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Most people understandably are very shocked if they get hit by a serious disease. This is no less true if it is a disease which hits such a vital and central organ like the heart, and it is therefore normal to suffer a crisis in such a situation.

However, a crisis is a condition which relatively quickly will pass, after which we learn to adjust to the new circumstances. Most people have the strength to adjust to new situations, and some of us even experience that we grow and become wiser as a result of the crisis.

But what happens when the crisis instead of passing just continues on and on and develops into a depression? The crisis then no longer causes us to develop and become stronger and wiser. Instead we get into a negative spiral, which pulls us into a chronic depressive condition that swallows both our strength and drive.

Depression is common amongst heart patients

Our culture has widely accepted that patients become depressed in connection with physical illness. Depression is very common amongst patients who suffer from heart disease, and it is therefore often regarded as a normal reaction.

Studies indicate that approximately 20% of the patients who are admitted with ischaemic heart disease develop severe depression, whilst up to 30% suffer mild depression after their discharge. The figure is similar for out-patients with ischaemic heart disease (heart disease with a lack of oxygen in the heart). And research data indicate that depression in this group of patients often isn't treated and generally is underdiagnosed, i.e. it goes undetected.

In the last 10-15 years the number of research results which link depression and ischaemic heart disease has increased significantly. Depression has been identified both as a risk factor for developing ischaemic heart disease and as a risk factor in the course of the heart disease. It was found that heart patients with depression have a higher death rate than heart patients who don't suffer from depression. Depression is therefore a disease which must also be treated in heart patients.

Increases the death-rate

The last 10 years' research indicates that depression in patients with ischaemic heart disease increases the death rate by 3-4 fold. Depressed heart patients therefore die 3-4 times as frequently as those patients who don't show any signs of depression during the first six months after the heart disease has been diagnosed.

This increase is not limited to severe depressions but also occurs in heart patients with mild depressions. Research has shown that the negative effect that depression has on ischaemic heart disease is just as great as the effect from other negative factors like smoking and high blood pressure, the degree of sclerosis and the effect of the heart's ability to pump effectively.

Other tests show a similar negative effect of depression after a cerebral thrombosis. Tests even indicate that being a little psychologically weak and vulnerable - without being depressed as such - can also make you susceptible to developing ischaemic heart disease and cerebral thrombosis.

The connection is not completely clear

The biological links that can explain the connection between depression and ischaemic heart disease has not been fully explained, but research data indicate several possible biological mechanisms. Amongst the factors that are central to the development of the disease in the combination of depression and ischaemic heart disease are

  • increased activity in the sympathetic nervous system

  • reduced variation in the heart's ability to vary the speed and power with which it beats

  • activation of the blood platelets so they form blood clots more easily

The hypothesis that depression causes an increased activity of the blood platelets is central to the connection between depression and death after ischaemic heart disease. The depression's effect on the risk of dying after ischaemic heart disease should supposedly be seen in the light of the strain that the body is exposed to due to stress. To be suffering from heart disease and depression simultaneously must be one of the most stressful situations that a person can be in. If we look at the effect that stress can have on the body of a normal and healthy person, we can begin to imagine why it can be distinctly dangerous for a heart patient to be suffering from stress caused by depression.

The effects of stress

The human stress response - i.e. our reaction to stressful influences - is primarily adapted to a life in a world which looked completely different to the way it looks today. We lived in a world, where the ability to react physically quickly and effectively was of vital importance in order to avoid getting killed. It was furthermore a prerequisite for being able to hunt and provide one's living.

Several thousand years later, it is the same reaction that occurs when a person becomes stressed:

  • increased activity in the sympathetic nervous system

  • reduced variation in the heart's ability to vary the speed and power with which it beats

  • activation of the blood platelets so they form blood clots more easily

The great problem today, however, is that we neither go hunting nor find ourselves in battle situations. We are probably lying in a hospital bed or pottering about at home and waiting to become well, and the body's reaction is therefore completely inappropriate. This is probably the reason why depression and the increased stress level it causes have such negative consequences for the heart patient.

Self-esteem is something you can learn throughout your life.

Many people believe that self-esteem is something you are born with, which you either possess or not. Low self-esteem is often connected with depression. It appears as self-criticism and self-reproach - in other words negative thoughts about yourself.

The depressive thinking is generally negative. When you are suffering from depression, you think negatively about yourself, the future, other people and your options. You also predominantly remember negative events.

Negative thoughts increase the feeling of sadness and bad moods, and there is evidence to suggest that the training of your self-esteem is very effective against depression.

However, it isn't only people who suffer from depression that suffer from low self-esteem. Low self-esteem is also seen in connection with all mental diseases and also exists in people who don't suffer from a mental disease but who don't believe in themselves at all.

Low self-esteem might lead to a mental disease in the long run in the same way as a lack in social skills can.

What is low self-esteem?

Psychologically, low self-esteem is defined as the way you are presented in your own thinking - the cognitive presentation of self. It concerns the way you think about yourself. Your thoughts about yourself are based on your early development and experience.

It is clear that a person who has been given a lot of praise, love, backing and positive confirmation throughout their childhood and youth, has developed their self-esteem to a higher degree than a person who has been criticised and far too early has experienced hostility and indifference.

But it is however more complicated that just having been praised. Self-esteem is directly connected with what you think about yourself, what you say about yourself, and what you are convinced about with regard to yourself.

Undermines your mood and self-confidence

By self-confidence we understand the way we act and communicate in relation to others. It is for example important that you are able to say no, draw the line, make demands to the people around you and go after what you need as well as simultaneously avoiding everything that is damaging for you in life.

We call it the desire-pain balance, when a person is both good at satisfying their needs, looking after themselves and being self-protective, when he or she is subjected to something bad.

Mental health is connected with self-esteem and self-confidence, and self-esteem as well as self-confidence are connected with skills - social skills.

It is important to have social skills to be able to communicate effectively and solve problems when they arise. The social skills are in themselves an antidote against anxiety and depression and the same goes for constructive thoughts.

We call it coping - the ability to cope with and live with that which cannot be any other way. And learning something from those bad events in order to become more robust. If you have learned something, everything is not in vain.

A happy life is not a life without problems but a life where the individual is able to solve the problems that will undoubtedly occur.

Negative thoughts

When it comes to the basic way you think about yourself, we talk about the personal schema, or that which we deep down believe in and are convinced of.

Low self-esteem is connected with the thought "I'm not good enough". This thought can appear in many forms. If it has become a personal schema due to too many defeats and disappointments, the negative and self-destructive thoughts are released automatically.

It works as a negative microchip that automatically sends signals out and makes up a whole pattern of thoughts, which destroys self and makes it difficult to feel worthy, good enough and have confidence in yourself and others.

Low self-esteem produces a series of negative thoughts, which makes it difficult to feel happiness and success. These negative thoughts often reflect what we call the underlying ideas or rules of what is right and wrong. In order to repair a low self-esteem, you first have to identify the negative thoughts.

Typical negative thoughts about self can be:

  • "If I make a mistake, I'm not good enough."

  • "If others disagree with me, it is because I'm not good enough."

  • "If others are angry with me, it is because I've done something wrong."

  • "If someone doesn't like me, it's because I have made so many mistakes."

Behind these thoughts often lie the unrealistic ideas about

  • never being allowed to make mistakes

  • never disagreeing with anyone

  • never showing that you are sad or disappointed

and an unrealistic wish about everyone always having to like you, accepting everything you do and not being able to find any faults at all with you.

They swallow all your energy and lock your focus on all the negative things, everything you think is the matter and wrong. The worst thing is to let low self-esteem cripple you in your relations with other people. Low self-esteem can manifest itself in submissiveness and seclusion or as aggression and rejection.

What can you do about low self-esteem?

In principle, it is easy. The core of cognitive therapy is to find the systematic disturbances in the thought processes and restructure negative thoughts into constructive thoughts.

We use the same principle in connection with training our self-esteem.

It's about increasing your good characteristics and becoming better at them through practice. To become good at something you need to practice it. If there is a characteristic that you don't possess, it is probably because it hasn't been active and hasn't been practiced sufficiently. A good characteristic such as being a good friend can be forgotten and neglected.

If you don't believe yourself that you are a good friend, you forget to practice being a good friend. Perhaps you use all your mental energy to shield yourself so that others don't discover all your bad characteristics.

With so much focus on the bad characteristics, they are the ones taking up most space in the presentation of yourself in your thoughts and in your behaviour, and the good characteristics don't have a chance.

The recipe has been scientifically proven, and it has been documented that you can increase the self-esteem in people who are very depressed or suffer from various mental diseases and have lost all desire and energy and belief in themselves and the future.

Recipe for increasing self-esteem

  • Make a list of your good characteristics, everything you value and would be proud of.

  • Measure on a scale from 0-100 percent how much you believe that you have that characteristic.

  • Make sure you put one or more good characteristics into practice every single day.

  • Notice what happens with your conviction when you focus on your good characteristics and are preoccupied with how good you are at the different things that you value.

When making a list of your good characteristics that you value and would be proud of, be careful that they are not connected with disadvantages. You have to carry out the work thoroughly, i.e. if you would like to "be a good friend", then find out why.

What is it that you want to achieve by being a good friend? Others' acceptance, others' friendship, others' admiration? How will you put being a good friend into practice? A good friend helps, is there, is reliable and always an encouragement.

A good friend is someone you can contact, visit, call without having any reason to. Someone who is there. Helping can be done in many ways. Make sure that there are no disadvantages connected with helping!

Not always simple

But it is not always so simple. A good friend will perhaps lend you what you need. But if you have stopped smoking, it is destructive to lend you cigarettes. It is on the other hand constructive to remind you of all the sensible reasons for stopping smoking.

It is not very clever either to lend you money if you end up having problems repaying it. If you keep your focus on what the best interests of your friend are - in the long run, it won't be too bad. Start regarding yourself as a good friend that you need to look after and protect.

When making the list of your good characteristics that you wish to develop in yourself, then remember to specify how you intend to put that good characteristic into practice. There are many possibilities but make sure that they are realistic and don't have disadvantages.

Some of the good characteristics might for example involve being

  • a good friend

  • someone you can trust

  • a loving person

  • good at your work, sport, something very special (music, singing, painting)

  • good at controlling yourself, even when you are provoked

  • optimistic despite adversity

  • healthy

  • beautiful

  • slim


The reason why you should be interested in the conviction is that you might believe that you are a good friend and at the same time be full of self-criticism and negative thoughts about all those times when you actually weren't a good friend. When you don't keep your focus on the reasons why you are a good friend, it lowers the conviction, perhaps below 25%.

When you are so unconvinced about having a good characteristic, you will be inclined not to practise it. To be convinced that you are a good friend, the good friendship skills must consciously be practised every day until they are a habit.

The activity makes the difference

When you actively practise good characteristics which make you happy and proud and simultaneously please the people around you, you begin to focus more and more on the fact that you possess good characteristics and become better at it for each day that passes.

It is the activity that makes the difference! And it is the details and the basic characteristics and skills that give the best result. That is how it is with all skills. They have to be practised. And they have to be practised in a way that makes you good at the basics before you continue with the more complicated.

Just think about a sport like tai-chi or yoga. The more you master the small basic movements and strengthen the different parts of the body, the better you get at the complicated exercises, and in the end everything is as easy as pie.

You also need to increase the degree of difficulty, when you practise your skills. Begin with the easiest and go on to more and more difficult exercises. For example, it is easier to be a good friend to a person who is friendly and obliging himself or herself and who you like, compared to being a good friend to someone who is hostile and tries to sabotage. The latter has even more pride connected with it.

Positive thoughts are increased

When you regularly look at your list of good characteristics and remember in detail how you have just practised them, then it increases your conviction about the fact that you actually possess those good characteristics.

In this way you begin to think more positively about yourself.

Write in a diary what it is you have done on that day which makes you a good friend. Tell others about it. Notice how the people around you react and be careful not to fall back into the old routine with negative thoughts and self-fulfilling prophecy.

There is a lot of truth in the old saying "the best way to feel love is to give it yourself". Many wait for others to love them and show that others love them. But what deep down gets people to feel the love within themselves is when they themselves show love and think in a loving way about others.

Remember that you are capable of practising good characteristics, even though you don't feel like it! When you have conquered your reluctance, and you do something, even though you don't really feel like it, you then feel a lot more like doing it! In this way, it is easier to keep up the enthusiasm and the energy when you are trying to maintain your characteristics and you self-esteem.

Can this be changed?

Remember most of all that self-esteem is the reputation you have in yourself. Speak nicely about yourself. Think nicely about yourself. Focus on what you like about yourself, and when there is something you don't like about yourself, then consider whether it is something that can be changed (it often is) or something you will have to learn to accept and see the advantages in.

If it can be changed, then make a detailed plan for how you want to change it and make sure that you do something each day which brings you closer to the goal.

Example 1

If you weigh too much, then make a plan of how you want to eat a healthy and slimming diet and how you want to make exercise an important part of your activities. Do it! Don't let bad moods or negative thoughts keep you from reaching your goal.

If it really can't be changed - and you need to be sure that it really can't be changed, then start to find its advantages.

Example 2

One of my clients was unhappy about his size and thought that all success in life depended on being tall (and handsome). There were numerous things he believed he would never achieve due to his low height.

He instead began to look for the advantages of being short and charming and finally reached the conclusion that his body in many ways served him well and that he was pleased to be physically well and strong, well proportioned etc. His mood and self-esteem rose significantly.

To think constructively is not just finding something positive to say about yourself. The work consists in believing it and increasing your belief in it. That means looking for proofs all the time of it being true. You will find those proofs in your own actions, your own thoughts and in the way you relate to other people.

Self-esteem is something you can learn throughout your life.

Social well-being - what is it? Is it something you can buy, teach yourself or is it something you learn throughout your life and which perhaps weakens if you become mentally ill?

I believe that we all learn it from when we are children and throughout our life through the influences, experiences, challenges and social connections we enter into.

It starts in our family, develops during our time spent in nursery, kindergarten, school, work, education, with friends, acquaintances and through life's ups and downs.

One's childhood and challenges are not equally and fairly distributed. But you can still have a good life and social well-being. It does demand though that you scrutinize your life and actual life situation, and depends on whether you wish to change your current situation.

Can't buy friends

Some people think that you can buy your way to well-being by for example always being the one to buy "another round" of one kind or another. This often only results in a short-term social contact, acceptance and socialising. When the money has gone, the "friends", the socialising and the care have gone.

Irrespective of what the childhood and challenges of someone's life have been, there are a couple of things you should make your mind up about: How can I achieve an increased well-being, and what conditions do I have to change to achieve it.

You can start modestly by taking one step at a time. When you have achieved success in one of your goals, you can then go on to the next.

Social well-being is to be respected, valued and cared about. It is also being able to cope with and master social situations and be with other people in a mutually giving way. You can furthermore fill up your spare time with activities and chores, which make you feel good.

Your self-esteem is strengthened by conquering your own feelings of inadequacy and turning them around so that you act in a positive and constructive way.

Better social well-being

But what can you do to get better social well-being? You can show respect for others, speak to them and behave in a way that you wish yourself to be treated.

This might be by giving and offering support to a friend, the family or acquaintances, who are currently feeling worse than yourself. By showing respect and that you care for this person, will make him or her feel an increased degree of well-being because you have shown an interest in him/her. You yourself will feel a sense of well-being from having done it.

It is a good idea to focus on what you used to be good at or liked doing and then try doing it again. This might for example be dancing. Perhaps you are good at dancing or maybe you would like to learn.

The question is whether you dare take a risk and do something about it. If you were to take a risk, it would lead to socialising and joy. This again would give you a better sense of well-being, more quality of life and courage to do other things and to get on.

Good advice

A couple of days before I wrote these lines, I sat and drank a cup of coffee with patients in the ward where I work. I told them that I was writing this article. I asked them what well-being is to them, and whether they had any good advice that I could pass on.

Here are some examples of what they prioritised the most:

It works as a negative microchip that automatically sends signals out and makes up a whole pattern of thoughts, which destroys self and makes it difficult to feel worthy, good enough and have confidence in yourself and others.

  • You have to look at the interests that you have or used to have, what you are or used to be good at and then strengthen that.

  • If you are receiving an early retirement pension, it mustn't become a pretext for doing nothing. You mustn't withdraw from social relations.

  • You must continue to function together with others and not feel inferior or superior but meet on an equal footing.

  • You can help others, in order to help yourself.

  • You must create and shape your everyday life by structuring it with different tasks, for example cooking dinner, do sport, meet up with friends.

  • It is important to have friends who can help, support and back you up, and to show humour in a mutual way.

  • You must make sure that you get "input" in your everyday life from friends, family, courses, newspapers and by communicating with the outside world.

  • A telephone is a good thing but when it never rings, it is a sad thing. So call a friend every day.

As Søren Kierkegaard used to say: He who dares, will loose his footing, he who doesn't dare, will loose himself.