I caught my mood slipping--this stopped the spiral
How to handle worry when your mind is overloaded
I’m feeling down the past week. In a funk.
Actually, I’m feeling depressed.
It’s bound to happen when you have a chronic illness. I think occasional depressed mood is actually an unavoidable part of chronic illness. Depressed mood is not necessarily clinical depression. It’s a mood shift—one that I’ve come to expect, and one I take seriously, because I want to prevent it from turning into a more serious depressive state.
Today I’m explaining the ways I recognize when I’m in a depressed mood, and how you can, too. I also share a science-backed exercise that helps me navigate out of it called Constructive Worry (CW).
I’ll explain:
The difference between depressed mood and depression
The clinical research behind the Constructive Worry technique
How it’s most commonly used
An example of my own CW journaling
Paid subscribers also receive a Constructive Worry worksheet to practice the technique today. Consider upgrading to support LCMD and access the printable.
My Symptoms
I notice some typical symptoms when my mood drops. I like to call them my warning signs. You may have a similar set:
It’s extra tough to focus and plan. Thoughts don’t stick.
I’m scrolling, watching a lot of meaningless YouTube videos.
I feel sleepy…which, as you may appreciate, is different than fatigue.
I feel worried and tense through the day.
I’m snacking a lot.
Sometimes I’m angry; not at my kids or husband. At the world. At this [spreads arms].
Depression vs Depressed Mood
Is this depression? Some of my symptoms do overlap with depression—sadness, change in sleep/appetite/cognition—but it’s too early to tell. Clinical depression is marked by at least two consecutive weeks of multiple symptoms, and it must include anhedonia (loss of interest) or depressed mood.
I may not have depression, but yesterday I admitted I have a depressed mood when I noticed one of my other warning signs: rumination.
Rumination refers to the spiraling thought-loops that often come with anxiety and depression. Unlike a meditative rumination that helps us make a decision, in psychology rumination refers to a dysfunctional pattern of reviewing the same thought. We keep thinking about the same few things over and over, without coming to a productive end-point. It can trigger a fear response (fight, flight, fawn, freeze) that we might stay in it for an extended time.
Constructive Worry
On a (kinda) positive note, since I’ve been in this long COVID boat for several years, I’ve learned what helps me turn it around.
Constructive Worry journaling is my starting point. Based in cognitive behavioral therapy, it’s supported by research to reduce rumination. CW journaling gives me a place to store and review my thoughts when my mind is simply too full.
Stanford psychologist Dr Hylton Molzof taught me the Constructive Worry technique during a CBT for Insomnia (CBT-I) course. Learn more about sleep psychology from our conversation last year:
Getting Better Sleep
Sleep issues are pervasive in Long COVID, often taking the form of insomnia, restless nights, or unrefreshing sleep. In the latest episode of Long Covid MD, I had the privilege of speaking with Stanford psychologist Dr. Hylton Molzof, who specializes in behavioral sleep medicine. We explore the biologic and emotional influences on sleep, and the ways Co…
When used regularly, Constructive Worry has been shown to reduce insomnia caused by rumination.
Constructive Worry didn’t help my sleep much, because like others with long COVID, my insomnia was caused by much more than anxiety—likely by profound physiologic changes after COVID-19 infection. But I’ve found the technique helpful for times like this, when I feel sad, overwhelmed, and unsure of where to start.
Constructive Worry is not complicated; it’s essentially a thoughtfully-written list. It starts with a “brain dump”—writing down everything on your mind—then asks you to reflect on the control you have over each item.
An important note:
Cognitive Behavioral Therapy (CBT) is a psychotherapy method meant to change the way we respond to our thoughts. Specifically, the goal is to interrupt harmful thought patterns to improve mood. It is not an effective treatment for long COVID. It has been used to treat depression, among other conditions, but today we’re speaking only about one CBT tool.
Talk to your healthcare provider about changes in your mood to learn all your options.
How to Write A Constructive Worry Journal
Here are the steps:
Write down the worry/concern/stubborn thought
Ask, “Do I have control over this?”
If it’s within your control, identify something—anything—you can do to impact the issue.
If the issue is outside your control, write a statement to acknowledge your emotions and accept that it is beyond your control at this point.
Let’s break it down step by step.
Step 1: The List
I like to write down all my worries first, get them all out of my head and onto paper. Then I go back and reflect on each one.
My worry list includes, among other things:
America’s current military excursion™️
I have a backlog of long COVID interviews and essays that are half-finished. How am I going to get them out?
My eyebrow hairs are grey
Will I lose my function and health again?
Are my kids ok? Maybe they deserve a better mom
My insurance is not authorizing my prescription
Is my medical career over? Does that mean I failed?
The lady at the grocery store was rude to me
I wasted my life
It smells weird in the foyer
Why am I like this?! I’m the worst!
By the time my list is finished I sit back in my chair and take a big sigh. Now that all my demons are laying on the page in front of me, they feel less dangerous.
Step 1.5 : Is This Real?
Before I start the second step, I take an overview of my list. I can tell that some of my concerns are completely reasonable, and others are misplaced or imagined. That’s the thing about anxiety and depression: they change the way we perceive reality, usually for the worse.
What I do next may not technically be part of CW, but for me it’s important: I mark the blatantly unrealistic thoughts. Next to each of these—like “I’m a bad mom,” “I failed,”—I write a response. Sometimes it’s a question mark, a way to ask myself, “is this really true?” Other times, I’ll write comments, “no evidence of this,” or simply “WRONG!”
Step 2: Do I Have Control Over This?
After that, it’s on to the next part of the Constructive Worry method. For each item I ask the important question, “Do I have control over this?”
We rarely have total control over anything, but for some of the items on my list, I can take concrete action. I write one realistic action to take during normal working hours. This could range from scheduling an appointment, researching a certain treatment, asking a friend to pick up my daughter from Girl Scouts, or something broader like brainstorming.
I tend to separate the time I decide my action list from the time I perform them. That’s because A) It can feel emotional to make the worry list and I want to pace my energy and B) I often journal in the evening, a time I want to unwind for bed, so I avoid activating activities like composing emails or reorganizing a kitchen drawer.
In CBT for Insomnia, Constructive Worry is recommended 2-3 hours before bedtime, for the same reasons.
Step 3: When You Can’t Change It
If there is really nothing I can do to impact a situation, Constructive Worry asks that I acknowledge my feelings about it and find a way to accept the reality.
If this sounds like Acceptance and Commitment Therapy, it’s because it is. Abbreviated ACT, Acceptance and Commitment Therapy is a method of living with uncertainty. “I accept that I live with uncertainty, and I commit to doing something anyway.”
It’s not easy and I don’t claim to be a master (or even a dedicated student) of the philosophy, but it’s easy to see ACT’s benefit when we’re in a period of upheaval—like the one long COVID brings.
Constructive Worry is containment, not denial. We face our fears, worries, concerns, then contain them in a healthy engaged way—so they don’t take over.
What My Constructive Worry Journal Looks Like
Backlog of Substack articles and videos:
Do I have control over this? Yes
What can I commit to doing about it? I’m hitting an energy limit and physically can’t do all the work to publish weekly. I’ve found help before. I may need to hire an editor, especially for the videos. I’ll email 3 people I know tomorrow to ask for recommendations. I’ll also admit to my subscribers that I need more time between posts.
My eyebrow hairs:
Tint them, dye them, pluck them, deal with them. You’ve got options. Contrary to what your anxiety is telling you, grey hair does NOT mean you’re on death’s door.
Is my medical career over?
Maybe in the way you knew it. Maybe not. What information do you need to determine this? Set aside some time this week —Monday from 1-1:30—to reflect/research. It might be worth reviewing what career and medicine really mean to you.
A stranger was rude to me
I accept that I cannot control some else’s actions. I felt disrespected and belittled, but I don’t want that interaction to keep hurting me. I won’t see her again, so I can’t resolve the issue with her directly. But her bad mood, and even her opinion of me, does not determine my worth and value.
Next time someone treats me this way, I’ll remember this and hopefully the interaction won’t sour me as much. I can also come up with a short reply to keep handy if something like that happens again.
America’s current military excursion™️
This one is a little more complicated. I can do something, but it doesn’t feel like much. So I identify both an action and acceptance.
Do I have control over this? Minimal.
What can I commit to doing about it? Email my senator.
I accept that I sadly don’t have much control over America’s military decisions. It’s scary. It feels unjust. I am worried about people—both civilians abroad and our own military members—whose lives will be in danger.
Final Step: Stop
Just as it’s important to face our worries, it’s equally important to stop at some point. That’s the ultimate goal of the exercise.
Constructive Worry interrupts the cycle of rumination by identifying concerns and recognizing our agency in them (and sometimes a lack thereof). I write my CW journal by hand because I can literally close the book on it when I’m done.
Like many other new habits, stopping takes practice. It can be particularly challenging when major complex issues, like our health or social justice, rank high on the list. Please remember that containing does not mean ignoring. For me, the Constructive Worry practice reminds me that I’m facing some big problems, and I need all the energy and cognition I can muster. At some point I have to stop committing my energy to worry and commit to action, even if that action is rest.
What Works For You??
For me, rumination frequently presents when I’m in a depressed mood, and the Constructive Worry exercise helps me ground. Remember to talk to your doctor about disruptive mood changes. You have—and often need—more options than a worry list.
You’ve learned the method, now paid subscribers can access the tool! Below, I share a a Constructive Worry template and tips on how to use it.
Considering supporting LCMD by upgrading, and I’ll see you again soon, funk or no funk.
🩵 Dr Khan
