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...

If my gut could talk to me, what would it say ?

July 12, 2024December 4, 2024 NeuroAffective-CBT by Daniel Mirea

Introducing James…

James is a successful banker enjoying significant authority and respect at work. Being into sports and a healthy lifestyle, he is tall and handsome, he has a beautiful wife and two children. On paper all is well, and so he would be taken by surprise every weekend when visiting his parents’ home for Sunday lunch, by the experience of intense, discomforting, and painful butterflies, in anticipation of this recurring event. He is left confused, without an explanation.

Allowing for an earlier narrative to unfold within the first few hours of therapy, childhood experiences were revealed, where he experienced similar painful feelings, generated by a critical and highly demanding father, the kind of parent that would be difficult to please. His mother never interfered and to James, this was as bad as his father’s attitude. His childhood was dotted with various episodes of unfavourable comparisons with a younger and brighter sister.

Despite his success and handsome appearance, he sees himself as ugly, unattractive, unwanted, enjoying some professional success through sheer luck, an impostor, and a trickster. He remained hypervigilant throughout the years around his father and eager to be validated. He gets overwhelmed with anticipatory anxiety before every single meeting with his parents.

When gently exposed to these issues during therapy, he acknowledged a connection with early experiences right away, he realised that he feels the same way around other men or women in authority, and yet he remained equally confused and troubled by these dominant, painful gut-feelings¹.

******

‘I can feel it in my gut‘ or ‘trust your gut’ we often say to ourselves or each other, perhaps for very good reasons. Scientists have recently established clear links between our gut and the brain, not necessarily through an analysis of the diversity of the microbiome that exists within our gut, although this turns out to be equally relevant (Skonieczna-Zydecka K et al., 2018), but also by paying attention to the actual structure of the gut at a cellular level (Kaelberer M et al., 2020).

The biological dimension

Dr Kaelberer and colleagues identified a direct pathway from the gut to the brain, that essentially allows sensing of what is happening in the gut, in order to inform specific emotions whether pleasure or disgust, and the resulting behaviours. This would, at least in part, explain cravings and associated compulsive actions, and furthermore, it helps explain why the regular practising of mindfulness or paying calm, non-judgemental attention inwards, could lead to a shift in feelings and better emotional-regulation (Golding and Gross, 2010).

The gut-brain communication happens through versatile and adaptable neuropod cells with electrical sensors within the gut structure, which are able to select and specialise in various essential chemicals like glucose, proteins or amino acids. These cells can program to organise digestion and send information via electrical signals straight to the brain, which will make further informed decisions on what to feel and how to respond to certain products, in a given situation. Although not the only sensorial command centre, it does appear that, the human 9- to 10-meter-long gut, could be the largest internal organ with immediate access to the external world. Running through the upper body, from the rectum to the esophagus, and in constant communication with the brain, the gut is able to provide an individual, with a fuller experience of what it means to engage with useful edible products, like enjoying a coffee with a cookie in the morning, where the individual is likely to experience both pleasure and a sudden increased in energy. Seems ‘the gut’ may indeed be one of the biggest organs inside our body, but reaching as far as the external or the social world, is not something psychologists would have taken into account until now.

Inside the gut something equally fascinating takes place, which further strengthens the relationship between the human gut and the brain. Our intestine has about 39 trillion microorganisms called microbiome and it consists mostly of bacteria, viruses and fungi – the microbiome produces chemicals which can send messages to the brain through the vagus nerve. This nerve starts in the brainstem, it travels down the neck and alongside the carotid arteries and into the chest branching out towards internal organs, as a result it can manage gut contractions (peristalsis) and heart rate – this makes the vagus nerve relevant when it comes to the human relaxation response.

We now know, that people who suffer from chronic stress have very different microbiomes and ‘bad’ bacteria that produce inflammation, as opposed to a healthy individual who would have a diverse population of bacteria strains. This has serious clinical implications and recent research has in fact shown, that levels of depression would improve when injected with a specific bacteria (faecal). Although these bacteria is proving difficult to reproduce artificially in a lab, the link between the gut micorbiome and the brain explains why certain diets, like the Mediterranean diet, and foods (like pre/probiotics) would have a direct impact on the mood. A healthy diet is associated with a 30% reduction in depression.

Good gut health means good overall health !

The psychosocial dimension

Humans like most other mammals have rituals around eating, drinking and socialising. Such events are usually inter-linked and incredibly important to evolution. Those are ideal occasions to get to know one another, to court each other, to test our emotions, bond and reproduce. Often a potential partner is treated to a freshly cooked meal with a personal touch. This enhances the possibility of having a relationship. Social rituals such as feeding a child, courtship or even kissing, demonstrate how the gut is constantly interacting with the brain and through a perfect symphony of electrical signals, enzymes, and various chemicals, it assists with social bonding, and the selection of the most appropriate partner. This is where the notion of ‘butterflies in the stomach’ takes a completely different meaning when two lovers meet, versus two people shouting at each other in extreme anger. All individuals involved in these very different scenarios, would report experiencing butterflies in the stomach with different levels of intensity. This turns out to be nothing short of cells and electricity at work, dutifully completing their shift. Just another day in the office.

Through stories we reach the world around us…

Homo-sapiens are also ‘homo-narrans’ (Meichenbaum D, 2017). We have an innate ability to observe our own thoughts, to think about our thinking in vivid images, pictures, or even short video clips, and ultimately describe with various details, the content of our thoughts and conclusions. This is what we label as ‘stories’. In fact, we rarely think in clear and brief thoughts, but instead our minds, seem to be dominated by stories involving all sensory modalities, a pleasant memory of a sensual encounter has sounds, smells and tastes, alongside vivid video-reels which unconsciously lead to arousal.

‘The early bird catches the worm’.

We grow up ‘feeding’ on stories, symbols and metaphors; most of us will remember with great pleasure childhood messages and proverbs repeated to exhaustion by our parents and grandparents, in the hope that we would learn to behave more appropriately, in line with our social context and culture. The messages we remember the most, have an interesting narrative behind them, rich in details and sensorial pleasures. The teacher that inspired us during school years, was most likely, the best storyteller. Story telling is a natural gift often unexplored and unnourished.

Stories we tell ourselves reflect earlier experiences and are used as a learning platform. They have to make contextual sense of the world we live in, and as such, our personal narratives, are influenced and adapted over time in order to fit in, with continuously evolving circumstances (Hickes and Mirea, 2012). This would of course, in turn, ensure survivability and psychological resilience over the course of lifetime. Failure to update old narratives can create psychological rigidity, which leads to internal distress and therefore, predispose individuals to mental illness.

Indeed, this fascinating oval-shape mass of grey, which we refer to, as the ‘brain’, is plastic. In other words, it has the ability to biologically modify itself and adapt to new circumstances (another area the conscious mind¹ is not consulted about), with only one important mission that supersedes everything else – keeping us alive! Therefore, the stories we tell ourselves are not designed to generate feelings of happiness or sadness, since those are not essential to our survival. Although we know this is at times possible, the brain’s main priority is to keep the organism or the body as a whole, functional and alive.

The cognitive-behavioural dimension

When the gut communicates with the brain, it is purposeful, and it demands an immediate reaction. Intense emotions lead to compulsive behaviours, bypassing the mind completely, e.g., when one is hungry, the resulting senses, known as cravings or feelings of pain and discomfort in the gut area, lead to an urgency to find something to eat, the mind is simply trying to resolve this problem by going to previously memorised solutions.

Therefore, cognitions are products of an extremely busy brain with no time off. Best understood as essential components of a regulatory system informed by thought, experience, memory, language, sensorial data or felt-sense², and deeply-rooted beliefs³. It may not always be easy, but it is possible to override one’s felt-sense or gut-feelings, if we start engaging our prefrontal abilities by reframing the experience and simply view DRBs as, the dialectical expression of a felt-sense. This can be achieved through new learning, and new experiences. Humans, unlike other mammals, do this all the time, we are very good at convincing ourselves that something is good for us, through repetition or rehearsal, when in fact, our gut is telling us that the opposite is true. For example, eating lots of sugar, drinking alcohol or smoking. In a different context, it could be argued that learning how to override painful gut-feelings, might be the very purpose of a psychotherapeutic treatment specifically, helping individuals overcome painful gut-feelings, or felt-senses which internally suggest they are flawed or not good enough.

Deeply-rooted beliefs might be best understood as the first layer of defence, a deeper screening or filtering system that helps an individual navigate through the complexities of life, in spite of a dominating gut-feeling that he is not good enough. These types of senses are reminders of previous experiences and nothing short of ‘brain statements’ or brain’s best possible interpretation of early life experiences. Whether frequent exposure to extended periods of affection, or at the other end of the spectrum exposure to neglect, characterised by intense pain signals and experienced mostly by the gut, and felt within the upper body regions. Since our brain does not use language per se, to ‘shout out’ warnings to the mind, various electrical signals are sent back and forth between brain structures and different parts of the gut, on every single occasion we find ourselves in a situation that points toward a reward or indeed a threat (i.e., neglect). Sensorial signals alerting an individual of a potential reward or threat, depending on the developmental stage, could be processed linguistically and translated into deeply-rooted beliefs of lovability (pleasure) or unlovability (rejection), but this is rarely needed outside of a therapy session. And of course, lack of awareness and language speeds up the process of getting a reward or running away from neglect or threat. Once the Mind gets involved, everything slows down and is investigated with the curiosity of a scientist.

We have now understood that DRBs are not seen or heard but felt deep inside the body at a gut level and they are not interpreted by a mind which does not even fully develop before the age of two. Therefore, not only that language is not needed when chasing a reward or running away from a threat, but DRBs have no immediate linguistic correspondent, since the gut-brain axis is bypassing the temporal lobe responsible for language processing. Studies suggest that the prefrontal cortex, or the ‘mind’, starts developing within the first two years of life, since basic brain structure and connectivity is present by this age (Huttenlocher & Dabholkar, 1997), but continues until the mid-twenties, which marks an end to our adolescent stage and a slowing down of brain neuroplasticity (Siegel D, 2020).

Attachments and emotional neglect

British developmental psychologist and psychiatrist John Bowlby is one of the most recognisable names associated with attachment research (1988). His evolutionary theory suggests that children come into the world biologically pre-programmed to form attachments with others, since this will help them survive. Indeed, a child that has been emotionally neglected by one of his main caregivers, might not have been a victim of a physically or sexually aggressive parent, nonetheless the child would internalise the absence of warmth and physical affection as threatening, incredibly painful, confusing and difficult to navigate. A child depends for many years on his parents, in order to survive and thrive. And therefore, to a child, the prospect of disappointing a parent is a risky business. Chronically it would be painful, with many types of manifestations and physiological symptoms, like muscle spasms or butterflies inside the body. Not being able to process the experience of rejection or make any sense of it, the gut-brain axis constantly makes decisions on what is healthy and what is not. Eventually these decisions are introduced into our contextual world via stories that we imagine and tell ourselves. These early narratives have implicit deeply-rooted beliefs, not yet linguistically formulated but with clear sensorial messages and themes centred around unlovability, rejection, unworthiness or unacceptability. When finally expressed or spoken ‘out loud’, the language is as varied as individuals’ backgrounds, largely subjected to individuals’ culture, education, imagination and linguistic skills.

Perceived social threats such as criticism and rejection or the prospect of living alone, can be frightening because the gut does not like neglect or going without. Emotional neglect is a real threat in childhood, because it is synonymous with deprivation of essentials, including food and ultimately death. Humans bond to survive. The threat of being alone is basically unbearable to the gut and body by extension.

Deeply-Rooted Beliefs and Contextual-Acceptance

When He says, He is ugly, He also means ‘’The world does not like Me’… and this is the part that really frightens.

It could be speculated that emotional neglect is more impactful on the gut because of the physiological deprivation suffered by the organism. Deprivation of positive affection is associated with lack of appetite or compensatory appetite which leads to the production of specific enzymes and hormones. Whereas, with other types of exerted aggression, the gut suffers less organic deprivation, refocuses on healing, and learns to reprogramme itself allowing for adaption of the whole organism (Kaelberer M, et al., 2020). This could explain why in certain cultures, where physical discipline is widely spread, the actual ‘physical abuse’ does not lead to post-traumatic stress, and it has little or no impact on the immunity and physical health. This type of parenting is not perceived as abusive within the community at large because biologically, it is not significantly harmful, and the emotional dimension is invisible and easier to ignore. The parenting model is therefore normalised, perceived as efficient and often replicated by other families. These sophisticated lines of defence could be viewed as a type of socio-homeostatic process or organism’s attempt to repair and adapt itself through the practice of cultural values and contextual-acceptance.

Deeply-rooted beliefs therefore, may have a regulatory purpose and essentially teach the organism, or the body to adapt.

‘My dad was a little hard on me yesterday, sorry I could not meet you but, I was in a bit of a state’… Friend replies: ‘your dad is fine, you should meet mine… but to be fair, I still hate my homework and love to sneak out for a smoke’.

In a practical sense, to survive and even thrive in, what could be perceived as a harsh environment, requires normalising and acceptance of external living conditions, also coined in this paper, as ‘contextual-acceptance’. Whilst seeing the world through myopic unlovability lenses, James has to adapt to various contexts and whatever else life throws at him, in order to continue to survive and grow in spite of, a dominating felt-sense which strongly suggests he is unappreciated, and likely to be rejected.

‘Since nobody likes me, I have to make more effort than anyone else and behave in ways that will ensure I am safe – despite what everyone really thinks of me’, James would often think to himself, during moments of self-reflection. This type of contextual-acceptance can override the dominating gut-feeling, it leads to psychological adaptation and resilience. When contextual-acceptance is denied, an episode of emotional crisis would be inevitably triggered.

The regulatory quality of deeply-rooted beliefs, also means that they can be accompanied by both negative and positive affective experiences. Someone falling in love or desiring someone sexually feels an acute pain inside the body, within areas of the gut, but this is not registered in a negative manner by the brain and, since it is not a threat, it does not activate fear and avoidance.

By contrast, just thinking about food when hungry can lead to secreting specific enzymes and further compulsive eating behaviours. Going for a driving test can lead to feeling sick in spite of being well prepared. At times, people throw up when faced with social fears and other times they avoid a challenging test all together. It all seems to depend on the lenses the individual uses, because sure enough, when individuals look at the outside world through their unlovability lenses, the whole world would appear likely to reject them, no matter how well behaved they are. It takes effort and motivation to override the gut-feeling. Deeply-rooted beliefs therefore, create myopic lenses but contextual-acceptance heals the pain that comes with it.

Conclusions

Deeply-rooted beliefs have been characterised in the psychotherapeutic literature as schemas by Jeffrey Young (2003) and Paul Salkovskis (1996), core organising principles, often sounding like a code of honour, which the individual cannot afford to break, the cost would be too high, and yet consciously unknown. As such, James’ life was rigidly governed and guided by his unlovability and worthlessness telescope-type lenses.

DRBs are the lenses through which we see the world and ourselves. Supported and confirmed by the gut and with help from specific brain structures, they act as deeply rooted filters, allowing into our consciousness only what the gut-brain-axis feels is relevant to our survival. And as we have already established, the human gut and brain, are not concerned with our happiness or material wealth.

However, the axis is capable of both good and evil and can be persuaded to change and reprogramme the lenses through which we see our life, through an ample process of education and self-awareness, new learning and new coping practices, all key aspects of change. It appears that, just like with any other muscle, all organs inside our body need retraining with consistency over time.

There is nothing more captivating than an authentic story which can send clear motivational messages about meaningful changes and potential solutions. People have been preoccupied with sharing their ideas, personal stories, discoveries, and inventions for thousands of years. Historical writings and drawings on the cave walls are testimony to that fact. Telling ourselves and each other stories, is so embedded within our psychological framework, it has become an essential part of our existence, for where would we be, if it was not for our stories? We tell stories to confirm and justify our very existence.

It appears that stories are very likely, part of our genetical make up and therefore it is not much of stretch to consider that internal storytelling or the narratives we repeat to ourselves, are not only generated, but also perpetuated by our felt-senses or gut-feelings, designed to cement beliefs about who we are, how we could fit into our world, how we need to behave, and what our future prospects are.

Some of our gut decisions are truly worthy of our trust, but we have demonstrated how at times, the gut is misinformed by neglect and emotional deprivation. It falls onto the therapist to guide the patient⁴ with sensitivity, kindness and compassion, through the sea of vast, often stormy narratives, in order to make sense of the deeply-rooted beliefs’ images, sounds and smells, covert meanings and values.

Perhaps because deeply-rooted beliefs are primarily supporting a survival instinct, those are not always in sync with ideal and current personal values, generated by a fast pacing, ever-changing society. The modern world, the speed of development supported by human creativity, forces us to constantly work on redefining what authentic living means, based on contextual-acceptance.

Whatever this means for each individual, it can only be achieved by constantly refocusing the lenses through which we see ourselves and others, and override deeply-rooted beliefs that support an older way of living or dated values. Charles Darwin, a passionate evolutionary biologist, and author of ‘The origins of species’ (1859) might have been among the first to note that organisms, much like the human organisms with all their guts and brains, would never fail to either adapt or die. It is simply a question of survival.

The ‘Gut – Brain – Affect’ triangle: paving the way to future research and development

Traditionally, psychotherapists have been more interested in the interplay between mind, feelings and actions that lead to ‘psychological pain’ often without being able to answer questions about the subjective feeling of ‘suffering’. Where is all the ‘suffering’coming from, and what are its main characteristics?

The notion of ‘deeply-rooted beliefs’ attempts to answer this dilemma by proposing an investigation into the fascinating world of the ‘gut-brain-affect’ triangle. Searching for answers in an area, that has not been fully explored by psychology just yet, is more than challenging and leads to more questions than answers. At the same time, new and older research studies from physiology, nutrition, attachments, and neuroaffective-biology seem to open a world of therapeutic possibilities.

If the gut and the brain are in constant and autonomous communication (or outside of our awareness), and they make behavioural decisions for us all the time, then it is safe to assume that nutritional and other daily occupational habits, such as the proverbial rest, work, and play, could impact more significantly on our mental health, than ever anticipated (Mirea, 2023). We have always known this instinctively, but the bio-psycho-social processes operating in the background remain a mystery.

This review barely scratches the surface of an intricate world of internal highways of communication, hidden within the human infrastructure, which ultimately leads to behavioural and social decisions, every moment, of every single day. Decisions that ultimately, impact on our wellbeing, quality of life and overall existance.

The article certainly raises more questions than answers, we do not seem to fully understand all the mechanisms that support gut’s constant communication with the brain. But if indeed ‘we are what we eat’ then, psychologists and psychotherapists need to start paying more attention to how nutrition is impacting on our mental health, not just the physical health. Perhaps it falls on the domain of evidence-based psychology to align itself with relevant research from the fields of nutrition, physiology, or neuroscience, in order to better understand the individuals’ relationship with food, digestion, hormones and mental health as well as the environmental impact.

Some progress has been noted in understanding the links between the gut microbiome and depression, but much remains undiscovered and sadly, the psychotherapy community continues to remain silent and uninvolved. This article therefore assumes the risk of going into unchartered territories, potentially exposing many gaps within psychotherapy research. It points toward the sophisticated inner technology of the gut-brain-affect axis with significant implications for mental health treatments. Let’s consider for instance, the relationship between our integumentary system⁵, emotions, sensations of pain, pain management and mental health. This is an area insufficiently explored within psychology outside of the CBT and Hypno-CBT⁶ arena.

An example much closer to the subject discussed in this article, would be the potential value of investigating the intestinal chemical formula, that informs us when and if, a product is good for us, and as such, is it worth pursuing in the future. Products consumed are only good, when they are not poisonous for the system, but also when the situation or the context is favourable, in other words, where and when these are consumed. An example would be, when a serious meat eater goes to a new vegetarian restaurant in town that serves an almost too ‘adventurous’ menu for him. On paper this should be a failed event but the ‘context’ takes over completely and so if the individual is in good company, like a date or with someone he actually likes to spend time with, the affective-response changes to joy and pleasure. Through associated learning, a product becomes even more rewarding, and the experience is more likely to be repeated, if the place where the product was discovered, as well as the company kept at the time, were equally rewarding. Culture, existential and personal values, conditioning and social learning theories, memory and language processing, neuroscience, biology and nutrition, all these research domains come into this one simple social experience, which is repeated by tens of thousands of humans every day. Learning theories only partly explain these social decisions and bonding events because, there is an entire domain of the digestive and sensory system that we haven’t even began to articulate in this paper. The same could be said about the links between the digestion system, memory, and language processing. How we describe linguistically an experience, impacts on how we feel about it!

Developing psychotherapy tools such as NeuroAffective-CBT (NA-CBT), which successfully integrates research from all of above mentioned domains, could pave the way for a fourth-wave⁷ of evidence-based psychotherapy practices (Mirea, 2012). NA-CBT is a transdiagnostic approach, which means that it does not rely on a psychiatric diagnosis and a prescribed treatment protocol, that integrates successfully nutritional advice, physical strengthening programmes, sleep training, and bloodwork analysis (i.e., the TED model, Mirea 2005/2023) alongside traditional behavioural and cognitive interventions. Similarly, future fourth-wave schools of Integrative-CBT⁸ would aim to improve self-efficacy and enhance individuals’ ability to listen to their bodies, essential skills that claim control over immunity and health overall.

No longer separating the mind from the body in at least, some of the research, might be an obvious step in the right direction. And, perhaps accepting the inevitable – the practice of positive, evidence-based psychology, may be in total contradiction with what we are taught by society that we need, in order to be high achieving and forward moving in life. Modern culture is about learning to override the signals from the body though it seems, at least some of the time, the exact opposite is what humans need. Learning to listen to the signals from the body might be the one of the keys that open the door to healthier living.

Glossary:

¹The Mind, or the conscious mind, these terms simplistically refer to higher structures of the brain including the prefrontal cortex (PFC), the section of the brain located behind the forehead; this particular area may be responsible for decision making and finding solutions.

²Felt-Sense, Gut-Sense, Gut-Feelings are senses which act as reminders of previous experiences, designed to alert us of a potential reward or indeed, a threat. These terms are used interchangeably through the paper.

³DRBs: abbreviation for Deeply-Rooted Beliefs. DRBs could be defined as the dialectical expression of (internally experienced) felt-senses, which are translated linguistically later in life when language becomes available, those could in fact, be (verbally) expressed as late as adulthood, often during therapy for the first time. DRBs forge a rigid identity within individuals at an earlier stage in their lives and therefore are harder to modify outside of the therapeutic environment, evidence against DRBs is disregarded through mechanisms like mental filters, described in detail in this paper.

⁴Patient or Client are the same terms, used interchangeably through the article, usually depends on the situational context or where the therapist is likely to have a practice, at times we refer to our clients as patients or vice-versa.

⁵Integumentary system refers to the human skin and its structures, the other largest human organ, besides the human gut, which makes up to 16% of the body weight, and also interacts with the external world and further communicates with different parts of the nervous system constantly and autonomously.

⁶Hypno-CBT – Cognitive Behavioural Hypnotherapy, a transdiagnostic third-wave CBT approach introduced by Donald Robertson and further developed by Mark Davis. Training in Hypno-CBT is offered online and can be accessed here.

⁷Fourth-wave CBT or the fourth-wave of evidence-based psychotherapy practice refers to the stages of development within the field of evidence-based psychology, CBT in particular. First-wave is marked by extensive behavioural research, this is the foundation of CBT essentially; second-wave brings together research from cognitive psychology and behaviourism; third-wave introduces philosophy and emotional-regulation; fourth-wave is likely to bring along more digital interventions, neuroscience, neurobiology and physiology. For instance, having routinely a blood-test before psychotherapy starts could be considered good practice – since a blood test would point towards physical conditions that have mental health symptoms, like pre-diabetes (Mirea, 2023).

⁸Integrative-CBT, on short I-CBT was mentioned for the first time at the 9th International Congress of Cognitive Therapy in Transylvania in 2017 @Babes-Bolyai University, event which brought together more than 400 researchers and clinicians from all over the world, event was hosted by Prof. Daniel David, Beck J, Clark D, Hays S and, other renowned clinicians.

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Articles – NeuroAffective-CBT (neuroaffectivecbt.com)

M. Maya Kaelberer, PhD | Center for Gastrointestinal Biology and Disease (unc.edu)

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Acknowledgements:

This article could not have been finished without valuable guidance and input from Dr Donald Meichenbaum. Dr Meichenbaum is considered by most the ‘Freud of CBT’, one of the three main pioneers, alongside Aaron T Beck and Albert Ellis, of early cognitive and behavioural therapies. Dr Meichenbaum subsequently played an instrumental role in understanding violent trauma, aggressive behaviours, and human resilience.

Editing by Dr D Meichenbaum, SIT and CBT founder; proof reading by Ana Ghetu psychosocial researcher and Dr S Reilly clinical researcher and general practitioner.

Relationship-OCD, how is this ‘a thing’…?

March 11, 2024October 21, 2024 NeuroAffective-CBT by Daniel Mirea

One of the problems we encounter in the field of evidence-based, applied psychology, is the firm and long-established reliance on the medical-disease model. In a nutshell, this means that we must diagnose first, and then treat. This is both a blessing and a curse, since indeed we have excellent disorder-focused approaches and CBT protocols, which treat specific psychiatric disorders with some predictable outcomes. On the other hand, not everything we observe in our clinics is diagnosable. Certain emotional problems or psychological conditions do not fall within the strict remit of a psychiatric disorder, as listed under DSM- 5 or ICD- 11. In fact, if we look at the history of such diagnostic manuals, those were firstly published in the 1950’s and subsequently suffered several changes and revisions, every single version introducing new psychiatric conditions and assessment processes.

This might suggest that our understanding of certain psychiatric manifestations has evolved. Or perhaps the reliability of research methods has improved, or maybe clinicians are better aided by better scales and measures. Or is it simply the fact that humans’ needs evolve all the time and cultural values and lifestyles are constantly shifting? Perhaps it is, more than likely, a combination of all of the above. Whatever the case may be, I personally subscribe to the concept that we understand much better than ever, that emotional and mental health conditions are a lot more complex than what we currently find summarised in one or two diagnostic manuals. On the contrary, we are able to identify and clinically observe a lot more ‘variants’ to existing conditions, variants that ultimately fall in-between the cracks.

Within this context, indeed Relationship-OCD or R-OCD is ‘a thing’, a psychopathology without a category, much like clinical perfectionism, or the emotional problems resulting from attachment-disorders or shame-based disorders and so on, the only commonality within these syndromes is the sharing of characteristics from both the anxiety and mood disorders spectrum.

Sounds complicated? It doesn’t need to be… R-OCD could be understood as a type of anxiety, a close relative to obsessive-compulsive disorder where people experience intrusive thoughts and co-respondent compulsive behaviours related to their relationship with their partner. Such condition can create long ruminative episodes and repetitive thoughts that centre on doubts or fears about the relationship. The R-OCD vicitm may experience uncertainty about whether their partner really loves them, or whether the relationship will last. These thoughts can then lead to hypervigilance and reassurance-seeking or behaviours that are designed to obtain reassurance.

In NA-CBT, the pendulum formulation suggests that this intensively felt core-affect, experienced as guilt or shame (or another similar emotion we don’t yet have a label for), leads to specific behavioural and thinking patterns (in no particular order), that could be organised in three types of reinforcing trends, as indicated in the examples further below. These patterns can create a great deal of anxiety for the person experiencing R-OCD symptoms, and of course it would place a considerable amount of stress on the relationship itself. Behavioural strategies are compulsive and paired with justifying beliefs, for example ‘I deserve to suffer, I am a terrible person’.

As such, R-OCD is successfully maintained over years by several vicious traps. An early red flag, could be not succeeding to deal with compliments in a boundaried and appropriate manner. If, for example a young lady already in a loving relationship, comes across someone kind and complimentary, with or without desirable attributes, she may find herself obsessing over the unwanted thought that, ‘I should leave my partner’. This leads to more obsessive thoughts such as ‘Oh my God, I’m interested in this guy when I am already in a relationship’, and this leads to a lot of feelings of fear, shame, and guilt and inevitably a lot of uncertainty about the future of the relationship. As already explained this emotional state, further leads to specific urges, actions or compulsions like hypervigilance, safety-seeking, and constant reassurance, for example doing a lot of research on the topic or asking Google how others are coping. A series of unsuccessful neutralising, or suppressing unwanted thoughts about the new person, or wanting to leave the partner, thoughts about dishonesty, and needing to share these feelings (which are in fact thoughts) with the partner. Should such action take place of course it would very likely lead to a range of difficulties and discussions, which in a way confirms the initial intrusions that one should leave her partner and maybe his best friend is a better option after all, because he is not as difficult and as jealous. This leads to more feelings of distress, more thoughts, more compulsions, and more arguments, perpetuating a problem that seems to have no end in sight.

The Pendulum-Formulation in NA-CBT, can be particularly helpful because it makes the anxious person aware of embedded and automated habits that are often deeply buried underneath layers of thoughts, justifications, excuses, and co-respondent behaviours. This type of formula proposes that R-OCD individuals are driven to extreme overcompensation, avoidance, and other covert self-sabotaging strategies by an inexplicable core-affect of shame and guilt, what we sometimes call a ‘gut feeling’ or an instinct.

Examples of Overcompensation:

Googling, reading forums, reading psychology websites, magazines.
Asking boyfriend for reassurance that the relationships is going well, and they are still in love.
Checking pictures to make sure one feels the same, observing how the body reacts (positive or negative arousal).
Speaking to medical and/or mental health professionals.
Being very early at work, always on time, not to be seen as useless or bad. This action happens because the anxious individual is often seeking external validation since internal validation is not accepted or acceptable (e.g., I cannot trust my thoughts and feelings since I am bad person but at least at work, I can do a decent job.. sometimes.. at least according to my colleagues.. in any case, this is something I can control)
Working very hard at work or revising, or for a school test after a period of procrastination (this is an example of a pendulum – the relationship between overcompensation and procrastination).
Weighing myself or measuring my waist – am I good enough, am I attractive enough, almost always the answer is ‘No’ (this is yet another example of a pendulum – the relationship between overcompensation and surrendering).
Constant body and mind scanning for symptoms, signs of things going wrong with the mind or body.
Increased listening to podcasts / YouTube videos about similar issues – trying to convince oneself that either there is or there is not a problem (depending on the context).
Obsessively watching TV-programmes or YouTube videos about relationship problems.
Over-reading medical and scientific documents, even when/if most of the research does not make sense.
Writing manifestations, desires, or things one wants over and over again (often filling pages).
Obsessing over thoughts of shame and guilt and trying to reassure oneself.
Making mental lists and mental notes about the reasons they actually love their partners.
Over-analysing and constant reviewing of the content of thoughts and past memories.

Examples of Avoidance:

Isolating, staying away from the possibility of meeting the other person.
Staying away from partner because of feelings of guilt.
Pretending one feels unwell to the point of believing that one is unwell and to support that, one might even take several screening tests, like covid tests, etc.
Avoiding people, not getting back to them.
Avoiding using spare time more productively.
Avoiding TV or movies that might trigger fear, shame, guilt, or self-disgust. Also avoiding movies about breakups and illness.

Examples of Surrendering:

Surrendering into the core-emotion that suggests ‘I am fundamentally really bad’. Surrendering strategies may be understood as self-sabotaging since they appear well intended but in fact, such behaviours are often subconscious admissions of guilt and being a bad person. Depending on the context, those are over-exercised and therefore over-compensatory in nature, once again highlighting the pendulum effect of these strategies.

Examples:

Praying to God or praying on angel numbers – for a list of things that I want to happen (list grows, but things get taken off, if they come true).
Taking pictures of oneself – either where one looks skinny or checking the skin to track acne or chalazion. Emailing everything to oneself to make sure it doesn’t get lost.
When one is upset or sad or angry (i.e., after a fight) – not eating. Again, emailing everything to oneself to make sure it doesn’t get lost.
Self-talk: Since I am so bad let me show you how bad you really are… I deserve to be ill and/or alone… I deserve to be sad and depressed… I deserve the worst… writing a message in my head during landing on a plane to send to family in case plane crashes.
Urges to tell partner about the so-called ‘infidelity’ or about the thoughts of ‘infidelity’.
Only doing web-research on the incognito browser or deleting internet history (which is once again, a subconscious admission of guilt).

Screenshotting, taking and saving pictures to confirm and remember things that prove how bad the individual, yet another subconscious admission of ‘guilt’.
Neutralising and suppression of thoughts to the point of exhaustion… Scrolling on phone watching reels or TikTok’s to numb racing thoughts and ‘stop’ the brain from working so hard.
Keeping a diary/ calendar of being bad, or crazy or mental (in victim’s language).
Writing symptoms into calendar – to convince oneself of being mad or ill.
Surrender into a depressive state, where one is completely convinced about their level of guilt and responsibility for the break up. Characterised by low motivation and low mood.

In conclusion…

NeuroAffective-CBT proposes that just like the pendulum of a traditional clock, people oscillate or swing between maladaptive coping mechanisms without being aware of these complex behaviours and in doing so, they reinforce deeply rooted negative views about themselves.

SHAME & GUILT (Core-Affect)

Overcompensating – Surrendering – Avoiding

Visualise for a moment, how the core-affect of shame or guilt is positioned at the centre of the clock’s face, and it represents the very central mechanism behind it. This centre mechanism would not turn the clock if it wasn’t for the oscillating movements – in other words the affect of shame or guilt is reinforced by compensatory, avoidant and surrendering strategies that are very well rehearsed over the years. The relationship that such self-sabotaging mechanisms have with each other, through the swinging-effect action or the oscillating-effect, also perpetuate the psychologically painful and hidden affect of shame or guilt.

In the case of R-OCD, the pendulum’s consistent oscillating-effect is like a chain-reaction exercised time and time again which can be exemplified in how the person often overcompensates in order to surrender in order to avoid. For instance, spending too much time online researching, leads to taking screenshots and making notes about the newly discovered evidence of ‘being bad or guilty’; only to then finally surrender into a depressive state, where one is completely convinced about their level of guilt and responsibility. This becomes the perfect excuse for procrastinating from essential tasks that could demonstrate the exact opposite.

Such dynamics have to be sensitively explored over time with compassion, no judgement but a clear intention to change. A supportive behavioural plan usually involves modifying or eliminating completely these reinforcing mechanisms from a victim’s repertoire. Working toward an authentic living which involves meeting one’s true needs and values is the new agenda.

Proof reading and editing by Ana Ghetu

***

Disclaimer: this site and article are not intended as a self-help manual; the intention with all NA-CBT articles is to help and to develop knowledge. All case studies described are a combination of facts and very little fiction from different sources including personal clinical experiences. More similar work and great resources for inspiration, can be found on TedX -Treating Perfectionism, Brene Brown, Roz Shafran, Christine Padesky, Donald Meichenbaum’s notes on resilience, and others.

This particular article follows anonymised cases who received NeuroAffective-CBT for R-OCD… this is part of a series of free handouts offered to students on doctoral or advanced training programs in Integrative-CBT; certain details have been changed in order to maintain anonymity; the article includes specific questions at various crucial points ‘[in square brackets]’ raised by the author which are meant to trigger further enquiry and insights into the treatment.

For further training opportunities in Clinical Perfectionism as part of your NA-CBT or Integrative-CBT certification, click on this link: Treating the Perfectionist: CBT for Perfectionism Workshop – with Daniel Mirea, BABCP Accredited Psychotherapist – The UK College of Hypnosis and Hypnotherapy – Hypnotherapy Training Courses (ukhypnosis.com)

Further recommended reading:

What is Cognitive Behavioural Therapy and how does this approach differ from other types of psychotherapy models (audio)

Click to access sexuality-and-obsessivecompulsive-disorder-the-hidden-affair-neuropsychiatry.pdf

Tired, Exercise and Diet your way out of trouble, TED is your best friend !

July 18, 2023September 17, 2025 NeuroAffective-CBT by Daniel Mirea

In the adult comedy TED, a handsome, strong alpha male specimen, becomes emotionally attached to an unusual character, a much smaller in size but cute teddy bear, wise beyond his apparent years, in spite of relying a bit too much at times, on a rather ‘colourful’ vocabulary to make his point. The unlikeliest friendship is starting to evolve where our main character, the ideal alpha male, learns to rely on his best friend TED, during episodes of crisis and more.

Before understanding where and how TED comes in, it is important to explore the context and the current clinical climate. The standard approach to the treatment of psychopathology is rooted in the medical-disease model (MDM) which is essentially a causal model. In the case of depression and anxiety, the most common pathologies, those disorders occur (according to the MDM), as a result of a chemical imbalance or insufficient amounts of neurotransmitters like serotonin, norepinephrine and/or dopamine. As such, depression and anxiety are treated by replenishing these neurotransmitters with SSRI medication that helps specific brain cells or neurons either produce more of the chemicals or stop the chemicals from being broken down after they are produced, so that they remain in the system a little longer. This is the concept behind SSRI medication treatments – which is short for Selective Serotonin Reuptake Inhibitors. SSRIs are by far, the most appropriate medication for depression and/or anxiety to date, according to data.

However, recent research also points towards the limitations of the traditional medical-disease model. It appears that 95% of body’s serotonin, aka the ‘joy’ chemical, is produced in our gut, which is an extremely sophisticated system responsible for more than just straight forward digestion. The human gut is populated by microbiome, which is among other things, producing GABA (gamma-aminobutyric acid), a neurotransmitter that helps us feel calm and relaxed. And this is why our gut health is closely linked to our mental health. It suddenly becomes clearer why certain diets are more effective than others and, have a positive impact on mental health. An individual can support the gut diverse microbiome by eating foods which contain live bacteria, for example natural sources of pre & probiotics like Greek yoghurt, kefir, garlic, green bananas or sauerkraut.

Diving deeper into the area of affect regulation – emotional regulation or self-regulation, refers to our ability to exert control over our own emotional state. It may involve cognitive-behavioural, attention-training or imagery-based methods for example, self-hypnosis, self-to-self dialogue, rethinking a challenging situation to reduce anger or anxiety, hiding visible signs of shame, sadness or fear, or focusing on images that create a sense of joy or peace.

‘TED’ was introduced to the therapy scene more than 15 years ago as a self-regulation tool that brings attention to the Body-Brain-Affect triangle which significantly impacts on the quality of our lives and health overall according to the most recent research.

TED is like a personal guide, an imaginary trusted friend or simply a checklist with a series of specific reminders and actions which may be summarised in one statement: ‘Tired – Exercise – (and) Diet your way out of trouble!’

The “T”

“T” or ‘Tired‘ is the character symbol that represents being physically tired and exhausted which ought to remind us of the need for some basic sleep hygiene. It is perhaps, also symbolic of a new beginning by saying to yourself, ‘ aren’t you tired of it all ? Well then let’s sleep, exercise and diet your way out of this pickle…’

It is extremely well evidenced by now, that sleep deprivation is the number one risk factor for a range of mental health problems. In 20 to 30 years of research, we have not been able to discover a single psychiatric condition in which sleep is normal and this fact has taught me everything I need to know about this interesting relationship between healthy sleep and our mental health. I’m sure everyone has visited a friend who is also a parent on a bad day. Your friend looks up at you, holding their crying child, and they might explain to you that they all just didn’t sleep well the previous night. Parental knowledge that bad sleep the night before equals bad mood and emotional reactivity in regulation the next day is interesting. Sleep scientists became fascinated by this link years ago but could not really unearth the basic science that would help us explain what was going on. A team of experts at Berkley University conducted an initial study where they took two groups of healthy people with no signs of psychiatric illness or emotional instability. One group had the benefit of a healthy sleep, whilst the other group was sleep deprived. The following day, they had brain scans whilst being exposed to a whole range of emotional and unpleasant visual images. Scientists were looking at how the brain was reacting to those emotional experiences with sleep versus without sleep. The structure that they initially focused on, is called the amygdala a peanut size region situated closer to the spine for easier communication with the body. The amygdala seems to be one of the centre regions, though not the only one, for the generation of emotional reactions both positive and negative. And this fact is interesting in itself, since for many years, it was believed that this region is in charge of ‘fear’ and negative emotions only. So, people are being shown images with varying degrees of emotionality, including images that are known to evoke negative averse emotions, like fear, anger, disgust, revulsion and so on. It became almost immediately evident that, the sleep deprivation group increased the activity in the amygdala to such images by 60% – and this is relevant because we now have evidence that contexts or situations that previously do not feel particularly emotional would start to become rather emotional (leading instantly to states of negative arousal) when/if individuals are not getting sufficient sleep, because of a reactive amygdala and heightened sensitivity of the initial triggering of the emotional response. The reason for a reactive and uncontrolled amygdala during an episode of sleep deprivation lies within another structure – the medial prefrontal cortex, the frontal lobe, located between our eyes which, with a normal night of good sleep, remains strongly connected to the amygdala. It appears that, the human frontal lobe is very good at acting like a rational-control-mechanism on our deep emotional brain centres. But without sleep, the connection is severed and therefore without sleep individuals become emotionally sensitive and reactive with very little regulatory control.

To make matters worse, during a typical psychotherapy session, nobody seems to want to talk about sleeping patterns, although it is crucial for emotional regulation. It may be useful to not only identify the challenging aspects of sleeping well, but to also to identify some of the benefits that sleep can provide in the longer term.

Sleep training ought to be within the repertoire of every therapeutic plan. The basic rule of thumb is 8 hours of sleep during the night – and I mean during the night ! This is the time when metabolism switches off, the digestive system slows down, though different parts of the brain remain active, processing, re-organising data and memories and rebooting. The regulation of sleep is processed by the homeostatic physiology of the circadian rhythm, the sleep-wake cycle. Circadian rhythm is the 24-hour internal clock in our brain that regulates cycles of alertness and sleepiness by responding to light changes in our environment. As such, it is important to sleep during the dark hours, and this is easier said than done during the shorter summer nights. No strength training and definitely no food three to four hours (and even longer in some cases) before falling asleep would help improve the quality of the sleep with a direct impact on your bloodwork (blood test results).

Please consider following Dr Matt Walker’s research in this particular area; Dr Walker is a professor of Neuroscience and Psychology at the University of California, Berkeley, founder and director of the Center for Human Sleep Science, he delivers excellent presentations and workshops on a range of sleep relating topics.

The “E”

‘E‘ or ‘Exercise‘ is a symbol for physical strengthening and the need to exercise on a daily basis. Again, it has been shown time and time again that a daily regular routine does not only boosts the immunity but helps with hormonal regulation, protein synthesis (much like sleep does) and can help with a range of, if not all mental health conditions. In the following section ‘D’, we will explore the positive impact that muscle size and growth has on our glucose levels (and vice-versa), which brings further evidence that physical, in particular muscle-strengthening exercises, have indeed an impact on both our physical and mental health states.

This is in fact, in line with evolutionary theories since, it is clear that human bodies have not been built around static jobs and sugar-rich foods but on the contrary, humans evolved by being creatively active, often aggressive, which implies physical strenght, healthy and, thirsty for adventure and discovery. Humans used to be and, hopefully still are, the most ‘curious’ mammal species on earth. It is arguably this curiosity, alongside inner resilience and outer physical strength, that helped humans push boundaries and eventually ensured total domination of the world, as we know it.

Of course, it is important to remember that physical strengthening programmes ought to be individually tailored to age, sex and physical ability. And within the context of a (NA-CBT) therapy session at least, the advice must include not only muscle strengthening or ‘tensing’ exercises but also ‘muscle relaxation’ exercises. Because what tenses up has to also come down, in order to recover and, start again! This is usually achieved through a process called ‘Progressive-Muscle-Relaxation’ (PMR), consisting mainly of abdominal breathing and a focused attention. During this exercise, which was firstly introduced by Edmund Jacobson in the 1930’s, attention is gradually directed towards different muscle groups, tensing and relaxing different muscles and thus learning firsthand how feeling ‘tense’ versus feeling ‘relaxed’ actually feels. This would eventually train our mind and brain to recognise stress in the body, identify the exact location and de-stress the muscle by simply breathing the tension out of it. Certain types of Yoga and Mindfulness programmes are very useful in that regard and designed for this very purpose. And so, ideally and when physical health allows it, one should train daily and alternate between muscle strengthening exercises and relaxation or destressing-attention-training exercises like PMR, yoga or mindfulness.

It is equally appropriate to consider a condition-specific sport. For example, martial arts training would be particularly appropriate for someone who struggles with confidence, assertiveness or low self-esteem. Whereas social anxiety might be better aided by a team sport. At the other extreme, body building might not be appropriate for a male that suffers from BDD (or body dysmorphic disorder).

The “D”

‘D‘ or ‘diet‘ refers of course, to eating and drinking – the link between nutrition and mental health disorders is surprisingly straight forward and supported by a long list of studies and data, of course outside the field of psychology, where this field is largely ignored.

This is a significant oversight since evidently humans’ relationship with food is complex and integral to our survival. But humans relationship with food goes far beyond mere survival. Unlike other animals, we attach deep cultural, emotional, and even spiritual significance to what we eat. Fasting is a perfect example—it exists in many religious traditions, not just as a means of physical discipline but as a tool for spiritual growth, self-purification, or even social solidarity.

Food also plays a role in identity, social bonding, and rituals. Think about how different cultures celebrate major life events like weddings, funerals or holidays, all with very specific foods that carry particular meaning. Even our personal comfort foods often tie back to childhood memories and emotions. One could argue that cultural influence sometimes overrides nutritional logic. For instance, people might continue eating traditional diets even when they’re not the healthiest option.

There is a growing body of research showing an association between our diet, internal inflammation and depression, pointing in particular toward a Mediterranean style diet which can lead to a 30% reduction in symptoms of depression, alongside 40% improvement in cognitive flexibility. This is related to internal inflammation which contributes to the activation and maintainenance of mental health symptoms. Inflammation is dangerous and could lead to many health complications associated with chronic conditions such as insuline resistance, pre-diabetes, diabetes, large deposits of visceral fat, cardiac problems, etc. Healthy diets are anti-inflammatory and, are rich in B-vitamins and folate which is equally important for brain function. It has been demonstrated that a healthy diet helps improve neuroplasticity which in turn improves new learning and cognitive flexibility.

Let’s examine another area of particular relevance. According to WHO, at least one billion people in the world have diabetes or pre-diabetes, mainly characterised by unhealthy glucose levels (spikes) and insulin resistance. The interesting thing about diabetes is that it does not have many aggressive physical symptoms to begin with, but a lot of mental health symptoms such as worry, other types of negative thinking, sleeplessness, irritability, short temper, lack of motivation, lower libido, low confidence, in other words recurring episodes of depression and/or anxiety. So, this condition often goes under the radar, until eventually discovered by accident. At the same time, most mental health practitioners would not be inclined to request a blood test during the initial consultation. And yet, treating the patient for depression or anxiety without dealing with the underlying chronic condition, cannot possibly lead to long lasting positive outcomes.

Consuming large amounts of foods, rich in sugar or carbs (carbohydrates) or starches (white bread, rice, pasta, potatoes, etc.) is very easy these days, those are widely available, cheap and tasty and, even comforting, not least because all such products lead to the release of high levels of dopamine which translates affectively into ‘pleasure’ and eventually an addiction to specific glucose rich products. In fact, the neurobiological and behavioural process is not much different from an addiction to alcohol or cocaine.

Sugar addiction is indeed a ‘thing’ and probably the modern world’s number one enemy. Here is why… Glucose in excess is stored in the form of fat which leads to an array of chronic problems including faster aging of various organs, diabetes and cardiac complications alongside mental health symptoms from the depression and anxiety spectrum. Glucose is in fact useful, even essential to the human body since it ought to provide the right amount of energy in order for the organism to survive and thrive, but when you have too much of it, the body eventually collapses under the pressure, much like a plant that is watered too much and drowns. At some point, one continues to ‘need’ sugar since the organism is addicted to the glucose but ironically the individual feels weaker and less energised because after years of sugar-abuse, one becomes overweight, suffering with diabetes or cardiac problems or worse.

There are basically several processes that take place in the body when one experiences regular glucose spikes. Glucose is over-supplied and stored into fat cells for later use, this increases inflammation in the body and accelerates the process of glycation, which is an aging of the cartilage. This translates into the internal aging of various organs and externally, the aging of the skin and, this is just for starters.

In response to excessive glucose, the pancreas sends a hormone called insulin out in the body, to grab all the extra glucose molecules and store them away, so they do not cause any damage. The insulin therefore, stores glucose into the liver, and muscles and then, when those are fully stocked, the insulin starts storing glucose away into fat cells which is one of the ways that an individual builds a lot of visceral fat. Muscular people and those who practice sports regularly are at an advantage at this stage, because big muscles need more energy. But for everybody else, the insulin itself has consequences and is the main driver of type-2 diabetes and insulin resistance.

What happens inside the gut is equally fascinating and gives a whole new meaning to the saying ‘Trust Your Gut‘. Scientists, like Dr Maya Kaelberer and colleagues, have established clear links between our gut and the brain, not necessarily through an analysis of the diversity of the microbiome that exists within our gut, although this would be equally relevant but also by paying attention to the actual structure of the gut at a cellular level. Dr Kaelberer discovered a pathway from the gut directly to the brain that essentially allows sensing of what is happening in the gut in order to inform specific ‘feelings’ of pleasure or disgust or cravings, which is incredible, and it partly explains why regular practising of mindfulness or paying calm attention inwards, could lead to a shift in feelings and better emotional regulation. This process happens via neuropod cells with electrical sensors within the gut structure that are able to select and specialise in various chemicals like glucose or amino acids, they organise digestion and send information (electrical signals) to the brain which will make further ‘informed’ decisions and it would eventually provide an individual with the full experience of what it means to consume sugar, both the pleasure and increased energy. Experiments on mammals like mice, have shown a preference towards sugary-water over aspartame-water which suggests that even though both type of liquids are sweet, gut cells have adapted for the full experience of glucose resulting from proper sugar and therefore the proper sugar-water is chosen every time even in the absence of other conditioning stimuli, like prettier labels, packaging and so on. Some cell sensors have even adapted to detect the temperature of a hot cup of tea and adjust the temperature within two seconds in order to accommodate the liquid inside the gut and successfully extract necessary nutrients.

So, the secret has been out for some time… indeed, you are what you eat… and research clearly shows that how, when and what we eat and drink throughout the day makes a difference to our mental health. On apositive note, this seems to be an area of growing interest, and as such, the internet is simply overwhelmed with interviews, podcasts and articles on this topic. With the risk of sounding like a broken record, I would attempt to recount some fun facts from recent research studies that correlate wellbeing with nutrition and have clinical implications for therapists.

About the all-important “C“

In addition to considering the impact that a daily diet has on mental health, research has also started to focus on the role of specific vitamins and minerals. Vitamin C is one such micronutrient that has drawn significant attention in the diet and well-being landscape. Vitamin C is in fact one of the few hormones that humans do not naturally produce, hence our predisposition to fruits and vegetables. In fact, if one considers the human anatomy, we could easily notice that we are a particular type of mammal lacking in the department of adequate equipment for the consumption of tough or raw animal meat. Most of us, do not possess strong fangs or tough long nails, therefore historically, it has always been much easier to rely on a vegetarian or even vegan diet, evidently rich in vitamin C and fibers. Not only that, but this simple water-soluble micronutrient that humans, along with several other species, are unable to synthesize themselves, remains an absolute requirement for a range of important biological functions. This contradiction between an absolute requirement for vitamin C and our species’ loss of ability to synthesise it, has been explained earlier, as such our early ancestors relied on diets rich in vitamin C which led to the eventual pruning of genes involved in endogenous vitamin C synthesis. Therefore, vitamin C must be obtained exclusively from diet, principally through the consumption of fruits, vegetables or more recently supplements. Vitamin C acts as an antioxidant and free radical scavenger and is an essential cofactor in numerous enzymatic reactions including that of dopamine β-hydroxylase, an enzyme that is central to the synthesis of adrenaline from dopamine. Vitamin C also acts as an essential cofactor in the metabolism of tryptophan, a necessary requirement for the synthesis of serotonin. Altered dopamine β-hydroxylase activity has been described in a range of psychiatric conditions including mood and anxiety disorders and disorders of the digestive tract and acute tryptophan depletion has been associated with reduced serotonin levels and lowered mood states. Emerging work in the field of epigenetics indicates that vitamin C contributes to epigenetic modifications in early development which in turn may influence key psychological and physiological outcomes across the lifespan. Reinforcing its role in neurocognitive functioning, the highest concentrations of vitamin C in humans are found in the brain and cerebrospinal fluid and vitamin C is preferentially retained in these areas even when plasma and other organs in the body are depleted of vitamin C.

There are several other important supplements which impact on our mental health, that are currently being investigated including magnesium, zinc, also proteins, and of course links have been established between depressive states and our gut bacteria. Results are conclusive enough for general medicine to at least start paying more attention.

About the “Mg“

Both physical and emotional stress, a constant reality in our multi-tasking society, drain the body of magnesium. In fact, studies show inverse relationships between serum cortisol and magnesium, the higher the magnesium, the lower the cortisol. Stress robs the body of magnesium, but the body must have magnesium to respond effectively to stress. Magnesium deficiency afflicts 90% of all people with ADHD and triggers symptoms like restlessness, poor focus, irritability, sleep problems, and anxiety. These symptoms can lessen or vanish one month after supplementation starts. And furthermore, magnesium can also prevent or reverse ADHD drug side effects.

Chronic stress and sleep deprivation due to exam stress impairs the blood flow and reduces intracellular magnesium levels according to observational studies (Takase et al., 2004).

Clinicians found that 125 to 300 mg of magnesium glycinate at meal times and at bedtime produces clinically significant benefits in mood. This form of magnesium is gentle on the digestive tract. 200 to 300 mg of magnesium glycinate or citrate before bed supports sleep onset and duration through the night. We also know that sleep deprivation can deplete magnesium levels and this creates a cycle affecting sleep quality. Observation studies have shown that adults with higher dietary magnesium intake often report better sleep quality.

Magnesium in powder or liquid form could be effective alternatives to capsules, particularly for children with ADHD. Ways to increase the bioavailability of magnesium include supplementing with vitamin D3, which increases cellular uptake of the mineral. Vitamin B6 also helps magnesium accumulate in cells. Taking the mineral in divided doses instead of a single daily dose. Taking it with carbohydrates, with improves absorption from the intestine. And taking an organic form, such as glycinate or citrate, which improves absorption by protecting the mineral from antagonists in the digestive tract. It may be best to avoid giving magnesium in enteric-coated capsules, which decreases absorption in the intestine. Magnesium oxide is poorly absorbed and tends to cause loose bowels. Magnesium-l-threonate has been shown to readily cross the blood-brain barrier, and animal studies show that it supports learning ability, short and long-term memory and brain function.

It may be important to highlight, that the therapeutic response to magnesium normally takes several weeks, as levels gradually increase in the body.

Although a lot less research on this topic is carried out in the UK in the US there is a growing interest. A cross-sectional, population-based data set, the National Health and Nutrition Examination Survey, was used to explore the relationship of magnesium intake and depression in nearly 9,000 adults. Researchers found significant association between very low magnesium intake and depression, especially in younger adults. And in a recent meta-analysis of 11 studies on magnesium and depression, people with the lowest intake of magnesium were 81% more likely to be depressed than those with the highest intake.

About the fatty acids “Omega-3“

Significant research supports the consumtion of anywhere between 1000-2000mg daily of Omega-3 fatty acids, found in fish oil (supplements or natural sources). It has been shown to have significant effects on focus and concentration levels as well as levels of depression. EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) found in Omega-3, are equally beneficial for heart health and help reduce internal inflammation.

Research specifically indicates that supplementation with around 1000 mg of EPA daily can provide relief from depressive symptoms comparable to some traditional antidepressants like SSRIs. In studies, 1000 mg of EPA was found to be as effective as fluoxetine in reducing symptoms of major depression 1. EPA is thought to exert its effects by influencing neurotransmitter systems and reducing inflammation in the body, which has been linked to mood regulation. Studies have shown that higher dietary ratios of omega-3 to omega-6 fatty acids can result in significant mood improvements, potentially lowering the risk of depression 1. It has been suggested that individuals consider taking 1000 mg to 2000 mg of EPA daily for optimal mood enhancement. Additionally, some individuals may find that combining EPA with lower doses of SSRIs could enhance the overall antidepressant effect and reduce side effects associated with higher SSRI doses 2. Overall, the inclusion of omega-3 fatty acids in one’s diet can be a valuable strategy for improving mood and managing depressive symptoms, suggesting a multifaceted approach to mental health that combines dietary, exercise, and therapeutic techniques.

And finally… “Creatine“, not just for athletes !

Creatine, a naturally occurring compound known for its role in energy metabolism, has long been used as a dietary supplement to boost physical performance. It plays a key role in producing adenosine triphosphate, the main energy source for cells, which is critical for maintaining optimal cellular function, especially during periods of high energy demand. Recent clinical studies have started to explore creatine’s antidepressant potential. Both animal and human trials have shown early evidence of creatine’s positive effects on mood. In animal models of depression, creatine has been found to reverse depression-like behaviors, improve brain plasticity, and modulate key areas of the brain involved in mood regulation, with some trials in particular, indicating that creatine can improve symptoms of major depressive disorder and bipolar depression, especially when used alongside standard antidepressant treatments such as SSRI’s (Juneah et al., 2024).

So what do we really know and what can we do about it…

One of the most compelling frameworks within NA‑CBT is the TED module, which uses an imaginal friend or a personal coach or a guide to help maintain focus on a daily basis on essentially what could only be described as significant lifestyle changes that aim to improve health and immunity overall as well as psychologically increase self-appreciation and self-love. Tiredness, Exercise, and Diet, each of these areas have strong empirical links to emotional and cognitive wellbeing.

Tiredness (lack of sleep):
Poor sleep disrupts both emotion regulation and brain function. Insomnia is strongly linked to heightened emotional reactivity, reduced cognitive control, and increased risk for mood disorders (Baglioni et al., 2011; Goldstein & Walker, 2014). Research shows that high sleep quality is associated with more effective use of adaptive cognitive emotion regulation strategies, such as reappraisal, which are in turn linked to lower self-reported levels of depression and anxiety (Palmer & Alfano, 2017; Kalmbach et al., 2018). Conversely, sleep deprivation impairs top-down regulation mechanisms like distraction and reappraisal, leading to heightened emotional reactivity (Ben Simon et al., 2020; Mauss et al., 2013). NA‑CBT therefore prioritizes sleep tracking and the promotion of restorative sleep within its treatment model.

Exercise:
Aerobic and regular physical activity produce significant benefits for emotional health. These include improved emotion regulation, reduced stress hormones, enhanced mood, and reductions in depression and anxiety comparable to psychotherapy or pharmacotherapy (Craft & Perna, 2004; Kandola et al., 2019). Exercise improves neurotransmitter balance (e.g., serotonin, endorphins), increases BDNF (brain-derived neurotrophic factor), and reduces cortisol levels, enhancing neuroplasticity and emotional resilience (Phillips, 2017). A large meta-analysis found that combining exercise with CBT improved depression outcomes more than CBT alone (Stathopoulou et al., 2006).

Diet:
Diet quality, especially one rich in fruits, vegetables, whole grains, and omega-3 fatty acids, predicts better mood, reduced symptoms of anxiety and depression, and improved emotional resilience (Lassale et al., 2019; Jacka et al., 2010). Although the evidence base for diet as a standalone treatment is less extensive, it is increasingly recognized as a major contributor to mental wellbeing. For example, in a study of the “Big Three” predictors of mental health, sleep quality emerged as the most important, but both physical activity and healthy diet significantly contributed to lower depressive symptoms and greater overall flourishing (Conner et al., 2017). Nutritional psychiatry has also linked ultra-processed diets to increased systemic inflammation and poorer mental health, while whole-food diets support improved mood and cognition (Marx et al., 2021).

It may be equally important to understand that an increase in fibers, proteins and pre/probiotics in parallel with a significant decrease in glucose-based products, including carbs will bring a lot of benefits to mental health and reduce internal inflammation, improve immunity and decrease the chance of telomere degradation, associated with age-related diseases.

A recent cross-sectional study surveying university students found that poor sleep, suboptimal diet, and low physical activity were independently associated with worse cognitive function, emotional regulation, mood, and stress resilience (Schlitt et al., 2022).

Implications for Psychotherapy Practice

Lifestyle–mental health integration: The TED model (Tired, Exercise, Diet) highlights modifiable factors that strongly influence craving intensity. Therapists can incorporate sleep hygiene, physical activity, and mindful eating into treatment plans, reinforcing how daily habits affect emotional regulation and impulse control.

Craving as learned response: By framing cravings as conditioned associations between flavors, energy states, and reward pathways, therapists can apply established behavioral techniques (exposure, response prevention, habit reversal) to weaken these associations.

Psychoeducation tool: TED provides a simple language to explain to clients how body states drive cravings, reducing self-blame and empowering clients with self-regulation strategies.

Motivation and self-efficacy: A structured model allows therapists to set small, trackable goals (e.g., improving sleep regularity, reducing ultra-processed foods, introducing movement) that can strengthen self-efficacy and reinforce broader therapy progress.

Integration with Neuroscience: The TED model, integrated into NeuroAffective-CBT, represents a natural progression in psychotherapy’s dialogue with neuroscience. By explicitly linking lifestyle-driven neurobiological states (e.g., sleep-hormone regulation, dopaminergic modulation via exercise, gut–brain signaling through diet) with cognitive and behavioral processes, it enriches the therapeutic toolkit with embodied, brain-based leverage points.

This emphasis dovetails with third-wave approaches such as ACT and DBT, which already foreground acceptance, mindfulness, and values-based action. TED/NA-CBT add a physiological grounding to these practices, showing how shifts in bodily states can either amplify or hinder psychological flexibility, emotion regulation, and distress tolerance. In this way, TED and NA-CBT are not alternatives but extensions, providing therapists with a language and structure to operationalise lifestyle neuroscience within established third-wave paradigms. The broader implication is the emergence of what could be called a fourth wave of CBT:

First wave: Behavioural conditioning (observable learning).
Second wave: Cognitive restructuring (thought–emotion links).
Third wave: Contextual and acceptance-based models (ACT, DBT, mindfulness).
Fourth wave (emerging): Neuroscience-informed, embodied CBT, explicitly integrating brain, body, and lifestyle science into psychotherapeutic practice.
This “fourth wave” is not about replacing previous waves but synthesising them, using neuroscience as a unifying lens to explain why behavioural and cognitive interventions work and how therapists can amplify their effects by attending to bodily states.
Forth wave CBT ought to also evolve and include an understanding at both micro (interanal world) and macro level (external world). For instance what are the true implications of the recent digitalisation of life and the increase reliance on AI platforms, how can this be used effectively in therapy.

Final thoughts…

By embedding empirical findings into the TED framework, NA‑CBT demonstrates both depth and scientific integrity, bridging theory, neuroscience, and lifestyle-based interventions. This strengthens the model’s relevance to contemporary therapeutic challenges, indeed a worthy model belonging to the the latest wave of cognitive and behavioural therapies. Within the new field of NeuroAffective-CBT, TED is one of the most compelling self-regulation frameworks. It uses the idea of an ‘imaginal friend‘ or ‘inner guide‘ to help the client stay focused on daily choices that support meaningful lifestyle changes at a micro and macro level. These changes strengthen both physical health and immunity while also building psychological resilience, self-appreciation, and self-love preparing the individual for confident relationships in the future.

It has been evident for some time that a better sleep, a healthier diet and more physical activity can improve our health overall. We now know that, the big three – T, E & D (aka my good friend TED) can no longer be separated from our need to evolve and remain balanced. We still do not have a clear idea about all of the mechanisms involved, and what is worse, research is divided, confusing and split between different areas of interests within medicine. However, the good news is that we know enough already to make informed and correct decisions and new research, alongside non-intrusive technology offer incredible insights.

A final and very important reminder – these articles do not aim to substitute real professionals or live clinical assessments. Regular bloodworks and health-checks via GPs or family doctors are a must post-adolescence but not only, if we are to consider a consistent increase in the incident of diabetes reported within the adolescent population. It would be wise to use regularly a personal trainer, a qualified a nutritionist or even consider an assessment with your NeuroAffective-CBT therapist, who will no doubt look at your bloodwork and try to understand how your lifestyle, daily choices and habits, impact on your mental health. Supplements in general, cannot and should not, replace psychiatric medication they operate differently and at a completely different level. However, some of the supplements mentioned in this article would very likely improve your prospects and perhaps bring you closer to your goals and health aspirations.

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