The Upward Spiral: Using Neuroscience to Reverse the Course of Depression, One Small Change at a Time

by Alex Korb

Essentially, your brain is full of intricate, interacting neural circuits. There’s a worrying circuit and a habit circuit. There’s a decision-making circuit and a pain circuit. There are circuits for sleep, memory, mood, planning, enjoyment, and more, and they all communicate with each other. We’ve all got the same circuits, whether you have depression or not, though the specific tuning of each circuit varies from person to person. The disease of depression is a pattern of activity that arises from the interactions of all these circuits. While that might not sound like much, the effects can be devastating.

Depression is a very stable state—your brain tends to think and act in ways that keep you depressed.

Two parts of the brain in particular are to blame: the prefrontal cortex and the limbic system. To simplify, the prefrontal cortex is basically the thinking part of the brain, and the limbic system is the feeling part. In depression, something is off with the way these regions act and communicate with each other. The thinking prefrontal cortex is supposed to help regulate the feeling limbic system, but it’s not doing a good job. Fortunately, it’s possible to change the way they act and communicate, and that’s what this book is all about.

It turns out that positive life changes actually cause positive neural changes—in the brain’s electrical activity, its chemical composition, even its ability to produce new neurons. These brain changes alter the tuning of your brain’s circuitry and lead to further positive life changes.

everyone has depressive tendencies to a varying degree. That’s just how the brain is wired. Thankfully, most people have wellness tendencies that keep them from getting stuck in the downward spiral of depression. For those who don’t, there’s hope: the last decade has seen remarkable advances in our understanding of the brain circuits involved in depression and, more importantly, how they can change.

In depression, there’s nothing fundamentally wrong with the brain. It’s simply that the particular tuning of the neural circuits creates the tendency toward a pattern of depression. It has to do with the way the brain deals with stress, planning, habits, decision making, and a dozen other things—the dynamic interaction of all those circuits. And once the pattern starts to form, it causes dozens of tiny changes throughout the brain that create a downward spiral.

This is an oversimplification, but in general, each neurotransmitter contributes to a different depressive symptom. A dysfunctional serotonin system is responsible for the lack of willpower and motivation. The difficulty in concentration and thinking is probably due to problems with norepinephrine. Dysfunction in the dopamine system leads to bad habits and lack of enjoyment. All of these neurotransmitters are necessary for proper functioning of dozens of circuits throughout the brain, and to make things more complicated, they all interact. Unfortunately, depression is not just a matter of not having enough norepinephrine, serotonin, and dopamine, and thus it’s not solved by simply increasing the levels of these neurotransmitters. But that is part of the solution. Boosting serotonin leads to a better mood and a greater ability to set goals and avoid bad habits. Increasing norepinephrine means better concentration and lower stress. And more dopamine generally means more enjoyment.

depression is primarily a result of poor communication between the thinking prefrontal cortex and the emotional limbic system. Together, these parts of the brain are often called the fronto-limbic system, because they form a group of closely interacting regions, the way Europe is a group of closely interacting countries. The fronto-limbic system regulates your emotional state, and when not functioning, it well can push you into depression.

The limbic system is the emotional part of the brain and is responsible for things like excitement, fear, anxiety, memory, and desire. It is primarily composed of four regions: the hypothalamus, the amygdala, the hippocampus, and the cingulate cortex. The hypothalamus controls stress. The amygdala is the key to reducing anxiety, fear, and other negative emotions. The hippocampus is responsible for creating long-term memories, and because its neurons are very sensitive to stress, it often acts as the canary in the coal mine of depression. Lastly, the cingulate cortex controls focus and attention, which is of huge importance in depression, because what you focus on, whether by automatic habit or willful choice, makes a huge difference to your mood.

Depression is often accompanied by bad habits such as impulsiveness, poor coping skills, addiction, and procrastination. That can also include feeling fatigued and unmotivated.

Worrying and anxiety are two big symptoms of—and causes of—depression. Worrying is mediated mainly by connections between several parts of the prefrontal cortex and the anterior cingulate. By comparison, anxiety is mediated by circuits within the limbic system. So there’s no reason to get upset with yourself for feeling anxious or worrying too much; it’s just a by-product of your brain’s evolution. Fortunately, understanding the brain circuits involved in worrying and anxiety can give you a better handle on the situation.

Worrying and anxiety are distinct but related concepts—you can have worrying without anxiety and anxiety without worrying.6 Worrying is mostly thought based, whereas anxiety has more to do with physical components like bodily sensations (such as an upset stomach) or associated actions (like avoiding a situation). Worrying involves the prefrontal cortex and its interactions with the limbic system, particularly the anterior cingulate, while anxiety involves only the limbic system, mostly interactions between the amygdala, hippocampus, and hypothalamus. In essence, worrying is thinking about a potential problem, and anxiety is feeling it.

Put another way, fear comes from seeing a lion jump out of the grass and start running toward you. Anxiety comes from seeing the grass rustle and assuming that a lion is hiding there.

There’s social anxiety and performance anxiety and even general anxiety, which makes you anxious about everything. But they all follow the same basic pattern, and it’s as easy to remember as ABC.10 “A” stands for “alarm.” You make an observation that something seems wrong (for example, My heart is racing or That tuft of grass seems to be shaking strangely).

“B” stands for “belief.” You evaluate the alarm and create a belief about the observation you just made (I’m having a heart attack or There’s a lion in the grass). The beliefs are often subconscious; you’re not even aware of them.

“C” stands for “coping.” Coping is whatever you do after the belief. Do you take a deep breath and tell yourself everything will be okay? Do you freak out? Yes, freaking out is a form of coping. But, while it gives you some semblance of control, it’s not the most effective response.

there are also many ways to calm the anxious limbic system that don’t require a prescription. In fact, your own prefrontal cortex is perfectly capable of soothing the amygdala and creating an upward spiral. The first step is simply to recognize your anxiety or worrying when it occurs. Becoming aware of your emotional state activates the prefrontal cortex and allows it to suppress the amygdala.

Putting emotions into words—however hokey that sounds—actually rewires your brain circuits and makes you feel better. Another great solution is to focus on the present moment. Because worrying and anxiety are projections of yourself into the future, they’re not things that exist when you are fully immersed in the now. So pay attention to what’s going on right now. If there’s an actual threat to your safety, then deal with it, but if it’s just anxiety, simmering somewhere below the surface, then make a note of it—and move on. Shift your focus to what’s occurring right now.

Interestingly, our emotion circuits are more easily activated by the negative, which means that most people need to experience numerous positive events for every one negative just to come out even. Furthermore, some people’s brains automatically focus more on the negative, which puts them at a greater risk for depression. Their brains are biased toward pain, loss, and the emotional toll of mistakes, and they often distort memories of the past and expectations of the future. In depression, the brain’s negative bias is responsible for making bad situations seem a lot worse than they actually are. In truth, the reality is almost certainly better than it appears: your relationships not as broken, your job not as pointless, and your abilities greater than you realize.

All of this means that to be happy in our daily lives, we need a high ratio of positive to negative. And it turns out, after considerable study, that ratio is three to one. We need three positive comments from a friend for every negative one, three wins at work for every loss.12 Of course, not everyone is the same. That three-to-one ratio is just an average. Some people might need only a two-to-one ratio and be fine, but others—people who feel losses and disappointments more deeply—might need a higher ratio. On top of that, if your brain simply ignores the positive events that happen to you—as is often the case with depression—you might need an even higher ratio.

“Life is a train of moods like a string of beads; and as we pass through them they prove to be many colored lenses, which paint the world their own hue.” The poet Ralph Waldo Emerson understood how moods can change perception—a process called the mood congruent attentional bias. It turns out that when your mood gets worse, so does your brain’s negative bias. Feeling down means you’re more likely to notice negative things about the world and about yourself. This includes context-dependent memory, mentioned in chapter 1, which, in certain contexts, makes you less likely to remember happy events and more likely to remember sad ones.

Nonjudgmental awareness is a form of mindfulness that simply means noticing without reacting emotionally, even when things don’t turn out as you expected. Awareness does not require emotion, because emotion and awareness are mediated by different brain regions. Noticing a mistake might automatically trigger the emotional amygdala, but becoming aware of your own reaction activates the prefrontal cortex, which calms the amygdala.25

It’s important to understand your brain’s response to uncertainty, because it can dramatically affect how you feel. When starting a new relationship or changing jobs, your brain may automatically interpret the new situation as something bad. But it’s not bad; it’s just unknown. And for almost anything worth having (true love, a great job) you have to pass through some period of uncertainty. We have to constantly remind ourselves that our brains may be skewing the unknown toward the negative, so we don’t miss out on the potentially awesome rewards on the other side.

Similarly, during actual painful stimulation, people with depression had greater increases in amygdala activity than nondepressed people. Their brains had a more emotional response to the pain. And the more helpless they felt, the greater the brain’s emotional response. Furthermore, they had decreased activation in the region of the brainstem that produces painkilling endorphins, so their brains did not try to suppress the pain as much. They also had decreased activity in the ventral anterior cingulate and prefrontal cortex, which meant that the pain had a greater impact on their optimism circuitry and lowered their ability to think rationally about the situation. Thus, if a depressed person and a nondepressed person both burn their hand on the stove, the depressed person is more affected by the pain. The brain’s response to pain is one reason that people with chronic pain are more likely to develop depression, and vice versa.

In depression, there is a brain bias toward bad memories.

To combat pessimism, you can strengthen the brain circuits responsible for optimism. The first step is to simply imagine the possibility of positive future events. You don’t have to believe they will happen, just that they could happen.

The second step to strengthening optimism circuits is not just recognizing that good things could happen, but expecting that they will happen.

Habits are, by definition, hard to change. And some habits are so deeply ingrained that we don’t believe they can be changed. Fortunately, the first step to accomplishing change is simple awareness, and the second step is believing it to be possible. Which it is. You might need therapy or medication, or you may simply need to perform some of the activities described in this book. But first and foremost, you need an understanding of how your brain creates and controls your habits.

This is the case with all addictions: if you don’t act on your habit, you feel anxious, which makes you want to act on the habit even more. And if you do yield to the habit, it just causes more stress later on, which retriggers the habit. It’s easy to see how we get stuck in a cycle—how it can feel impossible to break out of. But it’s not impossible. To get rid of a destructive coping habit, you can’t just stop doing it, because then you’re left with the stress. Instead, you have to replace it with another habit.

Ultimately, it comes down to the most clichéd but scientifically true maxim: practice, practice, practice. To create new, good habits, you have to repeat them over and over again until your brain rewires itself.

Exercise is possibly the most straightforward and powerful way to start an upward spiral. Not only is it easy to understand, but exercise also has many of the same effects on the brain as antidepressant medications and even mimics the buzz of recreational drugs. Yet exercise is natural, it causes more nuanced and targeted brain changes, and its benefits can exceed even those of medication.

Make a good decision, not the best decision. When trying to make a decision, we tend to focus on the relative drawbacks of each option, which often makes every decision seem less appealing.1 Nor do we usually have enough information to feel confident in the decision—the world’s just too complex. But remember, it’s better to do something only partly right than do nothing at all. Trying for the best, instead of good enough, brings too much emotional ventromedial prefrontal activity into the decision-making process.2 In contrast, recognizing that good enough is good enough activates more dorsolateral prefrontal areas, which helps you feel more in control.

Take a step in the right direction.

Figure out what’s important to you.

We are often under the impression that we are happy when good things happen to us. But in actuality, we are happiest when we decide to pursue a particular goal and then achieve it. One big problem with depression is that in the short term, nothing feels pleasurable. Because of frontal-limbic miscommunications, you can’t connect future happiness to today’s actions. Thus any action that isn’t immediately pleasurable becomes difficult.

Decide for something you want, not against something you don’t want.

Create specific long-term goals.

You don’t even need direct control over the cause of your stress to gain the benefits of decision making. As long as you have control over something, you can take advantage of the benefits.

The important thing here is not actual control, but perceived control. Making decisions may not increase your actual control over a situation, but it will likely increase your perceived control. And when you increase your perceived control, you increase your confidence, mood, and future decision-making capabilities.

Mentally, poor sleep worsens your mood, lowers your pain threshold, and interferes with learning and memory. It also diminishes your ability to concentrate and makes you more impulsive. Physically, it increases blood pressure, elevates stress, and harms the immune system. It can even cause weight gain. Poor sleep also has numerous negative effects on the brain, particularly in the prefrontal cortex and hippocampus. It also alters the function of the serotonin, dopamine, and norepinephrine systems.

Avoid bright lights after the sun goes down.

Write down your worries.

Make your environment comfortable. Quality sleep requires calming the brain, while being uncomfortable activates the brain’s stress response.

Brighten your day. Bright lights during the day help synchronize your circadian rhythms and improve your sleep. So take a few minutes to go walking in the sunshine.

Habits are the things you do when you’re not thinking about what to do.

Two studies from the United Kingdom figured out a clever way to help change your bad habits. The trick is self-affirmation, which may sound hokey, but the results were undeniable.

Self-affirmation. Before thinking about which habits you’d like to change, answer this list of questions with a yes or a no. If you answer yes to any questions, please elaborate.

Resolve to change. Making a resolution to change is more effective than simply wanting to change, and dramatically increases your chance of success.7 Being specific in what you want to change helps make it more achievable.

Remember the good times. Maybe you can remember a special birthday from childhood or a fun trip or even something as simple as a pleasant Sunday afternoon. Try to visualize it in detail or, better yet, write it down for future reference. If you’re having difficulty, talk to an old friend, look at photographs, or read your diary from happier times. Repeat as necessary.

The German philosopher Friedrich Nietzsche wrote, “He who has a why to live for can bear almost any how.” Having long-term goals gives you a why.