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Our minds can sometimes feel like a battleground of different thoughts competing with one another. In this exercise, you’ll be asked to write a fictional dialogue between your “positive self” and “negative self.”
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Steven Handel
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Conquer your social fears one step at a time by climbing up your “Anxiety Hierarchy.” Here’s a simple and powerful worksheet to get you started.
Social Anxiety Hierarchy Worksheet (PDF)
This worksheet mentions several mental tools and relaxation techniques that are essential for making the most of your anxiety hierarchy. Here are links to learn more about each one.
Mental Tools:
Relaxation Techniques:
Further Reading:
Check out more self-improvement worksheets here!
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Steven Handel
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About four years ago, a new patient came to see me for a psychiatric consultation because he felt stuck. He’d been in therapy for 15 years, despite the fact that the depression and anxiety that first drove him to seek help had long ago faded. Instead of working on problems related to his symptoms, he and his therapist chatted about his vacations, house renovations, and office gripes. His therapist had become, in effect, an expensive and especially supportive friend. And yet, when I asked if he was considering quitting treatment, he grew hesitant, even anxious. “It’s just baked into my life,” he told me.
Among those who can afford it, regular psychotherapy is often viewed as a lifelong project, like working out or going to the dentist. Studies suggest that most therapy clients can measure their treatments in months instead of years, but a solid chunk of current and former patients expect therapy to last indefinitely. Therapists and clients alike, along with celebrities and media outlets, have endorsed the idea of going to therapy for extended stretches, or when you’re feeling fine. I’ve seen this myself with friends who are basically healthy and think of having a therapist as somewhat like having a physical trainer. The problem is, some of the most commonly sought versions of psychotherapy are simply not designed for long-term use.
Therapy comes in many varieties, but they all share a common goal: to eventually end treatment because you feel and function well enough to thrive on your own. Stopping doesn’t even need to be permanent. If you’ve been going to therapy for a long time, and you’re no longer in acute distress, and you have few symptoms that bother you, consider taking a break. You might be pleasantly surprised by how much you learn about yourself.
Therapy, in both the short and long term, can be life-altering. Short-term therapy tends to be focused on a particular problem, such as a depressed mood or social anxiety. In cognitive behavioral therapy, usually used for depressive and anxiety disorders, a clinician helps a client relieve negative feelings by correcting the distorted beliefs that he has about himself. In dialectical behavior therapy, commonly used to treat borderline personality disorder, patients learn skills to manage powerful emotions, which helps improve their mood and relationships. Both treatments typically last less than a year. If you start to get rusty or feel especially challenged by life events that come your way, you simply return for another brief stint. Termination is expected and normal.
Some types of therapy, such as psychodynamic therapy and psychoanalysis, are designed to last for several years—but not forever. The main goal of these therapies is much more ambitious than symptom relief; they aim to uncover the unconscious causes of suffering and to change a client’s fundamental character. At least one well-regarded study found that long-term therapy is both highly effective and superior to briefer treatment for people diagnosed with a clinically significant psychiatric illness; other papers have shown less conclusive evidence for long-term therapy. And few studies compare short and extended treatment for clients with milder symptoms.
In fact, there’s reason to believe that talk therapy in the absence of acute symptoms may sometimes cause harm. Excessive self-focus—easily facilitated in a setting in which you’re literally paying to talk about your feelings—can increase your anxiety, especially when it substitutes for tangible actions. If your neurotic or depressive symptoms are relatively mild (meaning they don’t really interfere with your daily functioning), you might be better served by spending less time in a therapist’s office and more time connecting with friends, pursuing a hobby, or volunteering. Therapists are trained to use the tools they’ve learned for certain types of problems, and many of the stress-inducing minutiae of daily life are not among them. For example, if you mention to your therapist that you’re having trouble being efficient at work, he might decide to teach you a stress-reduction technique, but your colleagues or boss might provide more specific strategies for improving your performance.
One of my childhood friends, whose parents were both psychoanalysts, went to weekly therapy appointments while we were growing up. He was a happy, energetic kid, but his parents wanted him and his sister to be better acquainted with their inner lives, to help them deal with whatever adversity came their way. My friend and his sister both grew up to be successful adults, but also highly anxious and neurotic ones. I imagine their parents would say the kids would have been worse without the therapy—after all, mental illness ran in their family. But I can find no substantial clinical evidence supporting this kind of “preventive” psychotherapy.
Beginning therapy in the first place is, to be clear, a privilege. Therapy is not covered by many insurance plans, and a very large number of people who could benefit from it can’t afford it for any duration. Only 47 percent of Americans with a psychiatric illness received any form of treatment in 2021; in fact, federal estimates suggest that the United States is several thousand mental-health professionals short, a gap that is likely to grow in the coming years. Stopping therapy when you’re ready opens up space for others who might need this scarce service more than you do.
I do not mean to suggest that a therapy vacation should be considered lightly, or that it’s for everyone. If you have a serious mental-health disorder, such as major depression or bipolar disorder, you should discuss with your mental-health provider whether ending therapy is appropriate for your individual situation. (Keep in mind that your therapist might not be ready to quit when you are. Aside from a financial incentive to continue treatment, parting with a charming, low-maintenance patient is not so easy.) My rule of thumb is that you should have minimal to no symptoms of your illness for six months or so before even considering a pause. Should you and your therapist agree that stopping is reasonable, a temporary break with a clear expiration date is ideal. At any time, if you’re feeling worse, you can always go back.
Psychiatrists do something similar with psychiatric meds: For example, when I prescribe a depressed patient an antidepressant, and then they remain stable and free of symptoms for several years, I usually consider tapering the medication to determine whether it’s still necessary for the patient’s well-being. I would do this only for patients who are at a low risk of relapse—for example, people who’ve had just one or two episodes, rather than many over a lifetime. Pausing therapy should be even less risky: The beautiful thing about therapy is that, unlike a drug, it equips you with new knowledge and skills, which you carry with you when you leave.
About a year after my patient and I first talked about ending therapy, I ran into him in a café. He told me that stopping had taken him six months, but now he was thriving. Maybe you, like my patient, are daunted by the idea of quitting cold turkey. If so, consider taking a vacation from treatment instead. It might be the perfect way to see how far you’ve really come.
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Richard A. Friedman
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According to “common factors theory,” the essence of successful therapy lies in shared core elements, and the differences between therapeutic approaches are often less important than fulfilling these fundamental criteria.
One frequent question people ask themselves when they first decide to seek therapy is, “What type of therapy should I get?”
There are many different types of talk therapy to choose from. Often specific types of therapy are geared toward specific mental disorders. Cognitive-Behavioral Therapy is common for depression and anxiety disorders, Dialectic Behavioral Therapy is common for bipolar and mood disorders, and EMDR is common among those with PTSD.
How much do these therapies differ? How much does it matter?
One interesting idea in psychology is “common factors theory.” The basic premise is that effective therapy isn’t necessarily based on any specific type of therapeutic tool or technique, but rather there are underlying factors behind all therapies that make them successful.
Many therapeutic systems have been invented over the past century. Today, every popular therapist or coach has their own trademarked brand that’s sold as the absolute best approach to mental health.
The less glamorous truth is that most successful therapies aren’t special. There’s significant overlap between different approaches, with a couple extra bells and whistles. However, at the end of the day the biggest reason they are successful is because they all meet fundamental criteria.
Below you’ll learn more about these “common factors” behind successful therapy, including: collaboration, empathy, alliance, positive regard, genuineness, and individual differences.
One interesting study identified 6 common factors behind all “evidence-based” therapy. They also calculated estimates on how much each factor contributed to the overall variability of therapeutic outcomes.
Here are the 6 common factors behind all successful therapy:
These are the 6 most common factors behind successful therapy. They account for ~50% of the total variability in therapeutic outcomes, so there are still many other factors at play.
In truth, different types of therapies have their advantages and disadvantages, and certain approaches may work better for some and not at all for others.
Regardless of the system, successful therapy often needs to meet the basic requirements listed above. Without these common factors being met, no technique or approach is going to work.
A therapist needs to be flexible in their approach and try not to force fit everyone into their preferred model.
The more a person is trained and/or educated on a specific field in psychology, the more they seem to be “locked in” to only one way of observing the human condition. They don’t talk to people as human beings at face value, but instead think, “How does this person fit into my cognitive/behavioral/psychodynamic/evolutionary model?”
Expertise (and overspecialization) can narrow vision. A certain element of beginner’s mind is the best approach to therapy. Start with the basic questions, “Who is this person? What do they care about? What makes them tick? What do they want to change?”
Assume nothing and ask questions. Learn about the person from scratch. Connect to them human-to-human and see where it goes.
More concerning, certain therapies have become popularized and over-hyped in recent years. They’ve turned into commercial brands. “Cognitive-behavioral therapy” has become a buzzword in many circles because the average person associates it with the only “evidence-based” therapy.
Of course I’m not against specific therapies. I’ve learned a lot of helpful tools and techniques from various systems (including CBT) that I still practice today.
At the end of the day, I’m a pragmatist, so there’s almost no therapy, treatment, medication, or technique I’m 100% for or against. If it helps just one person, then it’s that much effective.
However, in general, a good therapist needs to have a comprehensive understanding of how humans work. Tools and techniques can be in your back-pocket, but first and foremost you need to approach people as individual human beings seeking growth.
Successful therapy can’t be reduced to a checklist.
This topic reminds me of an old series of videos known as the Gloria Tapes.
It was an educational film made in the 1960s to teach psychology students the differences between therapeutic approaches.
The series follows a single patient, Gloria, who receives therapy from three distinguished psychologists of the time: Carl Rogers, Fritz Perls, and Albert Ellis.
The therapy is limited since it’s only one session each, but you can get a good understanding of the radically different approaches by each therapist.
You can watch each of the sessions here:
Each of these videos reveals a different approach to therapy.
Albert Ellis is most aligned with modern cognitive and rational-based approaches. Carl Rogers has a more gentle and humanistic approach. Fritz Perls has a direct and provocative approach (almost to the point of bullying).
If I remember correctly, the patient Gloria felt the most comfortable with Rogers, but she actually went for a second session with Perls. I don’t know how to interpret that – it’s possible she felt “unfinished business” with Perls or she simply enjoyed arguing with him.
None of this says anything about “successful therapy.” Just one session isn’t adequate to measure “success” vs. “failure” when it comes to a long-term process like self-growth. However, these examples will give you a taste for the different types of therapies out there.
Ultimately, successful therapy depends on both therapist and patient. The most important factor is to have a healthy, working relationship and a “build together” attitude. Once you have that foundation, anything is possible.
Stay updated on new articles and resources in psychology and self improvement:
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Steven Handel
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Ready for a major lifestyle change? Uncover successful strategies when embracing the “cold turkey” approach to break bad habits, making the process of change both easy and manageable.
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Steven Handel
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How effectively can you explain yourself to others? Learn to embrace the healthy challenge of describing your beliefs to sharpen your thinking and worldview.
The post Explain Yourself: The Healthy Challenge of Describing Your Beliefs appeared first on The Emotion Machine.
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Steven Handel
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Here is a straightforward, clinical description of a migraine: intense throbbing headache, nausea, vomiting, and sensitivity to light and noise, lasting for hours or days.
And here is a fuller, more honest picture: an intense, throbbing sense of annoyance as the pain around my eye blooms. Wondering what the trigger was this time. Popping my beloved Excedrin—a combination of acetaminophen, aspirin, and caffeine—and hoping it has a chance to percolate in my system before I start vomiting. There’s the drawing of the curtains, the curling up in bed, the dash to the toilet to puke my guts out. I am not a religious person, but during my worst migraines, I have whimpered at the universe, my hands jammed into the side of my skull, and begged it for relief.
That probably sounds melodramatic, but listen: Migraines are miserable. They’re miserable for about 40 million Americans, most of them women, though the precise symptoms and their severity vary across sufferers. For about a quarter, myself included, the onset is sometimes preceded by an aura, a short-lived phase that can include blind spots, tingling, numbness, and language problems. (These can resemble stroke symptoms, and you should seek immediate medical care if you experience them and don’t have a history of migraines.) Many experience a final phase known as the “migraine hangover,” which consists of fatigue, trouble concentrating, and dizziness after the worst pain has passed.
These days, migraine sufferers are caught in a bit of a paradox. In some ways, their situation looks bright (but, please, not too bright): More treatments are available now than ever before—though still no cure—and researchers are learning more about what triggers a migraine, with occasionally surprising results. “It’s a really exciting time in headache medicine,” Mia Minen, a neurologist and the chief of headache research at NYU Langone, told me.
And yet the enthusiasm within the medical community doesn’t seem to align with conditions on the ground (which, by the way, is a nice, cool place to press your cheek during an attack). Migraine sufferers cancel plans and feel guilty about it. They struggle to parent. They call in sick, and if they can’t, they move through the work day like zombies. In a 2019 survey, about 30 percent of participants with episodic migraines—attacks that occur on fewer than 15 days a month—said that the disorder had negatively affected their careers. About 58 percent with chronic migraines—attacks that occur more often than that—said the same.
Migraines are still misunderstood, including by the people who deal with them. “We still don’t have a full understanding of exactly what causes migraine, and why some people suffer more than others do,” Elizabeth Loder, a headache clinician at Brigham and Women’s Hospital in Boston and a neurology professor at Harvard Medical School, told me. Despite scientific progress, awareness campaigns, and frequent reminders that migraines are a neurological disorder and not “just headaches,” too often, they’re not treated with the medical care they require. Yes, it’s the best time in history to have migraines. It just doesn’t feel that way.
Humans have had migraines probably for as long as we’ve had brains. As the historian Katherine Foxhall argues in her 2019 book, Migraine: A History, “much evidence suggests migraine had been taken seriously in both medical and lay literature throughout the classical, medieval, and early modern periods as a serious disorder requiring prompt and sustained treatment.” It was only in the 18th century, when medical professionals lumped migraines in with other “nervous disorders” such as hysteria, that they “came to be seen as characteristic of sensitivity, femininity, overwork, and moral and personal failure.” The association persisted, Stephen Silberstein, the director of the headache center at Thomas Jefferson University, told me. When Silberstein began his training in the 1960s, “nobody talked about migraine in medical school,” he told me. Physicians still believed that migraines were “the disorder of neurotic women.”
The first drug treatments for migraines appeared in the 1920s, and they were discovered somewhat by accident: Doctors found that ergotamine, a drug used to stimulate contractions in childbirth and control postpartum bleeding, also sometimes relieved migraines. (It could also cause pain, muscle weakness, and, in high enough doses, gangrene; some later studies have found that it’s little better than placebo.) The drug constricted blood vessels in the brain, so doctors assumed that migraine was a vascular disorder, the symptoms brought on by changes in blood flow and inflamed vessels. In the 1960s, a physician studying the effectiveness of a heart medication noticed that one of his participants experienced migraine attacks less frequently than he used to; a decade later, the FDA approved that class of drug, called beta-blockers, as a preventative treatment. (In the decades since their approval, studies have found that beta-blockers helped about a quarter of participants reduce their monthly migraine days by half, compared with 4 percent of people taking a placebo.)
Things changed in the 1990s, when triptans, a new class of drugs made specifically for migraines, became available. Triptans were often more effective and faster at easing migraine pain than earlier drugs, though the effects didn’t last as long. Around the same time, genetic studies revealed that migraines are often hereditary. Meanwhile, new brain-imaging technology allowed researchers to observe migraines in real time. It showed that, although blood vessels could become inflamed during an attack and contribute to pain, migraine isn’t strictly a vascular disorder. The chaos comes from within the nervous system: Scientists’ best understanding is that the trigeminal nerve, which provides sensation in the face, becomes stimulated, which triggers cells in the brain to release neurotransmitters that produce headache pain. How exactly the nerve gets perturbed remains unclear.
The past few years of migraine medicine have felt like the ’90s all over again. In 2018, the FDA approved a monthly injection that prevents migraines by regulating CGRP, a neurotransmitter that’s known to spike during attacks. For 40 percent of people with chronic migraines participating in one clinical trial, the treatment cut their monthly migraine days in half. Similar remedies followed; Lady Gaga, a longtime migraine sufferer, appeared in a commercial this summer to endorse Pfizer’s CGRP-blocking pill, and the company’s CEO launched a migraine-awareness campaign earlier this month. Solid evidence has emerged that cognitive behavioral therapy and relaxation techniques tailored to migraine can be helpful as part of a larger treatment plan. The FDA has cleared several wearable devices designed to curb migraines by delivering mild electric stimulation. Last year, the agency decided to speed up the development of a device that deploys gentle puffs of air into a user’s ears.
Researchers are still, to this day, making progress on identifying migraine triggers. Experts agree on many common triggers, such as skipping meals, getting too little sleep, getting too much sleep, stress, the comedown from stress, and hormone changes linked to menstruation or menopause. They’re also realizing that some long-held beliefs about triggers might be entirely wrong. MSG, for example, probably doesn’t induce migraines; changes in air pressure don’t do so as often as many people who have migraines seem to think.
Some supposed triggers might actually be signs of an oncoming migraine. The majority of migraine sufferers experience something called the premonitory phase, which can last for several hours or days before headache pain sets in and has its own set of symptoms, including food cravings. We migraine sufferers are frequently advised to steer clear of chocolate, but if you’re craving a Snickers bar, the migraine may already be coming whether or not you eat it. “When you get a headache, you blame it on the chocolate—even though the migraine made you eat the chocolate,” Silberstein said. “I always tell people, if they think they’re getting a migraine, eat a bar of chocolate … It’s more likely to do good than harm.”
Silberstein’s advice sounded like absolute blasphemy to me. Virtually every migraine FAQ page in existence had led me to believe that chocolate is a ruthless trigger. Maybe I shouldn’t have been relying on general guidelines on the internet, even though they came from reputable medical institutions. But I had turned to the internet because I didn’t think my migraines necessitated a visit to a specialist. According to the American Migraine Foundation, the majority of people who have migraines never consult a doctor to receive proper diagnosis and treatment.
Recent surveys have shown that people are reluctant to see a professional for a variety of reasons: They think their migraine isn’t bad enough, they worry that their symptoms won’t be taken seriously, or they can’t afford the care. The hot new preventative medications in particular “are extremely expensive, putting them out of reach of some of the people who might benefit the most,” Loder said. In 2018, when the much-heralded CGRP blocker hit the market, the journalist Libby Watson, a longtime migraine patient herself, interviewed migraine sufferers who described themselves as low-income, and found that most of them hadn’t heard of the new drug at all.
Even if you can get them, the treatments don’t guarantee relief. One recent study showed that triptans might not relieve pain—or might not be tolerable—for up to 40 percent of migraine patients. Experts are still trying to figure out why the same treatment might work wonderfully for one person, and not at all for another, Minen said. Some patients find that drugs eventually stop working for them, or that they come with side effects bad enough to discourage continued use, such as dizziness and still more nausea.
These problems remain unsolved in part because of a dearth of research. Like other conditions that mostly afflict women, migraines receive “much less funding in proportion to the burden they exert on the U.S. population,” Nature’s Kerri Smith reported in May. And many doctors are unaware of the research that exists: A 2021 study of non-migraine physicians found that 43 percent had “poor knowledge” of the condition’s symptoms and management, and just 21 percent were aware of targeted treatments. Specialists tend to have a much better knowledge base, but good luck seeing one: America has too few headache doctors, and there are significantly fewer of them in rural areas.
Many migraine sufferers rely on over-the-counter pain relievers, myself included. Years ago, my primary-care physician prescribed me a triptan nasal spray. It produced a terrible aftertaste and worsened the throbbing in my head, and I gave up on it after only a couple of uses. Back to Excedrin I went, not realizing—until reporting this story—that nonprescription medications can cause even more attacks if you overuse them. Some people get by on home remedies that the journalist Katy Schneider, who battles migraines herself, has described as a “medicine cabinet of curiosities”; one person she interviewed shotguns an ice-cold Coke when she feels the symptoms coming on.
When triptans and tricks fail, some people try to prevent migraines by avoiding triggers. Don’t stay up too late or sleep in. Don’t drink red wine. Put down that Snickers. This strategy of avoidance “interferes with the quality of their life in many cases,” Loder said, and probably doesn’t stop the attacks. And drawing associations is a futile exercise because most migraines are brought on by more than one trigger, Minen said. People can end up internalizing the 18th-century idea that migraines are a personal failure rather than a disease—and migraine FAQs perpetuate that myth by advising patients to live an ascetic life.
The misconceptions surrounding migraine, combined with its invisibility, make the disorder easy to stigmatize. The authors of a 2021 review found that, compared with epilepsy, a neurological disorder with a physical manifestation, “people with chronic migraine are viewed as less trustworthy, less likely to try their hardest, and more likely to malinger.” Perhaps as a result, many feel pressure to grind through it. Migraines are estimated to account for 16 percent of presenteeism—being on the job but not operating at full capacity—in the American workforce.
Before reporting this story, I had never thought to call my migraines a neurological disorder, let alone a “debilitating” one, as Minen and other experts do. Migraines were just this thing that I’ve lived with for more than a decade, and had accepted as an unfortunate part of my existence. Just my Excedrin and me, together forever, barreling through the wasted days. The attacks began in my late teens, around the same time that my childhood epilepsy mysteriously vanished. I never got an explanation for my seizures, despite years of daily medication and countless EEGs. A neurologist once told me that the two might be related, but he couldn’t say for sure; research has shown that people who have epilepsy are more likely to experience migraines. And so I assumed that I just had a slightly broken brain, prone to electrochemical misfiring.
All of the experts I spoke with were politely horrified when I told them about my migraines and how I manage them. I promised them that I’d make an appointment with a specialist. Before we got off the phone, Silberstein gave me a tip. “Put a cold pack on your neck and then a heating pad, 15 minutes alternating,” he said. “It’ll take the migraine away.” He told me that researchers are developing a device that does this, but the old-fashioned way can be effective too. At this point, my cabinet of curiosities is falling apart, its hinges squeaking from overuse. I’m already rethinking my entire migraine life, so I may as well try this too.
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Marina Koren
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In the 1970s, they tried lithium. Then it was zinc and THC. Anti-anxiety drugs had their turn. So did Prozac and SSRIs and atypical antidepressants. Nothing worked. Patients with anorexia were still unable to bring themselves to eat, still stuck in rigid thought patterns, still chillingly underweight.
A few years ago, a group led by Evelyn Attia, the director of the Center for Eating Disorders at New York Presbyterian Hospital and the New York State Psychiatric Institute, tried giving patients an antipsychotic drug called olanzapine, normally used to treat schizophrenia and bipolar disorder, and known to cause weight gain as a side effect. Those patients in her study who were on olanzapine increased their BMI a bit more than others who were taking a placebo, but the two groups showed no difference in their cognitive and psychological symptoms. This was the only medication trial for treating anorexia that has shown any positive effect at all, Attia told me, and even then, the effects were “very modest.”
Despite nearly half a century of attempts, no pill or shot has been identified to effectively treat anorexia nervosa. Anorexia is well known to be the deadliest eating disorder; the only psychiatric diagnosis with a higher death rate is opioid-use disorder. A 2020 review found people who have been hospitalized for the disease are more than five times likelier to die than their peers without it. The National Institutes of Health has devoted more than $100 million over the past decade to studying anorexia, yet researchers have not found a single compound that reliably helps people with the disorder.
Other eating disorders aren’t nearly so resistant to treatment. The FDA has approved fluoxetine (a.k.a. Prozac) to treat bulimia nervosa and binge-eating disorder (BED); doctors prescribe additional SSRIs off-label to treat both conditions, with a fair rate of success. An ADHD drug, Vyvanse, was approved for BED within two years of the disorder’s official recognition. But when it comes to anorexia, “we’ve tried, I don’t know, eight or 10 fundamentally different kinds of approaches without much in the way of success,” says Scott Crow, an adjunct psychology professor at the University of Minnesota and the vice president of psychiatry for Accanto Health.
The discrepancy is puzzling to anorexia specialists and researchers. “We don’t fully understand why medications work so differently in this group, and boy, do they ever work differently,” Attia told me. Still, experts have some ideas. Over the past few decades, they have been learning about the changes in brain activity that accompany anorexia. For example, Walter Kaye, the founder and executive director of the Eating Disorders Program at UC San Diego, told me that the neurotransmitters serotonin and dopamine, both of which are involved in the brain’s reward system, seem to act differently in anorexia patients.
Perhaps some underlying differences in brain chemistry and function play a role in anorexia patients’ extreme aversion to eating. Or perhaps, the experts I spoke with suggested, these brain changes are at least in part a result of patients’ malnourishment. People with anorexia suffer from many effects of malnutrition: Their bones are more brittle; their brain is smaller; their heart beats slower; their breath comes shorter; their wounds fail to heal. Maybe their neurons respond differently to psychoactive drugs too.
Psychiatrists have found that many patients with anorexia don’t improve with treatment even when medicines are prescribed for conditions other than their eating disorder. If an anorexia patient also has anxiety, for example, taking an anti-anxiety drug would likely fail to relieve either set of symptoms, Attia told me. “Time and again, investigators have found very little or no difference between active medication and placebo in randomized controlled trials,” she said. The fact that fluoxetine seems to help anorexia patients avoid relapse—but only when it’s given after they’ve regained a healthy weight—also supports the notion that malnourished brains don’t respond so well to psychoactive medication. (In that case, the effect might be especially acute for people with anorexia nervosa, because they tend to have lower BMIs than people with other eating disorders.)
Why exactly this would be true remains a mystery. Attia noted that proteins and certain fats have been shown to be crucial for brain function; get too little of either, and the brain might not metabolize drugs in expected ways. Both she and Kaye suggested a possible role for tryptophan, an amino acid that humans get only from food. Tryptophan is converted into serotonin (among other things) when we release insulin after a meal, Kaye said, but in anorexia patients, whose insulin levels tend to be low, that process could end up off-kilter. “We suspect that that might be the reason why [SSRIs] don’t work very well,” he said, though he emphasized that the theory is very speculative.
In the absence of meaningful pharmacologic intervention, doctors who treat anorexia rely on methods such as nutrition counseling and psychotherapy. But even non-pharmaceutical interventions, such as cognitive behavioral therapy, are more effective at treating bulimia and binge-eating disorder than anorexia. Studies from around the world have shown that as many as half of people with anorexia relapse.
Colleen Clarkin Schreyer, a clinical psychologist at Johns Hopkins University, sees both patients with anorexia nervosa and those with bulimia nervosa, and told me that the former can be more difficult to treat—“but not just because of the fact that we don’t have any medication to help us along. I often find that patients with anorexia nervosa are more ambivalent about making behavior change.” Bulimia patients, she said, tend to feel shame about their condition, because binge eating is stigmatized and, well, no one likes vomit. But anorexia patients might be praised for skipping meals or rapidly losing weight, despite the fact that their behaviors can be just as dangerous over the long term as binging and vomiting.
Researchers are still trying to find substances that can help anorexia patients. Crow told me that case studies testing a synthetic version of leptin, a naturally occurring human hormone, have produced interesting data. Meanwhile, some early research into using psychedelics, including ketamine, psilocybin, and ayahuasca, suggests that they may relieve some symptoms in some cases. But until randomized, controlled trials are conducted, we won’t know whether or how well any psychedelic really works. Kaye is currently recruiting participants for such a study of psilocybin, which is planned to have multiple sites in the U.S. and Europe.
Pharmaceutical companies just don’t seem that enthusiastic about testing treatments for anorexia, Crow said. “I think that drug makers have taken to heart the message that the mortality is high” among anorexia patients, he told me, and thus avoid the risk of having deaths occur during their clinical trials. And drug development isn’t the only area where the study of anorexia has fallen short. Research on eating disorders tends to be underfunded on the whole, Crow said. That stems, in part, from “a widely prevailing belief that this is something that people could or should just stop … I wish that were how it works, frankly. But it’s not.”
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Rachel Gutman-Wei
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This article originally appeared in Undark Magazine.
For one week of every month, I have a very bad time. My back aches so badly I struggle to stand up straight. My mood swings from frantic to bleak. My concentration flags; it’s difficult to send an email. Then, my period starts, and the curse is lifted. I feel okay again.
Like some 1 to 7 percent of menstruating women, I meet the criteria for premenstrual dysphoric disorder, or PMDD. According to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), a person with PMDD experiences marked emotional changes—such as sadness, anger, or anxiety—and physical or behavioral changes—such as difficulty concentrating, fatigue, or joint pain—in the week before their period. PMDD can also affect trans men and nonbinary people who menstruate.
When I first heard of PMDD, it was a revelation. Here was a concrete explanation for the pain and stress I was feeling every month. Better yet, there was a simple, effective treatment: common antidepressant drugs called selective serotonin reuptake inhibitors, or SSRIs, which can be prescribed for people to take only in the two weeks before their period. Birth-control pills, cognitive behavioral therapy, and calcium supplements may also help.
Then I heard about the controversy surrounding the diagnosis. When the American Psychiatric Association added a form of PMDD as a proposed disorder to the diagnostic manual in the 1980s—DSM-III-R—some scholars pushed back. They saw the diagnosis as part of the historical oppression of women, done in the name of mental health. The controversy reared up again as PMDD remained in the 1994 DSM-IV, where it was also listed under “Depressive Disorder Not Otherwise Specified.” Many people who menstruate experience emotional changes during their cycles, so defining it as a mental illness could have serious personal and societal consequences, critics argued. A 2002 Monitor on Psychology article, “Is PMDD real?,” quoted the late psychologist and author Paula Caplan: “Women are supposed to be cheerleaders,” she said. “When a woman is anything but that, she and her family are quick to think something is wrong.”
In the end, the APA weighed these concerns and pushed ahead, adding PMDD to the DSM-5 as an official diagnosis in 2013. But I found the criticism disquieting. Had I embraced a modern hysteria diagnosis? Were the symptoms I experienced even real?
Researchers have looked for hormonal differences between people who experience severe premenstrual distress and people who don’t. In some cases, they’ve found them: A 2021 meta-analysis found that people with PMDD tend to have lower levels of estradiol, a form of estrogen, between ovulation and menstruation. But other studies have shown little to no difference in hormone levels. “There are no biomarkers. There’s no test that can be done which helps identify someone with PMDD,” says Lynsay Matthews, who researches PMDD at University of the West of Scotland.
Instead, to receive treatment, people experiencing premenstrual distress have to monitor their own mind and body. PMDD diagnosis is based on a symptom diary kept over the course of multiple menstrual cycles.
The symptoms recorded in those diaries can be severe. In a 2022 survey, 34 percent of people with PMDD reported a past suicide attempt. More than half reported self-harm. “If someone has suicidal ideation or self-harm, or suicide attempts every month for 30 years, that wouldn’t be described as a normal female response to the menstrual cycle,” Matthews says.
There is evidence that SSRIs work for people with PMDD, in ways researchers don’t fully understand. “In some cases, hours after taking an effective SSRI, people can feel a lot better,” Matthews says, referring to PMDD patients. In contrast, people with depression usually need to take SSRIs for weeks before feeling the effects. Researchers know the drugs’ mechanism of action is different for PMDD—they just don’t know why. “When people find that out, they find it quite validating that it is a medical condition,” Matthews says.
Tamara Kayali Browne, a bioethicist at Deakin University, in Australia, agrees that some people experience serious distress in the week before their period—but disagrees with calling it a mental illness.
“The crux of the problem seems to be that we are in a patriarchal society that treats women very differently and puts a lot of women under a lot of significant, disproportionate stress,” Browne says. That disproportionate stress begins early. Eighty-three percent of a sample of Australian PMDD patients reported trauma in early life. It continues in adulthood. A Swedish survey of 1,239 people with PMDD found that raising children was associated with higher rates of premenstrual distress.
Between ovulation and menstruation, many people experience higher physical and emotional sensitivity. They may feel unwilling or unable to deal with the stressors they tolerate the rest of the month: the screaming baby, the messy partner. “Is it the time of the month where the truth comes out?” Browne suggests. Seen in this light, irritability, anxiety, and low mood are understandable reactions to life stressors, not symptoms of mental illness.
There is a long history of doctors labeling women crazy. There is also a long history of doctors dismissing women’s pain. Debates about premenstrual distress are caught in the middle.
When critics question PMDD and the less severe premenstrual syndrome, it can feel invalidating. “It’s time to stop questioning whether women’s experiences are real and instead start making them real priorities,” the journalists Emily Crockett and Julia Belluz wrote in response to an article that suggested PMS is culturally constructed.
At the same time, when left unchecked, casual sexism can seep into the medical discourse around PMDD. Early pharmaceutical advertisements marketing SSRIs for PMDD show how this works in practice. In 2000, Eli Lilly packaged fluoxetine hydrochloride in a pink-and-purple capsule and branded it Sarafem. Advertisements for the drug featured incapable, unreasonable women; one fights a shopping cart, another bickers with her (male) partner. “Think it’s PMS? Think again. It could be PMDD.” (The Sarafem brand has since been discontinued.)
What if we can question the structural factors that make life harder for women while providing medical support for people who are suffering? Could the critiques lead us to more, not fewer, options for people with PMDD?
Medical interventions can be lifesaving for people with PMDD. But they don’t address a society that places a heavy burden on the shoulders of people assigned female at birth.
Browne compares severe premenstrual distress to a broken leg. “If you have a broken leg, you really do need painkillers, because you’re experiencing pain,” she says. “But it’s not going to be helpful in the long term if you don’t deal with whatever the underlying cause is.” In the week before menstruation, the life stressors a person with PMDD deals with the rest of the month can feel unbearable. Those life stressors can and should be addressed alongside conventional medical treatment.
One common stressor is the caregiving load. “Parenting is not only a massive trigger, but it’s also the biggest burden or the biggest guilt that comes with having PMDD,” Matthews says. “Not only are you struggling yourself every month, but you also feel as though you’re failing your children every month.” The co-parent can help alleviate this burden. When fathers spend more time with their kids—and doing child-related chores—mothers tend to be less stressed about parenting.
Another stressor is relationship difficulties. The emotional changes that come with the premenstrual phase can make conflict with a partner more likely. They can also prompt the PMDD sufferer’s partner to dismiss those feelings. “Nowadays, a partner might still be inclined to say, ‘Wait a minute, I know it’s that time of your month again. You’re just being oversensitive,’” Browne points out. Women in relationships with women, who tend to be more understanding of premenstrual change than men, report a more positive experience of the week before their period.
Researchers have done great, necessary work to understand PMDD, work that should continue. How are people who experience premenstrual distress biologically different from people who don’t? Can we find new, more effective drugs to treat that distress?
In the meantime, we need to build a better world for people who experience premenstrual distress. Doctors can prescribe medicine, but managers can make accommodations in the workplace. Co-parents can take on more caregiving responsibility. And partners can provide love and support.
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Ciara McLaren
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Being depressed can make you feel helpless. You’re not. Along with therapy and sometimes medication, there’s a lot you can do on your own to fight back. Changing your behavior — your physical activity, lifestyle, and even your way of thinking — are all natural depression treatments.
These tips can help you feel better — starting right now.
1. Get in a routine.If you’re depressed, you need a routine, says Ian Cook, MD. He’s a psychiatrist and director of the Depression Research and Clinic Program at UCLA.
Depression can strip away the structure from your life. One day melts into the next. Setting a gentle daily schedule can help you get back on track.
2. Set goals. When you’re depressed, you may feel like you can’t accomplish anything. That makes you feel worse about yourself. To push back, set daily goals for yourself.
“Start very small,” Cook says. “Make your goal something that you can succeed at, like doing the dishes every other day.”
As you start to feel better, you can add more challenging daily goals.
3. Exercise. It temporarily boosts feel-good chemicals called endorphins. It may also have long-term benefits for people with depression. Regular exercise seems to encourage the brain to rewire itself in positive ways, Cook says.
How much exercise do you need? You don’t need to run marathons to get a benefit. Just walking a few times a week can help.
4. Eat healthy. There is no magic diet that fixes depression. It’s a good idea to watch what you eat, though. If depression tends to make you overeat, getting in control of your eating will help you feel better.
Although nothing is definitive, Cook says there’s evidence that foods with omega-3 fatty acids (such as salmon and tuna) and folic acid (such as spinach and avocado) could help ease depression.
5. Get enough sleep. Depression can make it hard to get enough shut-eye, and too little sleep can make depression worse.
What can you do? Start by making some changes to your lifestyle. Go to bed and get up at the same time every day. Try not to nap. Take all the distractions out of your bedroom — no computer and no TV. In time, you may find your sleep improves.
6. Take on responsibilities.When you’re depressed, you may want to pull back from life and give up your responsibilities at home and at work. Don’t. Staying involved and having daily responsibilities can help you maintain a lifestyle that can help counter depression. They ground you and give you a sense of accomplishment.
If you’re not up to full-time school or work, that’s fine. Think about part-time. If that seems like too much, consider volunteer work.
7. Challenge negative thoughts. In your fight against depression, a lot of the work is mental — changing how you think. When you’re depressed, you leap to the worst possible conclusions.
The next time you’re feeling terrible about yourself, use logic as a natural depression treatment. You might feel like no one likes you, but is there real evidence for that? You might feel like the most worthless person on the planet, but is that really likely? It takes practice, but in time you can beat back those negative thoughts before they get out of control.
8. Check with your doctor before using supplements. “There’s promising evidence for certain supplements for depression,” Cook says. Those include fish oil, folic acid, and SAMe. But more research needs to be done before we’ll know for sure. Always check with your doctor before starting any supplement, especially if you’re already taking medications.
9. Do something new. When you’re depressed, you’re in a rut. Push yourself to do something different. Go to a museum. Pick up a used book and read it on a park bench. Volunteer at a soup kitchen. Take a language class.
“When we challenge ourselves to do something different, there are chemical changes in the brain,” Cook says. “Trying something new alters the levels of [the brain chemical] dopamine, which is associated with pleasure, enjoyment, and learning.”
10. Try to have fun.If you’re depressed, make time for things you enjoy. What if nothing seems fun anymore? “That’s just a symptom of depression,” Cook says. You have to keep trying anyway.
As strange as it might sound, you have to work at having fun. Plan things you used to enjoy, even if they feel like a chore. Keep going to the movies. Keep going out with friends for dinner.
11. Avoid alcohol and other drugs. Substance misuse is common in people who have depression. You may be more likely to turn to alcohol, marijuana, or other drugs to deal with the symptoms of your depression. It’s unclear if drinking and using drugs causes depression. But long-term drug use could change the way your brain works and worsen or lead to mental health problems.
When you’re depressed, you can lose the knack for enjoying life, Cook says. You have to relearn how to do it. In time, fun things really will feel fun again.
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Brooke Aymes started drinking as a way to deal with the negative emotions that arose after the death of her cousin from suicide. Then it became a social activity — “a way to fit in and to feel good about myself,” she says.
Social drinking led to sneaking water bottles filled with alcohol into high school. Eventually Aymes found that she couldn’t pull herself away from the bottle.
Nearly 15 million people use alcohol to the point where it has harmful effects on their life and they can’t stop drinking. Those with alcohol use disorder have many treatments to choose from, including 12-step programs like Alcoholics Anonymous (AA), inpatient rehabilitation centers, and medication.
Some methods work better for certain people than for others.
At her parents’ urging, Aymes went to detoxes, rehabilitation programs, outpatient facilities, and 12-step programs. “None of those things worked until I was able to have the desire to not want to drink, and to have the willingness to follow through with doing work on myself.” she says.
Aymes eventually used techniques she’d learned from the programs she’d done to find her way to recovery on her own. Today, she is a licensed drug and alcohol counselor in Oaklyn, NJ.
“I do not believe recovery is one-size-fits-all,” she says. “There are a lot of roads to get there.”
AA is one of the best-known and most established alcohol recovery programs. Many other programs follow its 12-step method, which relies on 12 principles, the first three of which are admitting your powerlessness over alcohol, believing that a higher power can stop your drinking, and turning over your will to that higher power.
It’s a system that centers on spiritual belief, which made Fay Zenoff uncomfortable because she hadn’t been brought up with religion. For her, alcohol had become a way to deal with the “tremendous grief and loss” from the death of her older brother and her parents’ divorce.
By high school, Zenoff was a blackout drinker. But it was only at age 40, after two children and a divorce, that she realized that she couldn’t keep up the façade anymore that she was OK.
Zenoff says that when she first walked into a 12-step program, she cried. “I didn’t see reflections of myself there.” But after 6 months of “white-knuckling it” on her own, she went back.
She realized she had more in common with the people in the program than she’d thought. “They were talking about solutions, and they had stories that were similar to my lived experience,” she says. “I actually felt hope for the first time.”
Zenoff learned the coping skills and resiliency she needed to break the behaviors that were controlling her life. She has been in recovery for almost 15 years, which she says is a continuing process. Now she’s a recovery strategist who helps others learn how to thrive after leaving rehab.
A 12-step program also helped Ty Reed stop drinking, but only after he had hit bottom. Once a successful mortgage salesman, Reed had been living “a double life.” After work, he’d go out drinking late into the night. Eventually, he also got hooked on crack and meth.
By 2014, Reed was homeless. He was in and out of jail and mental institutions. He even tried to take his own life. He credits the sense of community in his 12-step program with helping him stop using alcohol and drugs as well as keeping him from slipping back into a relapse.
Getting a job was also instrumental to his recovery. “It gave me structure,” he says. “Having responsibility and an obligation to show up somewhere, and learning to be dependable again were critical.” The company he has since founded, Recovery Career Services, helps other people in recovery rebuild their careers.
Ashley Loeb Blassingame’s “drinking career” started early. At 7, she would steal beers from her family’s fridge and drink them alone in her closet. By high school, she was filling water bottles with wine or vodka and downing them before school. She also used drugs and got into trouble with the law.
Therapy helped her understand the reasons for her drinking. “I was using it to medicate feelings of discomfort. I was using it to medicate anxiety,” she says. Two types were helpful: Cognitive behavioral therapy (CBT), which addresses the harmful thoughts and beliefs that trigger the urge to drink, and another kind called eye movement desensitization and reprocessing (EMDR).
Therapy, plus support from her peers, has kept her sober for 15 years. Now, Loeb Blassingame is a certified alcohol and drug counselor and co-founder of Lionrock, an online substance abuse counseling program.
For some people with alcohol use disorder, trying to recover at home or in an outpatient program may not be enough. Inpatient programs offer a higher level of care, including detox to ease the withdrawal process.
Patrick Venzke ended up in an inpatient facility in Jacksonville, FL, a decision that he says probably saved his life. The German-born former NFL player had been investing his football earnings to buy and flip luxury houses when the 2008 housing crisis hit and his life crashed down around him. “I was living the American dream, and within 3 years we were on food stamps and had to file for bankruptcy,” he says.
“I used alcohol like a tool, like a painkiller, just to get through one more day,” he says. By 2014, he was drinking two to three bottles of wine a day.
The inpatient program helped him get sober. Then the NFL Alumni Association got him into the Desert Hope Treatment Center in Las Vegas, where he now continues his recovery while working as a patient liaison.
Venzke is 5½ months into his program, but he realizes that recovery is a long journey. “It’s not like I’m healed,” he says. “It’s a lifelong process for me.”
For Joe Marks, drinking had become so ingrained that 90 days in a treatment facility barely made a dent. “Two weeks later, I was going to pick up a pack of cigarettes, and what do I have in my hands? Two half-gallons of booze. It started all over again,” he says.
More than 35 years of drinking had brought him to the brink of death. He would drink to the point where he passed out, only to wake up and start drinking again. “Alcohol had hijacked my brain,” he says. “I needed to get off alcohol for a long enough time to let those pathways find the right way to go.”
His rehab counselor suggested that he move into a sober living housing community in Hickory, NC. “There was enough stability, and it put structure into my life,” he says.
It took a couple of years, and making connections with like-minded people, to help him get sober. “I discovered a new life,” he says. “They took me by the hand and walked with me when I couldn’t walk on my own.”
Today, Marks has found a renewed sense of purpose in helping others. As an ambassador for the Talk It Out initiative, speaking to young people about the dangers of underage drinking is a big part of his recovery.
Some people prefer to stop drinking in their own way, like actress, filmmaker, and podcast host Raeden Greer. Tired of the negative consequences (including a DUI and two arrests) from her drinking, she got sober by managing her anxiety and by substituting new rituals for the ones that used to involve alcohol.
“Five o’clock is still going to roll around, regardless of whether you’re drinking or not. So what are you going to do now at 5, because you’ve got to do something different,” she says. When 5 o’clock does roll around, she drinks sparkling water with fruit juice or herbal tea. And she’s replaced the time she used to spend drinking with more positive pursuits focused on self-care.
Greer takes recovery one day at a time, and tries not to put too much pressure on herself to never drink again. “The longer I go, the more I feel like I probably won’t ever do it again. But if I do at some point, I don’t want to create an environment for myself where I feel ashamed and … like a failure that I didn’t live up to this huge expectation that I put on myself,” she says.
Recovery from alcohol use happens for each person in their own way. Don’t beat yourself up if you don’t succeed the first time. See it as a step in the right direction.
“It is very common for people to try recovery multiple times before it takes hold,” Reed says. “It’s tough not to be discouraged, but every time we fail, it’s actually an opportunity for growth.”
If you or someone you love has trouble with alcohol use, call the Substance Abuse and Mental Health Services (SAMHSA) National Helpline at 800-662-HELP (800-662-4357).
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With the pinch of a needle, cosmetic dermatologists such as Michele Green can make forehead wrinkles disappear and deep-furrowed crow’s-feet puff back out like yeasted dough. Botox is totally magic, a little unsettling, and very in demand: Green’s New York City practice has been swamped as Americans seek to give themselves a “post-pandemic” glow-up. But these days, many of her patients aren’t after eternal youth and sex appeal. When Green reviews her schedule for the week each Monday morning, she told me, “I’m just like, Oh my god.” At least a quarter of her Botox appointments are for people with a different motive entirely: They can’t stop clenching their jaw and grinding their teeth.
Across the country, patients dealing with the meddlesome condition are now turning to Botox—yes, Botox. “It’s a very popular treatment” for people who grind and clench their teeth, Lauren Goodman, a L.A.-based cosmetic nurse, told me. Bruxism, the official term encompassing both behaviors, is an involuntary action that tends to happen when people are sleeping at night, for reasons including alcohol and tobacco use, sleep apnea, and stress—perhaps why the condition has soared in the United States during the pandemic. The condition is a tolerable nuisance for many people, but the symptoms can get very real: With bruxism on the rise, dentists are reporting more chipped and cracked teeth in patients, along with jaw pain and facial soreness. In the most severe cases, patients can suffer debilitating headaches and jaw dislocation. The most common treatments, such as mouth guards and lifestyle changes, only sometimes help get rid of symptoms.
That’s what makes Botox so appealing for the recent flood of teeth grinders. Jaw injections relax the chewing muscles that clench and grind with up to 250 pounds of force—potentially relieving pain and preventing dental issues in the process. It’s not as though every teeth grinder in America is hotfooting it to their nearest Botox clinic, but the procedure seems to have blown up since the start of the pandemic. Five dentists and cosmetic experts told me they’d noticed an increase in teeth grinders and clenchers getting Botox. People who have exhausted more traditional routes are “really just committed to alleviating their pain,” said Samantha Rawdin, a prosthodontist in New York City. “If that means getting a needle to the face, so be it.”
But even if Botox has some upsides, it’s hardly the permanent, sure-thing solution that dentists and patients have long searched for. That’s been the narrative all along with bruxism: Because there are so many possible causes, treatments are an educated dice roll—and none of them is universally effective. “I don’t tell my patients I can treat them,” Gilles Lavigne, a dentistry professor at the University of Montreal, told me. “I tell them I can help them manage their condition.” So, how do we still not always know how to handle this incredibly common ailment?
Botox has been creeping onto the teeth-grinding stage since long before the pandemic. Although it has gained noticeable traction over the past few years, research on the efficacy of Botox stretches back to the late 1990s. In the years since, researchers have also discovered that the injections, which temporarily paralyze the masseter muscles responsible for grinding and clenching, can reduce the frequency and intensity of bruxism. It’s one of a slew of non-cosmetic Botox uses that have been identified since the drug hit the market in 1989: Injections also treat issues such as excessive underarm sweating, acne, and migraines.
Botox for bruxism hasn’t been FDA approved, so it’s still considered off-label—but anyone with a Botox license can legally inject a willing teeth grinder. And at least in theory, Botox has some advantages over other bruxism treatments. Night guards might prevent you from gnashing your teeth into smithereens while you sleep, but they can be ineffective at stopping the behavior and can even make it worse—especially if you have sleep apnea, Jamison Spencer, a dentist and sleep-apnea expert based in Boise, Idaho, told me. Minimally invasive regimes such as yoga, meditation, cognitive behavioral therapy, and physical therapy are hit or miss. Muscle relaxers can be helpful for some patients, but those aren’t universally popular among the dentists I spoke with, some of whom cited America’s opioid crisis as a concern.
When less invasive treatments don’t work, Botox might be “the next frontier,” Leena Palomo, a professor at New York University’s College of Dentistry, told me. Grinders and clenchers seem to be learning about the injections from a variety of sources. Rita Mizrahi, an oral surgeon in New York who offers Botox for bruxism, told me that her patients are typically referred by their regular dentists. Others discover jaw Botox in online forums such as Reddit and the beauty network RealSelf, where often anonymous discussions of the procedure abound. And some are reading mainstream-media testimonials or hearing about it from friends or family—particularly as more and more Americans embrace Botox for cosmetic purposes.
At its best, the procedure can really help certain teeth grinders: Studies have indicated that Botox can decrease pain levels. One RealSelf reviewer described trying night guards, stress relief, and cutting out caffeine before getting jaw injections. “Thank goodness for something like Botox to come along in this day and age,” they wrote four months after getting the procedure. The procedure comes with some cosmetic changes too: Grinding and clenching all night can be a workout, which might lead to enlarged chewing muscles and a square, boxy face. The injections slim the jawline for many patients, giving it “more of a V-shape,” Green said.
But Botox has some real downsides—and plenty of dentists are still hesitant to recommend it. For starters, it’s expensive and impermanent. The procedure typically costs at least $1,000; is not covered by medical or dental insurance; and usually won’t last for more than four months. “This isn’t a onetime thing and you’re good,” Mizrahi said. And like most of the other treatments available, jaw Botox attacks teeth-grinding and clenching symptoms, but not the cause. Because people still need to chew, the masseter muscle isn’t totally immobilized—meaning that patients “will just grind with less power,” Lavigne said.
And all of the risks associated with the cosmetic use of Botox apply here too, such as bruising at the injection site, headaches, allergic reactions, and less desirable changes in facial expressions due to misplaced Botox. One RealSelf reviewer experienced no improvement in jaw pain but the unfortunate onset of a creepy grin that resembled a “chucky doll smile.” Another said that their headaches disappeared after the procedure, but so did their cheeks: “I couldn’t recognize myself in the mirror and looked like I had aged 10 years within a couple of months.”
That grinders and clenchers are more frequently turning to Botox is hardly a pure success story. Early mentions of teeth gnashing exist in the Bible, yet we still don’t really understand how to make it stop. I know firsthand how frustrating that feels. In January, after trying (and failing) to open wide enough for a crispy chicken tender, I was finally motivated to see a dentist—who gave me a night guard so I’d quit slamming my teeth together. I meditate like it’s my job, I don’t have sleep apnea or take medications of any sort, and yet I still gnaw on that hunk of plastic like it’s gristle. My jaw doesn’t lock anymore but it’s still tense most mornings. I’m priced out of getting Botox—so, like many teeth grinders, I’m stuck in medical purgatory.
Teeth grinding isn’t like a broken arm, where cause and effect are obvious and fixable. “Because the origin of [jaw] pain is not singular, you have to attack it from various modalities,” Mizrahi told me: “All the things that potentially contribute to the pain have to be addressed,” and that can involve fields far outside dentistry. Even dentists themselves aren’t always equipped with all the information: “We get virtually no bruxism education” in dental school, Spencer, the sleep-apnea researcher from Idaho, said.
With all these roadblocks, many patients never find out why they’re clenching or grinding, says Alan Glaros, an emeritus professor of dentistry at the University of Missouri at Kansas City, who’s been researching the issue for more than 40 years. That’s partially because it’s a difficult problem to not only treat, but also study. Bruxism’s many causes intersect “a lot of disciplines,” such as dentistry, sleep health, and psychology, which muddies the research process. Each field is studying the behavior, but the results will only ever tell part of the story. “People act as if this is all solved, but it’s not,” Glaros told me.
So for now, mouth guards, meditation, and Botox are what we have. The treatment, in all likelihood, isn’t going anywhere. “As people get to know others who have responded well, I predict that we’re going to see an uptick,” Palomo said. Grinders and clenchers will keep chomping on their plastic night guards or forking up thousands of dollars a year for temporary injections, all in a maybe-successful attempt to quell their pain. If only Botox could banish bruxism like it does stubborn wrinkles.
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Ali Francis
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