By Kirsti A. Dyer, MD, MS, FAAETS

A Charlie Brown Christmas: The Making of a Tradition

This year as I watched the Charlie Brown Christmas special for the umpteenth time, I found myself suspecting that he was experiencing a "Charlie Browniest Christmas" or a case of the "Holiday Blues." As the show proceeded he revealed his feelings about Christmas, "I think there’s something wrong with me. I just don’t understand Christmas. I like getting presents, sending cards, decorating tress and all that. But I always end up feeling sad." Listening to these comments I became even more sure of my diagnosis. I found it strange that even though I have watched the program nearly every holiday, until this year I had never noticed how blue about the holiday Charlie Brown really was.

The Holiday Blues - Why am I feeling like Charlie Brown?

People often have different experiences of the holidays. For many, it is a time of joy, happiness, peace on earth, good will, celebrating with family and friends, and hope for the future. But for others, the holiday season can be a difficult time, a time of sadness and loneliness, a time of self evaluation and reflecting on past accomplishments and failures, and a time of anxiety about the future year. During this time of year there is a high potential for psychological, physical and financial stress. As a result, the holidays can leave millions of people feeling blue, not happy or merry. The holiday blues can affect men and women of all ages with intense and unsettling feelings ranging from mild sadness to severe clinical depression. Based on his description of how he is feeling, Charlie Brown appears to have a classic case of the Holiday Blues.

The holiday season can also be especially difficult for those who have lost a loved one and are facing the first or the umpteenth season without them. For those who have experienced a significant loss or change during the year, it is normal to feel subdued, reflective and blue like Charlie Brown "I don’t understand Christmas.…Instead of feeling happy, I feel sort of let down." Laughter and happiness are perceived as sentiments for others, not for someone grieving a loss. The joyful public celebrations and media portrayal of the "perfect" holiday can be painful reminders of what the grieving person is missing. Memories of holiday season's past will invariably surface, or thoughts of a season that will never be; these remembrances and reflections can trigger an episode of the blues. It is normal for the holidays to exaggerate feelings of stress, sadness and loneliness.

Other factors can contribute to the stress, loneliness, and sadness experienced during the holidays. Those separated from loved ones by circumstances, distance or death can find this season to be an intensely painful time, one that further reminds them of how much they are alone. The increased demands of shopping, parties, family reunions, and house guests leave many feeling overwhelmed by their holiday obligations. The over commercialization of the Holidays by retailers makes one begin to believe this time of year is synonymous with "buying" and "spending" and no longer about "caring" and "sharing." The spirit of the season seems to have been lost in a corporate take-over, or fired in a managerial down-sizing. Financial hardships during a slowing economy, a time of rising unemployment and the multitude of end-of-the-year layoffs may severely limit what people can spend this year. Add to this the idealistic plans of trying to create the perfect "Martha Stewart Holiday," unrealistic expectations may be raised which may be impossible to meet.

The Blues During Medical School and Training: A Personal Experience

For many of the years during my medical training—medical school and residency—I would find myself slipping into the holiday blues before Thanksgiving emerging sometime after Valentine's Day. I also have a birthday over the holiday season near New Year’s Eve, so both of these occasions served as a time of self reflection. I would spend these days looking back on the year that was and where I was in my life—personally, professionally, and economically. I did not meet my husband until after I completed my residency training, so I spent holidays during medical school and residency as a single person. Adding to my world of being alone were the seemingly endless reminders from Thanksgiving through Valentine’s Day by advertisers—the images of happy couples and happy families having the perfect holiday. These constant media reminders only made things worse underscoring that my personal life was nonexistent. I believed the holidays were for children and for those in love. Not being either made it an extremely difficult time. Professionally, I found there was often little to look forward to during this season. In the midst of medical training the end is often no where in sight and there are no guarantees of finishing. Additionally as with so many other interns and residents, being the low people in the medical residency hierarchy, I was often scheduled to work on the weekends and holidays. Surprisingly for me, I discovered that working was better than being home pining for a person that did not exist in my life, being away from family and friends, and feeling quite lonely. Economically the holidays during my education and training years were hard. The resources didn’t exist to do something fun, even if I’d had the time off and the energy with which to do so. I felt like Charlie Brown, thinking there was something wrong with me for feeling sad at Christmas. "Good Grief! I’m having a Charlie Brown Xmas."

After seven years of feeling blue and having Charlie Brown Christmases, my final year of training 1995, I decided to change how I was viewing my life, my situation and stop turning Christmas into a problem. I began looking for positives rather than only seeing the negatives, focusing on the true reasons for the season—peace and good will. I consciously started behaving more compassionately so I would feel better. Altruism, performing acts of kindness selflessly for others, was my way of coping and surviving. That year I decided if I couldn’t be with my family, friends or someone that I loved then I would create a family and find friends for whom I could do Christmas things and spread some holiday cheer. Thus, Christmas 1995 I experienced several unexpected blessings. I called a few of my physician girlfriends, friends, and family members who were also alone for the season. Reaching out over the phone and connecting with someone else who was also feeling lonely made the season more bearable. As a senior resident I insisted on covering for one of the interns so she could make it to her family celebration—the first big Christmas for her 2 year-old son. Looking back on this gesture, I now realize as my own 21 month-old daughter is nearing her first big Christmas, just how special the simple "gift" of my time was to this female intern. Several of the other ways I used for coping during my training are included below.

Coping with the Blues During Medical Training

• Call friends, family or colleagues who are also alone for the holidays, or otherwise home-bound.
• Consider taking call for those with families. Volunteering to take call for those "who have a life" can be viewed as doing a good deed and makes the call day more tolerable. Being forced to take call because you are "single" seems like an unfair punishment.
  
• Think of being in the hospital over the holidays caring for others who are dying, ill or injured as being the ultimate in the helping profession—sacrificing your happiness and holidays, being away from loved ones to help others. (This worked for me for a few years.)
  
• Remember your patients are spending their holidays in the hospital away from their loved ones.
  
• Volunteer for non-profit organizations or visit a nursing home. · Send personalized holiday cards to friends, family and colleagues. In this era of e-mail, people still enjoy receiving "real" letters. You might get one in return and not have to face an empty mailbox.
  
• Donate time or money a homeless, battered-women or animal shelter.
  
• Knit, sew or crochet blankets or hats for the homeless, children or animals.
  
• Enjoy free activities: Look at holiday decorations. Window shop. Listen to free holiday concerts. Attend a religious service. Enjoy Christmas carolers.
  
• Bring the holidays to work. Decorate the resident’s community area with lights, a Christmas tree and Menorah.
  
• Buy a living Christmas tree and get fellow residents to help plant the tree after the holidays as something good for the environment.
  
• Organize a gift exchange, "Secret Santa" or "Angel Buddies" Decide on a monetary gift limit. Draw names and pick a time for the exchange or revealing "Santa" or the Buddies. (Strangely enough my "Secret Santa" was the intern that I covered for on Christmas Day.)
  
• Share holiday traditions. Bake favorite bread and cookies for friends and "family" in the hospital or the community. Treat fellow interns and residents stuck on call, the new mom too harried with her first child to bake for Christmas, or hospital personnel that have been particularly helpful to home- made cookies or other holiday goodies.
  
• Leave candy canes or Christmas roses in the house staff’s mail boxes.
  
• Celebrate the holidays with family at a different time, when you are able to get away.

Basics of Coping with the Blues

For anyone feeling blue or sad like Charlie Brown during the holidays, there are some very basic, common sense steps that can be taken to help in coping.

• Maintain a normal routine. Try and continue with normal daily activities.
  
• Be sure to get enough sleep or at least rest if sleeping is difficult. · Regular exercise, even walking, helps relieve stress and tension and improve moods.
  
• Maintain a balanced diet. Watch out for the temptation to eat high calorie "junk" foods and comfort foods. This will help avoid the post-holiday depressing weight gain.
  
• Alcohol should be used in moderation, not to mask the pain. Excessive drinking can contribute to feeling blue or depressed.
  
• Take it one hour at a time, one day at a time.
  
• Do those activities, or be with the people that comfort, sustain, nourish and recharge you.
  
• Remember other times in the past when you have experienced loss and the strategies used to survive the loss.

Ways of Coping with the Blues

Charlie Brown found several ways of coping with his blues. His "psychiatrist" Lucy suggested getting involved and offered to let him direct the Christmas play. He found a tiny Christmas tree that needed a home. He wondered if anyone could tell him about the true meaning of Christmas. The following list includes other suggestions for coping with the blues.

• Determine priorities, establish realistic goals and expectations for the holiday season. Don't expect that everything will be perfect—food, decorations, parties, family behavior or presents. Keep expectations manageable. Decide what can be comfortable done and what cannot be done.
  
• Delegate responsibilities to others—spouse, children, parents, siblings or other relatives. Plan a calendar or "To do" list for shopping, baking, visiting and other events. Let your family and friends know about your plans.
  
• Take time for yourself—for rest and relaxation.
  
• Minimize financial stressors by knowing your spending limit, setting a budget and sticking to it. Let family members know if you are limiting or changing exchanging gifts.
  
• Remember that the best gifts often come from the desire to make someone happy, not the price tag. Gifts given from the heart can bring much joy. Many cannot be purchased—gifts of time e.g. baby-sitting or volunteering, visiting and reminiscing with loved ones.
  
• Enjoy free holiday activities: looking at home or city holiday decorations; window shopping; viewing holiday light displays; making a snow person with children; participating in community activities such as tree decorating or lightings or community sing-a-longs; listening to free holiday concerts; enjoying Christmas carolers.
  
• Watch favorite old holiday season classics—"A Charlie Brown Christmas," "How the Grinch Stole Christmas," "A Christmas Carol," "The Miracle on 34th Street," or "It’s a Wonderful Life." These classics may bring back good memories and remind one of the true reason for the season.
  
• Feelings of grief, loss or sadness should be acknowledged, not ignored or repressed by those who have experienced a death, romantic break-up, tragedy or significant loss.
  
• For some surviving the holidays may require limiting activities or avoiding the season altogether.
  
• Spend time with caring, supportive, nurturing people. Limit the amount of time spent with people that are aggravating, insulting, negative or otherwise difficult to be around.
  
• Reach out and reconnect with old friends or make new ones; this can help deal with the loneliness experienced during this season. Don't wait to be invited—invite someone over.
  
• Do something in memory of departed loved one, create a remembrance or start a new ritual. Some suggestions include: light a special candle; play a favorite song; hang a certain ornament or stocking; listen to music enjoyed by the loved one; donate to a homeless or animal shelter; adopt a needy family; donate the money that would have been spent on a gift to their favorite cause; plant a tree in memory of a departed loved one.
  
• Old holiday traditions may no longer be possible as families change. Find new ways to celebrate the season. Create new rituals, traditions or remembrances.
  

When to Be Concerned

Fortunately, Charlie Brown’s feelings of depression and sadness were short-lived. He didn’t require medication or extensive therapy to deal with his blues. He needed to be around people and have a trusted friend (Linus) support him during this time. Charlie Brown’s symptoms lessened following his involvement in the Christmas play. His spirits lifted after listening to Linus explain what Christmas was really all about…"Peace on Earth, Good Will to Men." As Linus remarked about the bedraggled, little "Charlie Brown" tree that they selected, "It’s not a bad little tree, really. It just needs a little love." These words could also be applied to Charlie Brown. He just needed someone to give him a little tender loving care. The Holiday Blues tend to be short-lived lasting only a few days to a few weeks around the holiday season. The emotions—sadness, loneliness, depression, anxiety—usually subside after the holidays once a daily routine is resumed. However, if the symptoms of hopelessness and depression last for more than two weeks, persist past the holidays, or intensify during the season, a simple case of the blues may in reality be a serious case of depression.

Concerning symptoms include: ·

• Persistent sad, anxious, or empty mood
  
• Sleeping too much or too little, middle-of-the night or early morning waking
  Reduced appetite and weight loss or increased appetite and weight gain
  
• Loss of interest or pleasure in activities, including sex
  
• Irritability or restlessness
  
• Difficulty thinking, concentrating, remembering or making decisions
  
• Fatigue or loss of energy
  
• Thoughts of death or suicide
  
• Feeling inappropriate guilt, hopelessness or worthlessness
  
• A person experiencing the "blues" consistently over a period of several weeks should seek professional help from physicians, mental health care providers, clergy, crisis lines, support groups, or mental health centers. Talking with a professional or taking a mental health screening test can help assess whether it's the "blues" or depression. Those with suicidal thoughts or ideation need to seek immediate care with their physician, crisis line or the nearest hospital emergency department.

Remember to REST during the Holidays

The key to coping with the Holiday Blues is in understanding them. Setting realistic expectations for the holidays, knowing what people, events, thoughts or memories can trigger feeling sad, blue or depressed, developing ways of responding to these feelings and being around supportive people can all be helpful in coping with the holidays. Most of all it is important to remember to get your R-E-S-T:

Reasonable expectations and goals. Be realistic about can and cannot be done. Get plenty of rest. Exercise, even walking daily.
Eat and drink in moderation. Enjoy free activities.
Simplify to relieve stress. Set a budget for time, social obligations and gifts. Simple gifts can bring happiness - give service coupons, spend time together, donate to charity, call or visit a friend.
Take time for yourself for relaxation and remembrance. Give time to others—volunteer. Spend time with caring, supportive people. Keep in mind that Traditions can be changed.

Final Thoughts

I’d never really noticed that Charlie Brown provides a good case example of the holiday blues. First he feels a sense of sadness, then struggles with feeling different and out of place. Finally, he resolves his symptoms, all within 30 minutes and in enough time to still enjoy part of the season.

I continue to have some non-seasonal "career blues" pondering how best to balance the new role of mother with the demands of a medical career. Thankfully my holiday blue periods have diminished since finding my husband, getting married and having our first child. By Christmas 1996, a year after I had decided to shift my way of dealing with the season, I was engaged. By Christmas 1997, I was married. By Christmas 2000 we had welcomed our first daughter. This Christmas 2001 I am expecting our second child.

It is difficult to determine how much of my change in experiencing the blues is due to being away from the stressors and pressures of medical training, how much is due to being in a stable relationship, and how much was due to the internal shift in attitude. One has to wonder how much of my holiday blues were caused or at least exacerbated by the stressors of medical education and training. Once out on my own, I have had more of a say in my work schedule and how I am treated. I do know, for a fact, that several of my single physician colleagues still dread their holiday season, indicating that there may be some inherent stressors present in just practicing medicine.

This year in particular, with all that has happen in the world, it is even more a year of reflection and a time to count blessings. As I watch my 21 month-old daughter understand Christmas for the first time, see the wonder and magic of the season through her eyes, and begin to start our own family traditions, I feel very fortunate. We also feel blessed with another healthy pregnancy that is going well. With luck we will have our second daughter sometime around Easter. My husband and daughters, my cherished non-monetary "gifts" are far better than any present I could ever receive. They are also my best personal cure for the blues.

Note: I am interested in hearing other ways that other medical students, residents and physicians, have of coping with the holidays, special remembrances, or traditions used by families to honor departed loved ones. E-mail me at griefdoc@kirstimd.com.

The suggestions may be included in updates to this article.
Online Articles for More Information:

Center for Disease Control
Preventing the Holiday Blues. Last Updated October 31, 2001. Available at: http://www.cdc.gov/safeusa/blues.htm

National Mental Health Association
Coping During This Holiday Season 2001. Available at: http://www.nmha.org/reassurance/holiday.cfm
Holiday Depression & Stress. 1998. Available at: http://www.nmha.org/infoctr/factsheets/103.cfm

MentalHealth.org
Highlights Holiday Blues. December 2000. Available at: http://www.mentalhealth.org/highlights/December2000/holidayblues/

Journey of Hearts
Dyer KA. The Holidays 2001: Coping in the Year of Change & Uncertainty. December 7, 2001. Available at: http://www.kirstimd.com/blues_01.htm
Dyer KA. Basics about the Holiday Blues. December 9, 1998. Available at: http://www.kirstimd.com/blues1.htm
Dyer KA. More Suggestions for Dealing with the Holiday Blues. December 13, 1998. Available at: http://www.kirstimd.com/blues.htm

American Association for Geriatric Psychiatry
Holiday Blues or Depression. Available at: http://www.aagpgpa.org/p_c/blues.asp Good Assessment for Depression.

American Institute of Preventive Medicine
Powell DR. Defeat the Holiday Blues. American Institute of Preventive Medicine. February 1999. Available at: http://cbshealthwatch.medscape.com/cx/viewarticle/150090

Charlie Brown Quotes taken from: Schulz CM. A Charlie Brown Christmas. New York, N. Y.: Little Simon, 2001.