Tolerating distress: why is it so difficult to quit smoking?

I remember how relieved I was when the smoking ban came into effect and the air in pubs and restaurants was no longer filled with cigarette smoke. I guess the aim of the policy was not only to protect the health of those of us who don’t smoke but also to encourage smokers to quit. Most of us understand that discontinuing an addictive habit is not that simple but what exactly is involved in quitting and why is it more difficult for some?

Most attempts to quit smoking, especially without help, result in failure (West, 2012). This is at least partly due to unpleasant withdrawal symptoms such as irritability, anxiety, low

Most of us are aware of the harmful effects of cigarette smoking. Image by Helgi Halldórsson from Reykjavík, Iceland - Dangers Of Smoking, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=33780867
Most of us are aware of the harmful effects of cigarette smoking. Image by Helgi Halldórsson from Reykjavík, Iceland – Dangers Of Smoking, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=33780867

mood, problems with concentration and difficulty sleeping (Hughes, 2007). However, success also depends on an individuals characteristics such as their ability to tolerate discomfort (Sirota, Rohsenow, Dolan, Martin, & Kahler, 2013) and distress, i.e. unpleasant psychological states (Leyro, Zvolensky, & Bernstein, 2010). If we believe that we can withstand the withdrawal symptoms, then we are much more likely to be successful, especially if we also reappraise the experience and tell ourselves that it will be worth it in the end. Some research also suggests that people smoke in order to soothe anxiety and negative feelings in the absence of better ways of coping with these unpleasant emotional experiences (Leyro et al., 2010). Thus, the nicotine users becomes trapped in a vicious cycle where they smoke because they believe that a cigarette will soothe their negative feelings, and smoking  becomes a rewarding activity through its association with reduced distress. In other words, the less we can tolerate unpleasant feelings, the more rewarding smoking becomes.

Certain health problems, such as posttraumatic stress disorder (PTSD), can also make quitting smoking harder. This is due to the increased negative emotions, greater arousal, anger, and anxiety associated with such disorders. With regard to anxiety, a ‘fear of fear’ can also cause elevated worry, specifically worrying that stress/anxiety could have a harmful effect on our health (Kashdan, Zvolensky, & McLeish, 2008; Powers et al., 2016) therefore further diminishing an individual’s ability to cope (Leyro et al., 2010). Increased negative affect and severity of withdrawal symptoms also plague those with social anxiety who attempt to quit smoking (Buckner, Langdon, Jeffries, & Zvolensky, 2016). These additional difficulties are particularly important considering that those of us who have mental illness tend to smoke more and die earlier (Ziedonis et al., 2008). In addition, PTSD affects up to 30% of women who give birth (Grekin & O’Hara, 2014), and can therefore interfere with smoking abstinence among the new mothers addicted to nicotine.

Psychological therapy which teaches smokers to accept their internal feelings and sensations can considerably improve chances of quitting compared with standard intervention (quit planning, skills training, advice on pharmacotherapy, and social support for quitting) for smoking cessation (Bricker, Wyszynski, Comstock, & Heffner, 2013). For example, Acceptance and Commitment Therapy (ACT) encourages the individual to allow the thoughts, emotions and sensations that trigger smoking to come and go without attempting to control them. The resulting increased acceptance of these feelings allowed 23% of participants to remain smoke free up to 3 months after the therapy, compared with only 10% of those relying upon standard intervention alone. ACT also performed better than cognitive behavioural therapy (30% vs. 13% abstinence rate at 1 year) (Hernandez-Lopez, Luciano, Bricker, Roales-Nieto, & Montesinos, 2009).

It seems that the struggles with our own unpleasant feelings and the need to escape them play an important role in managing addiction: quitting smoking is not just about willpower or awareness of its harmful effect. Although this area needs a lot more research, it might be worth looking for help in increasing acceptance and mindfulness when battling withdrawal symptoms.

Post by: Jadwiga Nazimek

References:

Bricker, J., Wyszynski, C., Comstock, B., & Heffner, J. L. (2013). Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine & Tobacco Research, 15(10), 1756-1764. doi: 10.1093/ntr/ntt056

Buckner, J. D., Langdon, K. J., Jeffries, E. R., & Zvolensky, M. J. (2016). Socially anxious smokers experience greater negative affect and withdrawal during self-quit attempts. Addictive Behaviors, 55, 46-49. doi: 10.1016/j.addbeh.2016.01.004

Grekin, R., & O’Hara, M. W. (2014). Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev, 34(5), 389-401. doi: 10.1016/j.cpr.2014.05.003

Hernandez-Lopez, M., Luciano, M. C., Bricker, J. B., Roales-Nieto, J. G., & Montesinos, F. (2009). Acceptance and commitment therapy for smoking cessation: a preliminary study of its effectiveness in comparison with cognitive behavioral therapy. Psychol Addict Behav, 23(4), 723-730. doi: 10.1037/a0017632

Hughes, J. R. (2007). Effects of abstinence from tobacco: Valid symptoms and time course. Nicotine & Tobacco Research, 9(3), 315-327. doi: 10.1080/14622200701188919

Kashdan, T. B., Zvolensky, M. J., & McLeish, M. C. (2008). The toxicity of anxiety sensitivity and worry as a function of emotion regulatory strategies. Journal of Anxiety Disorders, 22, 429–440.

Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychol Bull, 136(4), 576-600. doi: 10.1037/a0019712

Powers, M. B., Kauffman, B. Y., Kleinsasser, A. L., Lee-Furman, E., Smits, J. A., Zvolensky, M. J., & Rosenfield, D. (2016). Efficacy of smoking cessation therapy alone or integrated with prolonged exposure therapy for smokers with PTSD: Study protocol for a randomized controlled trial. Contemp Clin Trials, 50, 213-221. doi: 10.1016/j.cct.2016.08.012

Sirota, A. D., Rohsenow, D. J., Dolan, S. L., Martin, R. A., & Kahler, C. W. (2013). Intolerance for discomfort among smokers: Comparison of smoking-specific and non-specific measures to smoking history and patterns. Addictive Behaviors, 38(3), 1782-1787. doi: 10.1016/j.addbeh.2012.10.009

West, R. (2012). Estimates of 52-week continuous abstinence rates following selected smoking cessation interventions in England.

Ziedonis, D., Hitsman, B., Beckham, J., Zvolensky, M., Adler, L., Audrain-McGovern, J., . . . Riley, W. (2008). Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine & Tobacco Research, 10(12), 1691-1715. doi: Pii 905756217

10.1080/14622200802443569

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Have yourself a wild winter: Preparing your garden for winter wildlife

screen-shot-2016-11-20-at-19-42-10As the last leaves fall from our trees and the outside world beds down for winter, we at the Brain Bank are turning our thoughts to the UK’s wild critters braving this cruel and often unpredictable season.

A quick peek at the BBC’s monthly weather outlook, taking us into the early part of December, shows the typical British weather pattern of unpredictability continuing forward. The jet stream is likely to develop a blocking pattern which prevents prevailing westerly winds blowing low pressure systems across our shores – this should favour a period of quiet weather, although whether this will be cold or mild is still open to doubt.

One thing I do know, however, is that over the last two weeks my garden has experienced mild sunshine, torrential rain, flooding, hail, snow and everything in-between. As I glance from the window to my wardrobe, grumbling about what to wear I can’t help but think – however hard we find this season, the wildlife fighting for survival just outside our doors are undoubtedly having a much harder time than us.

So what can we do to make the festive season just a bit jollier for them?

Birds:

For birds struggling through the winter months berries can be a lifeline. However, as the season draws on, berry supplies are dwindling and many birds will be in search of another food source – this is where you come in. A well stocked, clean and reliable bird feeder could be the difference between life and death for wintering British birds.

screen-shot-2016-11-20-at-19-46-09If you are unsure of what to feed your garden visitors you can find an extensive list of common British birds and their dietary idiosyncrasies here. Briefly, sparrows and finches have a preference for seeds while tits enjoy fat unlike thrushes and robins who have an appetite for fruit and worms.

Many feathered garden visitors also have an appetite for our leftovers: fruit cake, mince pie, dried fruit, unsalted nuts, apples and pears are all excellent appetisers for garden birds. Some more timid species like wrens and dunnocks can even be tempted to snack on grated mild cheese sprinkled under trees and bushes.

But be sure you choose the right stuff for your garden gang. Be mindful that birds will not eat anything mouldy or salty (too much salt can be poisonous to small birds). Also, however much you may have enjoyed your Christmas dinner, few birds have a taste for leftover sprouts and turkey fat can stick to their feathers making it harder for them to stay warm and dry. Finally, if you have dogs be very careful of feeding your garden birds grapes or currents since vine fruits can be toxic to dogs.

Finally, although an outdoor winter dip may sound horrific to us, birds need to bathe and drink every day – even when it’s cold outside. So if you can, try to make sure there is fresh unfrozen water somewhere in your garden.

Bees:

Although our minds may now be firmly fixed on snuggly jumpers and hot chocolate, it’s not uncommon for the UK to experience unseasonably warm days at the end of autumn and in early spring. This unseasonable warmth will often bring bees buzzing out of their winter homes and into your garden. So, to give our buzzing buddies a helping hand it’s always good to ensure your garden has it’s fair share of late and early-flowering plants. Ivy is in flower at this time of year and bulbs, which you can plant now, are a good source of food for bees early in the spring – fritillaries, crocus and snowdrops can also all be buzzing with bees on a sunny day.

screen-shot-2016-11-20-at-19-48-36A fun, if slightly unusual Christmas activity, would be to make yourself a solitary bee house. With bee numbers dwindling, it’s never been more important for us to take care of these hard working pollinators, this includes providing them with safe winter accommodation. Bee houses can be bought from your local garden center and hung somewhere warm and dry, however it’s also great fun to make one of these yourself. I recently ran a small event at a local botanical garden where we taught youngsters to make their own bee homes. The activity only took 15 minutes, was relatively cheep and of course the kids all enjoyed getting a bit messy – I’m pretty sure the local bee population were quite pleased with the results too! Instructions for two types of homemade bee houses can be found here.

Other wildlife:

It’s also important that we try to create habitats in the sunniest most sheltered parts of our gardens to benefit a wide range of wildlife. Never underestimate the winter warming powers of an old stack of bricks or plant pots in a sunny corner (a favourite of toads and newts) or a pile of wood and leaves (the preferred hidey-hole of hedgehogs and frogs). But, perhaps the most important advice we can offer our winter gardeners is to be a little bit messy… Strategically forget to rake leaves from a sunny corner of your garden or perhaps decide against cutting down the perennials in December. Then make sure you leave all these habitats undisturbed until well into spring. Your local wildlife will undoubtedly thank you for it.

Post by: Sarah Fox

Stigma and stimulants: the ADHD controversy.

screen-shot-2016-11-14-at-08-43-59In recent years, the growing number of children diagnosed with attention-deficit hyperactive disorder (ADHD) has received a huge amount of media scrutiny. A quick Google search turns up pages of articles suggesting ADHD can be blamed on everything from less time spent outside, greater demands at school, to bad behaviour and poor parenting. Unsurprisingly, the disorder can have severe social and educational consequences, which can often affect relationships and workplace productivity throughout adult life. These problems are exacerbated by the fact that an estimated 89% of cases of adult ADHD in the USA alone are still inadequately recognised and treated.

ADHD is characterised by a combination of behavioural traits including inattentiveness, hyperactivity and impulsivity. Despite being the most commonly diagnosed neurodevelopmental disorder, there is still no global consensus on the real prevalence of ADHD. Estimates range between countries and even across states due to discrepancies in social acceptance, regulation and healthcare availability. Also, despite recognisable biological symptoms including altered brain wave activity and dysfunctions in dopamine and noradrenaline transmission, research is yet to identify a clear cause for this disorder, making it far more difficult to decipher a clear explanation for the recent rise in cases.

As more and more children are labelled with the condition, concerns have been raised by some as to whether the influx of new cases is simply the result of a society searching to medicalise disruptive behaviours. Some argue that increased diagnosis can be attributed to better awareness of the disorder. Others however, suggest that high rates of mis- and over-diagnosis of ADHD have been the cause of this apparent surge in new cases. An article published this year in the Daily Mail even claimed that ‘unrealistic expectations from parents’ were to blame for the recent rush of new cases.

Such disagreement over the validity of an ADHD diagnosis is partly to blame for the growing stigma surrounding the condition. Poor public perception results in patients often being stereotyped simply as naughty children.

This leads us to the matter of how to tackle these misconceptions. At present, diagnosis focuses on psychological assessment along with fulfilment of certain behavioural criteria. However, this form of diagnosis can be subjective. In a bid to better regulate assessment of potential cases, research is now being carried out with the aim of developing a safe and affordable routine testing method for ADHD. One promising area of research is focussed on finding brain wave biomarker for ADHD based on electroencephalogram results. Researchers are also currently in the process of testing a behavioural animal model of ADHD. This model will provide us with a better understanding of the causes of this disorder and a more accurate way of testing potential treatments.

As is the case with many mental illnesses, there is as yet no cure for ADHD. Medication is often used to control symptoms rather than target the underlying cause of the condition – with nearly a million children prescribed either Ritalin (methylphenidate) or Adderall (amphetamine and dextramphetamine) in the UK in 2014. Unfortunately, alongside symptom control, these psychostimulant drugs can come with a multitude of unpleasant side effects, including insomnia and weight loss. Concerns have also been raised about the abuse potential of these drugs, particularly at a time when availability is increasing. In 2013, it was estimated that 13% of American teenagers had abused either Ritalin or Adderall.

It is hoped that further research could lead to a better understanding of the disorder and improved treatments, perhaps mitigating the need for the prescription of stimulants. Furthermore, until a failsafe diagnostic test has been developed, questions are likely to remain concerning the accuracy and legitimacy of ADHD as a medical condition. This will leave children at risk of prejudice and stigmatisation, with potentially devastating effects on their quality of life and self-esteem.

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Post by: Sarah Lambert

Sarah is a neuroscience Masters student at the University of Manchester with a particular interest in mental health and the effect of drugs on behaviour. Currently working on a project in episodic memory deficits in schizophrenia, in her free time she enjoys writing, travelling and baking.

Reference:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174588/

https://www.theguardian.com/society/2015/aug/15/ritalin-prescriptions-double-decade-adhd-mental-health

http://www.dailymail.co.uk/health/article-3462680/Are-blame-child-s-ADHD-Adults-unreasonable-expectations-blame-surge-diagnoses.html

http://www.drugfree.org/newsroom/full-report-and-key-findings-the-2012-partnership-attitude-tracking-study-sponsored-by-metlife-foundation/

Mothers-to-be may be sick of “morning sickness”, but does this symptom of pregnancy serve a purpose?

screen-shot-2016-11-06-at-18-01-08Pregnancy, a beautiful time in any woman’s life when she witnesses her child growing inside her, feels her baby kick for the first time, and spends a great deal time vomiting into her toilet. Rather misleadingly termed “morning sickness”, nausea and vomiting during pregnancy (or NVP for short) is experienced by around 70% of expectant mothers during their first trimester and is rarely confined just to the first half of the day. NVP can begin as early as 5 weeks into a pregnancy, peaks between weeks 8 and 12, and generally continues up until about week 20. But what is the point of NVP I hear you suffering mothers-to-be cry? Is there a reason for this less than appealing part of pregnancy or is it just an unwanted side effect of this miraculous event?

Despite the difficulties and unpleasantness NVP can bring the mother, mild to moderate forms of NVP have been widely associated with favourable outcomes for her baby. Reductions in the risk of preterm delivery, low birth weight and miscarriage have all been shown to accompany NVP and suggest this condition may in fact possess an important function in pregnancy. It should be noted that the nausea and vomiting discussed here does not include the pathological condition hyperemesis gravidarum, which occurs in approximately 1% of mothers-to-be and can lead to serious complications if left untreated.

There are a number of theories which may help explain why NVP has evolved as a part of pregnancy. The first of these sees NVP as a method of “communication” to a woman’s partner, alerting them to the pregnancy and the need to modify their behaviour screen-shot-2016-11-06-at-18-01-16accordingly. This would lead to a reduction in their desire to have sexual intercourse, instead providing more protection and an increased food supply to the expectant mother.

While it may sound like an attractive idea to have our partners evolutionarily programmed to wait on us hand and foot during pregnancy, the “communication” theory seems unlikely. Firstly, the peak of NVP occurs later than the cessation of periods, an equally clear and a less unpleasant signal of pregnancy. NVP would therefore be superfluous, meaning it would be eliminated through natural selection. Secondly, there is no evidence to suggest sexual intercourse is detrimental to pregnancy and so no need to reduce its desirability.

An alternative hypothesis is that NVP is a side effect, or “by-product”, of the internal conflict which occurs between the expectant mother and her foetus. This is not an aggressive or violent form of conflict of course, but rather a competition for the mother’s limited resources. Pregnancy, childbirth and parenthood are all costly investments for a mother, and while taking more of her nutritional intake allows the foetus to maximise its fitness, this act also reduces the nutrition available to the mother and consequently lowers her fitness. Such a tussle for resources is bound to result in visible side effects, hence the presence of NVP.

Similarly to the “communication” hypothesis, this “by-product” theory has a number of flaws. For example, if NVP were a sign of foetal fitness, the presence of NVP should denote a successful pregnancy. However, NVP does not occur in all viable pregnancies, nor does its presence always result in positive pregnancy outcomes. In addition, this theory suggests that NVP symptoms should occur later during pregnancy when the foetus is larger and therefore requires more resources which, as previously discussed, is not the case.

screen-shot-2016-11-06-at-18-01-23The final and most widely favoured theory for the function of NVP is the “mother and embryo protection” hypothesis. This states that NVP acts to reduce an expectant mother’s intake of agents which could harm her pregnancy (known as teratogens), including caffeine, alcohol and tobacco. It also removes any dietary toxins or food-borne teratogens which are ingested by the mother-to-be before they reach the baby and, as a consequence, teaches her to avoid these foods. Hence, the well-known “food aversions” experienced by many pregnant women. By the same method, NVP and food aversions protect the expectant mother from foods that may contain pathogenic microorganisms that could make her ill. This is particularly important during pregnancy as a woman’s immune system is lowered during this period to prevent her body rejecting the embryo, which appears to her body as a foreign tissue.

Many of the features of NVP and pregnancy support the “mother and embryo protection” theory. To begin with, NVP symptoms usually occur in the first trimester, at the same time that the expectant mother and embryo are most immunologically vulnerable and therefore need increased protection from toxins and teratogens found in food. In accordance with the “protection” hypothesis, food aversions also tend to be greatest during the first trimester and the types of food that pregnant women tend to find aversive are those most likely to contain pathogenic microorganisms or teratogens, such as meat, caffeinated drinks and alcohol.

Over the years, a number of theories have been put forward, aiming to provide a reason for the characteristic “morning sickness”, or NVP, experienced by the majority of expectant mothers in their first trimester. Whether the front-running “mother and embryo protection” hypothesis is true or if another explanation exists, NVP certainly does appear to possess a function, being widely associated with positive pregnancy outcomes. While this is unlikely to make the experience of NVP a pleasant one, hopefully such knowledge will provide at least some comfort to all the mothers-to-be out there currently well acquainted with their toilet bowls.

Post by: Megan Freeman @Meg_an12