blame

Conceptually, this can be represented as:

These responses were understood not as pathology, but as adaptive survival strategies shaped by past and current relational stress (Mirea, 2018; Porges, 2011). An early narrative contributing to Susan’s internalised shame involved comparison with an idealised maternal figure perceived as coping effortlessly, reinforcing beliefs of inadequacy and shame-based self-evaluation.

Therapeutic work focused on reducing pendulum amplitude by strengthening affect regulation, increasing awareness of oscillation patterns, and cultivating compassionate choice, rather than attempting to eliminate emotional experience altogether.

Description of the NA-CBT® Intervention

Module 1: Engagement and Affective Assessment

Assessment emphasised collaborative formulation, mapping Susan’s pendulum patterns, and identifying bodily markers associated with distinct affective states. Emotional responses were normalised as nervous-system reactions shaped by experience and rooted in the brain’s predictive regulatory processes, whose primary function is to maintain physiological survival. This framing supported affect tolerance and therapeutic engagement (Schore, 2012; Mirea, 2018).

Within NA-CBT–informed practice, early sessions are understood as a critical opportunity to establish safety, trust, and a robust therapeutic alliance oriented toward authentic living rather than a life organised around internalised shame states. During this phase, the therapist’s role involves providing guidance and psychoeducation alongside compassion and active listening, thereby supporting engagement while modelling a regulated, responsive, and relationally attuned stance.

Module 2: Psychoeducation

NA-CBT® can appear to be a phased treatment; however, clinical practice demonstrates that modules are applied flexibly and intersect dynamically according to formulation and regulatory needs (Mirea, 2018). Psychoeducation was therefore embedded throughout therapy rather than delivered as a discrete phase.

This approach is consistent with evidence that learning and meaning-making enhance neuroplasticity and psychological flexibility, now recognised as a transdiagnostic protective factor (Kolb, 1984; Davidson and McEwen, 2012; Kashdan and Rottenberg, 2010).

Susan was introduced to:

• the role of pendulum-effect oscillating strategies in reinforcing shame
• distinctions between core affect and cognitive appraisal
• the regulatory function of emotions such as shame (signalling perceived social threat and guiding protective behaviour)
• the impact of physiological stress on emotional intensity
• the role of lifestyle stability in moderating affective reactivity

This psychoeducation reduced self-blame and strengthened engagement, consistent with NA-CBT®’s emphasis on emotional literacy (Mirea, 2018).

Module 3: TED – Tired, Exercise, Diet

The TED module was implemented as a foundational affect-regulation strategy rather than as adjunctive lifestyle advice (Mirea, 2023; Mirea, 2025). Within NA-CBT–informed practice, TED targets background physiological instability known to amplify emotional reactivity and undermine cognitive and behavioural learning (Damasio, 1999).

Behavioural changes and corresponding behavioural experiments were introduced across all three TED domains. Within the Tired domain, interventions prioritised sleep regularity and pacing rather than sleep optimisation. Within the Exercise domain, distinctions were made between incidental activity and intentional regulating movement such as yoga or purposeful walking, which were more consistently associated with reductions in affective volatility. Within the Diet domain, psychoeducation addressed the short-term stimulating and longer-term destabilising effects of high sugar intake, reframing reliance on sugar as a stress-driven coping strategy rather than a sustainable energy source.

Susan observed that spikes in self-criticism and shame reliably followed prolonged sedentary days characterised by binge eating and alcohol use. Within the Pendulum-Effect formulation, these patterns were understood as oscillations between overcompensation, avoidance, and capitulation, functioning as a recurring self-reinforcing cycle driven by unresolved shame-based affect.

In response, brief “exercise snacks” were introduced not as fitness goals, but as identity-repair behaviours (e.g., “I am someone who cares for my body and nervous system”).

Susan also noted heightened fear and emotional reactivity following poor sleep, skipped meals, and excessive caffeine intake. Using the TED self-check, these affective shifts were re-contextualised as substantially physiological rather than as evidence of personal failure. This reframing reduced shame and overwhelm, allowing subsequent exposure-based and cognitive interventions to proceed with greater tolerance and engagement.

Where relevant, Susan was encouraged to seek medical or dietetic input to support nutritional adequacy and metabolic stability, consistent with TED’s positioning as complementary to, rather than a replacement for, healthcare input (Mirea, 2025). Following consultation with her general practitioner, routine blood investigations identified physiological factors (e.g., iron and vitamin D insufficiency) considered contributory to fatigue and fluctuating energy levels. Addressing these factors further supported affect regulation and behavioural engagement within therapy without displacing psychological intervention.

As emphasised by Mirea (2025), within NA-CBT informed practice, lifestyle regulation, affective formulation, exposure, and identity repair are conceptualised as interlocking components of a single regulatory system rather than as parallel or competing therapeutic tracks.

Module 4: The Integrated Self

Within NA-CBT, this phase of therapy focuses on working with specific, emotionally salient (“hot”) memories that activate cascades of negative affect and self-defeating behavioural responses. Attending to discrete memory fragments is often more effective than attempting to process broad or global relational narratives, which may become cognitively assimilated over time into fear, guilt or shame-based conclusions that are resistant to change (Erten MM, 2018; Mirea, 2018).

Clients were supported to maintain present-moment physiological awareness while narrating specific memories in a contained and titrated manner. This process enabled the gradual re-appraisal of trauma-linked affect as tolerable bodily sensation rather than overwhelming threat. Over time, emotional fluctuations were experienced as manageable variations in internal state, supporting acceptance and the integration of a more adaptive and cohesive sense of self (Gilbert, 2010; Mirea, 2018).

Module 5: Coping Skills-Enhanced Behavioural Experiments

Although behavioural experiments are described as a discrete module within NA-CBT, the creation of new lived experience is emphasised throughout therapy, reflecting the model’s use of intersecting and flexible modules rather than a linear sequence (Mirea, 2018). Behavioural experimentation was therefore conceptualised as an ongoing learning process supporting affect regulation, belief revision, and identity repair.

Across therapy, experiments were designed to test emotional predictions alongside cognitions, consistent with experiential learning theory (Kolb, 1984; Engelkamp, 1998) and the principle that belief change occurs primarily through emotionally meaningful action (Chadwick, Birchwood and Trower, 1996).

Module 6: Consolidation and Ending

Ending focused on recognising early pendulum swings, applying TED independently, and maintaining ongoing affect awareness. Relapse prevention was framed as a process of continued regulation rather than symptom elimination (Mirea, 2018). TED was positioned as a long-term inner compass, with setbacks reframed as signals of nervous-system strain rather than personal failure.

Outcomes

Therapy progressed steadily across 18 sessions. The initial six sessions focused on assessment, collaborative formulation, psychoeducation, and the introduction of the TED framework, with particular emphasis on affect regulation and lifestyle stabilisation.

The subsequent nine sessions facilitated early narrative processing and the development of acceptance through self-compassion. These sessions also incorporated behavioural and social experiments aimed at promoting new learning, strengthening adaptive coping, and gradually modifying overcompensatory, avoidant, and capitulating coping strategies. Such patterns were frequently organised around shame-based conditional assumptions, for example: “If I do not sacrifice myself and meet others’ demands perfectly, I am worthless,” accompanied by implicit affective experiences of shame and guilt.

The final three sessions were conducted on a monthly basis and focused on consolidating therapeutic gains, strengthening relapse-prevention strategies, and supporting the client’s increasing capacity for autonomous self-regulation.

By the end of therapy, Susan demonstrated:

  • Adoption of a more regulated lifestyle informed by TED principles
  • Reduced affective volatility and improved emotional self-regulation
  • Increased tolerance of uncertainty and distress
  • Greater behavioural consistency across work and caregiving contexts
  • Development of a more compassionate and flexible self-narrative

Although significant external stressors persisted, Susan experienced emotional responses with greater awareness, reduced escalation, and increased capacity for regulation, indicating meaningful consolidation of therapeutic learning.

Symptomatic progress was monitored using the Hospital Anxiety and Depression Scale (HADS) and CORE-32, administered at assessment, session nine, and session eighteen. Improvements were observed across key domains of concern, including chronic stress, day-to-day functioning, shame-organised self-criticism, affective instability, anxiety, and low mood.

Learning Outcomes

This case demonstrates that:

  1. “Affect regulation may be a prerequisite for sustained cognitive and behavioural change.”
  2. “The Pendulum-Effect formulation offers a dynamic, non-pathologising framework for understanding oscillating coping patterns.”
  3. “TED-based interventions can function as core therapeutic tools rather than adjunctive lifestyle advice.”
  4. “Behavioural experiments are most effective when designed to be emotionally salient.”
  5. “NA-CBT may be particularly well suited to presentations characterised by chronic stress, low self-esteem, and shame-organised responding.”

Critical Evaluation

Strengths

  • Integrates affective neuroscience, lifestyle regulation, and principles from nutritional psychiatry within an evidence-based CBT framework
  • Reduces self-blame through the normalisation of physiological and affective processes
  • Provides a coherent and non-pathologising framework for complex, non-diagnostic presentations

Limitations

  • Requires advanced therapist skill in affective attunement and regulation
  • Requires additional therapist knowledge drawn from domains that traditionally fall outside the core remit of psychotherapy, including nutrition, neuroscience, and exercise psychology
  • Some concepts may initially feel abstract or unfamiliar to clients
  • Time-limited therapy constrained the depth of narrative integration and longer-term consolidation

Clinical Reflexivity

With hindsight, earlier emphasis on TED-based stabilisation may have reduced initial pendulum oscillations more rapidly. Encouraging liaison with primary healthcare services, including general practitioner consultation and routine blood investigations, provided clinically useful contextual information that complemented psychological formulation and supported affect regulation.

This early physiological stabilisation facilitated increased engagement in self-care and self-compassion practices, which in turn enabled deeper therapeutic work with shame-laden narratives, including beliefs linking personal worth to constant performance and self-sacrifice.

Agenda management required ongoing sensitivity to balance therapeutic structure with respect for the client’s lived complexity, ensuring that therapeutic direction did not inadvertently replicate earlier experiences of invalidation or over-demand.

Conclusion

This case illustrates how NeuroAffective-CBT can extend traditional CBT by directly engaging the affective and physiological processes that organise psychological distress. Through the combined use of the Pendulum-Effect formulation and TED (Tired–Exercise–Diet), NA-CBT supported sustainable emotional and behavioural change within the context of ongoing psychosocial stress. Rather than functioning solely as a time-limited intervention, NA-CBT may be understood as a lifelong self-regulation framework, offering clients a practical internal compass for stabilising physiology first and thereby expanding freedom in how they think, feel, and act.

More broadly, this case reflects a growing movement within psychotherapy toward a deeper integration of mind and body. As neuroscience, psychosomatic medicine, nutritional psychiatry, and biologically informed treatments increasingly converge, it is becoming difficult to justify approaches that address cognition and emotion in isolation from physiology. Integrative models such as NA-CBT are well positioned to contribute to this evolving landscape by offering clinicians a coherent framework that bridges affective neuroscience with everyday therapeutic practice (Mirea, 2025).

NA-CBT® positions itself not merely as a set of techniques, but as a compassion-centred, neurobiologically informed psychological approach. While many traditional psychotherapeutic schools have historically approached lifestyle factors with caution, emerging evidence and clinical experience suggest that disrupted sleep, nutritional instability, and insufficient movement are pervasive across mental health presentations and frequently undermine therapeutic progress. Addressing these factors thoughtfully and collaboratively does not dilute psychological depth; rather, it creates the physiological conditions necessary for insight, emotional processing, and behavioural change to take root.

From this perspective, interventions such as TED are not ancillary to therapy but foundational. Encouraging appropriate medical collaboration when clients present with chronic fatigue or low energy can help identify modifiable physiological contributors that, when addressed, enhance affect regulation, therapeutic engagement, and overall quality of life. Such integration reflects a broader shift away from symptom-focused treatment toward whole-person care, where psychological flexibility, embodied awareness, and compassionate self-regulation become central therapeutic outcomes.

Taken together, this case suggests that the future of psychotherapy may lie less in refining ever more specialised techniques and more in developing integrative, transdiagnostic frameworks capable of holding mind, body, affect, and behaviour within a single coherent model. NA-CBT offers one such framework, grounded in neuroscience, oriented toward compassion, and designed to meet the complex realities of contemporary clinical practice.

Future Directions for Psychotherapy

The evolving landscape of mental health care increasingly calls for psychotherapeutic models that move beyond rigid diagnostic categories and isolated treatment techniques. As research continues to clarify the reciprocal influence of physiology, affect, cognition, and behaviour, future psychotherapy is likely to become more integrative, transdiagnostic, and biologically informed.

Approaches such as NeuroAffective-CBT point toward a future in which affect regulation and nervous-system stability are recognised as foundational prerequisites for psychological change. Rather than positioning lifestyle, embodiment, and self-regulation strategies as peripheral or adjunctive, emerging models are likely to incorporate these elements centrally within formulation and intervention. This shift has the potential to enhance treatment accessibility, durability of outcomes, and client autonomy.

Future developments in psychotherapy may also involve closer collaboration between psychological practitioners and other health disciplines, including primary care, nutritional psychiatry, and psychosomatic medicine. Such interdisciplinary integration may support earlier identification of physiological contributors to emotional distress and reduce unnecessary chronicity across mental health presentations.

Finally, the field may increasingly value therapeutic frameworks that prioritise psychological flexibility, compassion, and embodied self-awareness over symptom suppression alone. In this context, psychotherapy may evolve from a primarily corrective endeavour into a developmental process, one that supports individuals in cultivating sustainable self-regulation, resilience, and a more integrated sense of identity across the lifespan.

Disclaimer

This case study is intended for educational and professional discussion purposes only. It does not constitute clinical guidance, diagnosis, or treatment recommendations. Therapeutic approaches described should be applied only by appropriately trained professionals and adapted to individual client needs. Readers are advised to consult relevant clinical guidelines and professional supervision when translating concepts into practice.

Ethics and Anonymisation Statement

All identifying client information has been altered to protect anonymity. Informed consent was obtained for the use of anonymised clinical material for educational and dissemination purposes.

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Fight SAD with “S-A-D”: A Practical Guide to Seasonal Affective Disorder

NeuroAffective-CBT by Daniel Mirea

If winter reliably knocks your mood and energy, you’re not alone and you’re not broken. This NeuroAffective-CBT guide reframes Seasonal Affective Disorder as a manageable seasonal pattern, offering practical strategies to prepare for winter rather than dread it.

Chapter 1: When “SAD” isn’t just sad

Every year, somewhere between late October and early January, the same thought quietly appears in thousands of minds: “Here we go again…!” The days shorten, the light fades, motivation dips, sleep changes, and suddenly everything feels heavier. Many people call this “SAD,” sometimes accurately, sometimes loosely, sometimes with a mix of humour and despair.

But here is the first important distinction. In this article, sad (lowercase) points to a common affective state, a normal emotional response to loss, stress, fatigue, or even the bleak poetry of a British winter. SAD (uppercase), by contrast, denotes Seasonal Affective Disorder: a recurrent pattern of depressive symptoms that predictably emerges at specific times of year and subsequently remits. Official diagnostic systems (DSM-5) currently list “seasonal pattern” as a specifier within major depressive disorder or bipolar disorder, meaning the seasonal timing of episodes is part of diagnosis rather than a standalone illness.

A third, and in many respects the most clinically relevant meaning, also appears in this article: S–A–D, an acronym describing the self-regulation framework developed within NeuroAffective-CBT®, distinct from both everyday emotional sadness and the clinical diagnosis of SAD.

Confusing these meanings often leads to unnecessary self-blame. If winter mood change is interpreted as personal weakness rather than a predictable interaction between biology and environment, individuals end up fighting themselves rather than the problem.

This article is about doing the opposite.

Chapter 2: What Seasonal Affective Disorder actually is

Seasonal Affective Disorder is best understood not as a separate illness, but as a seasonal pattern of depression. In diagnostic terms, it now appears as a specifier, “with seasonal pattern”, within major depressive disorder or bipolar disorder.

The key word here is pattern.

People with SAD are not depressed all year. They are often well-functioning, engaged, and emotionally stable for months at a time. Then, with remarkable regularity, a particular season brings changes in mood, energy, sleep, appetite, motivation, and social behaviour.

For most, this occurs in autumn and winter; for a smaller group, symptoms appear in spring or summer. The form differs, but the predictability is striking.

And predictability is good news, because what is predictable can be anticipated, planned for, and softened.

Chapter 3: Is SAD “real”? Yes.. and also nuanced

SAD has had a complicated scientific history. On the one hand, many individuals describe a clear seasonal signature to their mood, and treatments such as light therapy and behavioural activation show consistent benefit.

On the other hand, large population studies sometimes fail to find strong average seasonal effects on mood. This has led to understandable scepticism and headlines suggesting that SAD may be overstated.

Both things can be true.

At the population level, seasonal mood effects can look subtle or inconsistent. At the individual level, a meaningful subgroup experiences recurrent, impairing seasonal depression that responds to targeted intervention.

Clinical work happens at the individual level.

If winter reliably disrupts your sleep, energy, mood, and functioning, you don’t need a philosophical verdict on SAD’s existence. You need a strategy.

Chapter 4: How common is it in the UK?

UK estimates vary depending on definitions (strict diagnosis vs. milder seasonal changes). The Royal College of Psychiatrists commonly cites around 3 in 100 people experiencing significant winter seasonal depression. And then there’s the much larger group with subclinical winter mood dips—not necessarily a disorder, but still very real in lived experience.

Translation: you’re not “dramatic.” You’re in a very large club, and none of you asked for the membership card.

Chapter 5: Why seasonal depression doesn’t have to dominate your year

The most damaging feature of seasonal depression is often not the low mood itself, but the story people tell about it:

  • “I’m weak in winter.”
  • “I can’t cope like other people.”
  • “There’s no point trying until spring.”

NeuroAffective-CBT takes a different view. Seasonal mood shifts are treated as brain–body adaptations to changing environmental cues, not moral failures or personality defects.

When you stop expecting winter to feel like summer, you can stop fighting reality and start working with it. This is where a different kind of S-A-D enters the picture.

Chapter 6: Fight SAD with “S-A-D.”

Having clarified what SAD denotes clinically, we now turn to S-A-D, the practical NeuroAffective-CBT® self-regulation framework designed to counter seasonal vulnerability.

S — Sleep (and the anti-hibernation principle)

Winter-pattern SAD often brings a paradox: sleeping more while feeling less restored. Longer nights, reduced morning light, and lower daytime activity all push the nervous system toward a semi-hibernation mode. The instinctive response—sleeping longer, withdrawing more—often worsens the problem.

The goal is not heroic early mornings or sleep deprivation. It is rhythm.

Key principles that consistently help:

  • A fixed wake-up time, including weekends
  • Morning light exposure, ideally outdoors (even grey light counts)
  • Avoiding excessive time in bed when it increases lethargy rather than rest

A helpful reframe:
You are not trying to maximise sleep. You are trying to stabilise your circadian signal.

If you feel tired earlier in winter, going to bed earlier is sensible. Propping yourself up with sugar or caffeine late in the day usually backfires. Sleep works best when it follows biology, not negotiation.

A — Anticipate (instead of being ambushed)

Seasonal depression often feels overwhelming partly because it is treated as a surprise each year, even when its return is entirely predictable. Within NeuroAffective-CBT®, anticipation is therefore one of the most powerful therapeutic tools.

Mapping one’s seasonal pattern can be transformative. Individuals are encouraged to identify:

  • when symptoms typically begin,
  • when they peak,
  • the early warning signs that signal deterioration, and
  • what consistently helps—even a little.

This information enables intervention before motivational collapse occurs.

Planning for winter is not pessimism; it is realism. Effective anticipatory planning emphasises:

  • shorter, more frequent activities rather than overly ambitious goals,
  • routines that require fewer decisions,
  • social contact that is consistent but low-pressure, and
  • regular movement rather than heroic effort.

Mood rarely improves first; behaviour usually leads. Anticipation therefore supports realistic goal-setting, reduces decision fatigue, and sustains engagement in movement, social contact, and daily structure. Practically, this may involve the development of seasonal mapping worksheets, early warning sign checklists, pre-winter self-regulation plans, and “If–Then” implementation intentions for example, “If my mood drops below 4/10 for three consecutive days, then I re-establish my morning light routine, resume structured outdoor movement, and increase planned social contact”.

From a behavioural perspective, SAD commonly generates a self-perpetuating cycle of lethargy → inactivity → lowered mood → further lethargy. Behavioural activation techniques therefore play a central role, including activity monitoring, weekly scheduling, values-based goal planning, minimum viable action strategies, and the use of pleasure–mastery ratings to strengthen engagement with rewarding activities.

Anticipation also involves cognitive preparation. Individuals with SAD frequently develop harsh internal narratives such as “I’m lazy”, “I should be coping better”, or “This always ruins everything.” Cognitive restructuring provides alternative meaning-making frameworks through thought records, compassionate reattribution, behavioural experiments, and cognitive defusion strategies for instance, reframing winter-related changes as “seasonal physiology” rather than personal failure.

Finally, anticipatory intervention encourages graded engagement with winter rather than progressive withdrawal from it. Structured re-engagement hierarchies, winter avoidance mapping, and “opposite action” plans support maintenance of functioning rather than seasonal constriction of life. Self-compassion becomes a protective regulatory tool, with compassionate coping statements, externalising language (“this is my winter brain physiology”), and self-validation scripts helping to stabilise psychological self-relating during periods of seasonal vulnerability.

D — Vitamin D (supportive, not magical)

In the UK, public-health guidance recommends that most adults consider a daily vitamin D supplement during autumn and winter, when sunlight exposure is insufficient for reliable skin synthesis. The commonly cited maintenance dose is 10 micrograms (400 IU) daily, which is considered adequate for the general population.

At the same time, more recent research and clinical practice suggest a wider safety margin than was historically assumed. For some individuals—depending on factors such as baseline vitamin D status, age, body composition, limited sun exposure, or certain chronic health conditions – higher doses may be appropriate, often in the range of 1,000–5,000 IU daily, and occasionally more when correcting a documented deficiency.

Two academic footnotes, without killing the vibe:

First, vitamin D deficiency is common, particularly at northern latitudes and during prolonged periods of low sunlight. Vitamin D plays a role in general physical health, immune function, and indirectly, brain health and energy regulation.

Second, dosing beyond standard public-health guidance should be individualised. Blood testing and clinical input are advisable when higher doses are being considered, especially for people with medical conditions, those taking certain medications, or during pregnancy.

The key reframe is this:
Vitamin D is not a mood cure or a personality upgrade. It is best understood as reducing physiological friction, supporting baseline health so that other interventions (sleep, light exposure, activity, and psychological strategies) have a better chance of working.

That modest but meaningful role is enough to justify its place in a thoughtful seasonal plan.

Chapter 7: A brief winter story

Consider “Daniel,” a composite example. Every November his energy dips, gym attendance collapses, and he starts sleeping nine hours while feeling exhausted. By January he’s convinced he’s failing at adulthood.

This year, Daniel treats winter as a predictable season rather than a personal flaw. He fixes his wake time, walks outdoors most mornings, shortens workouts instead of abandoning them, plans social contact that doesn’t rely on feeling enthusiastic, and starts his vitamin D in October.

The result is not joy. It’s something more realistic: containment.
Winter still feels like winter, but it no longer derails his year.

Chapter 8: When to seek extra support

This article is reassuring by design, but it isn’t dismissive.

Professional support is important if:

  • symptoms are severe or worsening,
  • functioning is significantly impaired,
  • suicidal thoughts are present,
  • or there is a history of major depression or bipolar disorder.

Seasonal patterns are treatable, but they don’t need to be managed alone. psychiatry.org+1

Final Chapter: Conclusion: How “S-A-D” connects with TED in NeuroAffective-CBT

As we’ve seen throughout this article, understanding and managing Seasonal Affective Disorder doesn’t have to be a yearly struggle of shock and surprise. By reconceptualising SAD through S-A-D — Sleep, Anticipation, and Vitamin D support — we place agency, biology, and self-regulation at the centre of the experience. This shift moves us from blame and bewilderment toward predictability and purpose.

What many readers might not immediately notice is how deeply these ideas overlap with the TED model within the NeuroAffective-CBT® framework, a model designed to stabilise the Body–Brain–Affect triangle by reinforcing three core biological regulators: Tired (sleep/rest), Exercise (movement), and Diet (nutrition). This is indeed, the framework on which Mirea bases the S-A-D model.

In NeuroAffective-CBT®, TED operates on the understanding that emotional regulation emerges not in isolation, but from coherent physiological regulation:

  • Sleep and circadian alignment support affective stability and cognitive flexibility.
  • Movement and physical activation buffer stress reactivity and enhance mood regulation.
  • Nutrition and metabolic health influence neurotransmission, energy balance, and resilience.

When we map S-A-D onto TED, we see that:

  • S (Sleep) directly echoes the Tired pillar of TED, attending to sleep quality and rhythms as a foundational step in stabilising mood and neural prediction systems.
  • A (Anticipate) mirrors TED’s emphasis on preparatory regulation, building routines around movement, behavioural activation, and metabolic steadiness before mood dips deepen.
  • D (Vitamin D and implicitly, broader nutritional support) sits comfortably within the Diet pillar, reminding us that metabolic inputs matter for emotional systems and that targeted nutrient support can reduce physiological friction.

Viewed through this lens, Seasonal Affective Disorder isn’t a seasonal mystery or a psychological oddity. It is, instead, a predictable interaction between environment, physiology, and affective regulation, a pattern that TED and NeuroAffective-CBT explicitly address by linking sleep, movement, and diet with emotional wellbeing.

In other words, the same self-regulation scaffolding that helps someone build resilience against panic, shame, or low motivation also helps us understand why Denmark’s winter affects sleep, mood, and behaviour and, crucially, how to respond before winter feels overwhelming.

So the takeaway is simple but powerful:

Seasonality doesn’t need to own your year. When you build routines around sleep, anticipate your mood patterns, and support your body with nutrition and movement, you are not just surviving winter, you are regulating your body–brain system with intention. This is not seasonal luck, it’s seasonal preparation.

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Practical Takeaways: Using the S-A-D Framework

S – Sleep (stabilise circadian rhythm)

  • Keep wake-up times consistent (including weekends).
  • Get early-day outdoor light exposure, regardless of weather.
  • Limit time in bed when it increases lethargy rather than rest.

A – Anticipation (plan before winter hits)

  • Map your seasonal pattern: typical onset, peak, early warning signs.
  • Create a pre-winter self-regulation plan (sleep, movement, social contact, light exposure). Use this link to read the TED (tired-exercise-diet) series – a self-regulation module part of NeuroAffective-CBT.
  • Use “If–Then” plans (e.g., “If mood < 4/10 for 3 days, then resume morning light, outdoor movement, and planned contact.”).
  • Challenge self-critical winter narratives; reframe as “seasonal physiology, not personal failure.”

D – Vitamin D (reduce physiological friction)

  • Follow public-health guidance on vitamin D supplementation.
  • Check for deficiency and discuss dosing with a healthcare professional.
  • Treat vitamin D as an adjunct to, not a replacement for, evidence-based SAD treatments.

When to seek extra help

  • If symptoms are severe, progressive, or associated with suicidal thoughts or major functional impairment, seek professional assessment. Self-regulation strategies complement but do not replace clinical care.

*****

Clinical Disclaimer: The information in this article reflects current understanding of Seasonal Affective Disorder and seasonal mood patterns, but it is not intended to diagnose, treat, or replace professional assessment or care. Individual experiences vary, and treatment decisions should always be discussed with a qualified healthcare professional. If symptoms are severe, progressive, significantly impair functioning, or include suicidal thoughts, urgent professional support is recommended.

The Use of Lifestyle Interventions in Psychotherapy

NeuroAffective-CBT by Daniel Mirea

Why Sleep, Movement, and Metabolic Stability Matter in NeuroAffective-CBT®

Many clients enter psychotherapy believing their distress is “all in the mind”. From a NeuroAffective-CBT® (NA-CBT®) perspective however, this assumption is incomplete. Mind and body form a single regulatory system, and emotional suffering often emerges from how physiological states interact with learned affective patterns.

NA-CBT® is grounded in the idea that the brain’s core function is prediction and protection. The nervous system constantly asks: Am I safe? What is about to happen? How bad could it be? These predictions are shaped not only by thoughts and beliefs, but by bodily signals—sleep, movement, metabolic stability, and neurochemical balance.

When physiology is unstable, prediction systems become more threat-sensitive. Neutral events are more easily experienced as dangerous, shame responses are triggered faster, and emotions escalate more quickly and last longer. This is why NA-CBT® integrates TED—Tiredness (sleep/rest), Exercise (movement/fitness), and Diet (metabolism/nutrition)—as a core stabilisation framework within psychotherapy.

TED is not a wellness add-on. It is often the foundation that allows cognitive, emotional, and relational work to become tolerable and effective.

NeuroAffective-CBT® and the emerging “fourth wave”

Within the broader CBT tradition, NA-CBT® can be understood as part of an emerging, process-based fourth wave, integrating neuroscience, physiology, lifestyle science, and embodied experience into psychological treatment.

While earlier waves of CBT focused on behaviour, cognition, and acceptance, NA-CBT® places affective underlayers such as shame, self-loathing, and internal threat, at the centre of formulation and intervention. Affect is treated as precognitive, fast, and survival-driven; cognition is the meaning-making layer built on top of it.

Central to this model is the Body–Brain–Affect triangle:

  • physiological states shape emotional and cognitive processes,
  • emotions influence thoughts and behaviour,
  • thoughts and behaviours, in turn, reshape physiology.

Within this system, TED functions as the physiological regulation arm of NA-CBT®, reducing background volatility so deeper psychological learning can occur.

Therefore, the central aim of NA-CBT® is helping clients distinguish between:

  • raw affect (the body’s immediate threat or pain signal), and
  • interpretation (the meaning the mind assigns to that signal)

When these collapse into one another, clients experience emotions as overwhelming, self-defining, or dangerous. TED helps slow this process down by first asking: what is the body signalling right now, and is the reaction accurately calibrated?

Why lifestyle belongs inside psychotherapy

When sleep is poor, movement is minimal, or blood glucose is unstable, clients often experience:

  • heightened anxiety or irritability
  • emotional reactivity and rumination
  • intensified shame and self-criticism
  • reduced tolerance for exposure, uncertainty, or intimacy

From an NA-CBT® perspective, these are not failures of willpower or insight. They are signs that the nervous system is operating under strain.

TED aims for sufficiency rather than optimisation. The goal is not perfect habits, but a stable internal environment that reduces threat sensitivity and supports emotional regulation as exemplied in the three case studies below.

Case examples (TED in action)

Case 1: Anxiety amplified by fatigue and metabolic instability

A client with panic-like anxiety noticed that their most intense fear spikes occurred late morning after poor sleep, skipped breakfast, and significantly increased caffeine and sugar intake. Using the TED self-check, they recognised that the fear was only partly warranted and heavily fuelled by tiredness and metabolic volatility. Addressing these factors first—reducing caffeine and sugar, introducing appropriate vitamins and minerals where indicated, and adding a daily morning walk—made later exposure work possible rather than overwhelming.

Case 2: Shame-driven depression softened through movement

Another client with chronic self-loathing noticed that shame spikes reliably followed long sedentary days. Short “exercise snacks” were introduced not as fitness goals, but as identity repair behaviours (“I am someone who cares for my nervous system”). Tracking the relationship between movement, mood, and self-attacks led to reduced shame intensity before deeper cognitive restructuring was attempted.

Case 3: Relationship reactivity reduced through physiological regulation

A client experiencing explosive arguments discovered that intense reactions often followed long workdays, exhaustion, poor sleep, and minimal movement. The TED self-check helped distinguish warranted relational frustration from unwarranted threat amplification, enabling repair conversations instead of escalation.

Assessment and formulation: the Pendulum-Effect model in context

NA-CBT® assessment extends beyond symptoms and surface cognitions to explore developmental affective learning.

A common pattern seen in clients with chronic shame, anxiety, or perfectionism involves early experiences such as: parents were hard to satisfy; poor school results or mistakes led to angry remarks, humiliation, withdrawal of warmth, or visible disappointment.

Over time, the child learns that performance determines safety and acceptance.

Core affect installed: shame

In this environment, a core affect of shame becomes installed. Shame functions as a predictive alarm: “If I fail, I will be exposed, rejected, or humiliated.”

This learning is not primarily cognitive. It is subcortical, embodied, and anticipatory. As adults, these individuals often experience shame spikes before anything has gone wrong. Situations involving evaluation, feedback, uncertainty, or rest activate the same prediction system.

Trigger pattern: most situations where failure is predicted (i.e., imaginal), not necessarily occurring, activate shame and internal threat.

The Pendulum-Effect: how shame maintains distress

NA-CBT® uses the Pendulum-Effect formulation to map how clients attempt to manage shame. Three poles typically emerge:

  • Overcompensation:
    Perfectionism, overworking, people-pleasing, hyper-preparation, harsh self-criticism as “motivation”.
  • Capitulation:
    Low mood, hopelessness, self-loathing, “What’s the point?”, giving up.
  • Avoidance:
    Social or professional withdrawal, procrastination, numbing behaviours, reassurance-seeking, distraction, emotional withdrawal.

Although these strategies look different, they share the same function: protecting against the felt experience of shame. Over time, however, they reinforce it.

Physiological vulnerabilities—poor sleep, low movement, metabolic instability—often increase the amplitude of the pendulum, making swings more intense and harder to interrupt. This is where TED becomes clinically central.

The TED Self-Check

A 30-second reset you can use anytime emotions start to spike

When you feel anxious, irritable, flat, overwhelmed, or stuck in self-criticism, pause. Before analysing yourself or the situation, gently run through these steps—without judgement.

1. What hurts right now — and where?

What is the actual pain signal in this moment?

Name the felt experience, not the story:

  • tight chest
  • heat in the face
  • drop in the stomach
  • lump in the throat

This separates raw affect from interpretation.

2. Is this emotional reaction warranted, unwarranted, or warranted to a degree?

Given the situation, does this intensity fit the facts—or is threat being amplified?

You are not asking “Is this emotion bad?”
You are asking “Is my nervous system accurately calibrated right now?”

Example:

  • Event: My boss says the presentation needs more work.
  • Interpretation: “This is terrible. I can’t tolerate this. I’m being shamed.”
  • Affect: Sharp shame spike, threat response.
  • Warrant check:
    • Some discomfort is warranted (feedback can sting).
    • The intensity of shame is only partly warranted.
    • A shame underlayer is amplifying the reaction.

This step creates psychological space without invalidating emotion.

3. TED check: what might be fuelling the spike?

T — Tiredness
How rested am I right now?

E — Exercise
How much have I moved today?

D — Diet
How steady is my energy and nourishment?

When the body is steadier, emotional calibration improves, and meaning-making becomes fairer!

Behavioural experiments and exposure work (with physiological support)

In NA-CBT®, exposure is framed as updating predictions, not forcing fear away.

For shame-based threat systems, exposure often involves:

  • allowing imperfection,
  • tolerating feedback without immediate self-attack,
  • staying present while shame sensations rise and fall.

TED is crucial here. When physiology is unstable, exposure can feel overwhelming or retraumatising. When the system is steadier through regular exercise, improved diet and sleep, clients can remain succesfully within the window of tolerance, allowing corrective learning to occur.

Behavioural experiments might include:

  • submitting work that is “good enough,”
  • asking a question without over-preparing,
  • delaying reassurance-seeking,
  • allowing small mistakes without immediate repair.

Each experiment tests the old prediction: “If I’m not perfect, I’ll be shamed or rejected.”

Shame and self-loathing repair

Because shame is the core affect, NA-CBT® does not rely on cognitive restructuring alone. Repair occurs across multiple levels:

  • Affective: staying with bodily shame sensations without collapse or attack
  • Narrative: identifying internalised parental voices and shame-based meanings
  • Relational: experiencing being seen without humiliation
  • Physiological: reducing baseline threat sensitivity through TED

Over time, clients develop a non-shaming internal regulator—an Integrated Self capable of noticing shame without obeying it.

Relapse prevention and self-regulation planning

Relapse prevention in NA-CBT® focuses on recognising early signs of pendulum acceleration, not eliminating emotion.

Clients learn to notice:

  • rising perfectionism or avoidance,
  • faster shame activation,
  • disrupted sleep, reduced movement, irregular eating.

Here, the TED self-check becomes a long-term inner compass. Returning to TED (i.e., the fundamentals – better sleep, exercise, better diet) during periods of stress often prevents full relapse by stabilising physiology before old affective loops take over.

Setbacks are reframed as signals, not failures: “My nervous system is under strain; what support does it need right now?”

Conclusion

Within NeuroAffective-CBT®, lifestyle regulation, affective formulation, exposure, and identity repair are not separate tracks. They are interlocking components of a single system aimed at recalibrating threat, softening shame dominance, and restoring psychological flexibility. TED does not replace depth work, in fact it makes deeper work possible. As such, the TED and Pendulum-Effect formulation modules in particular, can be used in conjunction with any school of psychotherapy, as illustrated in the case examples above. They offer a transdiagnostic framework for understanding how physiology, affect, and behaviour interact to maintain or reduce psychological distress.

NA-CBT®, is not necessarily a short-term protocol but a lifelong self-regulation compass. When emotions surge, clients are encouraged to return to three simple questions:

  • How tired am I?
  • How much have I moved?
  • How steady is my nourishment?

By repeatedly stabilising physiology first, clients gain greater freedom in how they think, feel, and act—supporting deeper emotional regulation, reduced shame, and more integrated identity over time.

Medical and Nutritional Disclaimer

The information on this page is provided for educational and therapeutic context only and is not intended as medical, nutritional, or prescribing advice. NeuroAffective-CBT® practitioners do not diagnose medical conditions or prescribe supplements outside of a comprehensive assessment and only if individual core profession allows it. As such, any discussion of nutrition, micronutrients, or lifestyle factors is offered as part of a psychological assessmnet formulation and should not replace consultation with a qualified medical professional. Clients are encouraged to discuss supplements, medications, and health concerns with their GP or relevant healthcare provider.