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,
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,

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


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



Yoga for health: uniting body and mind

Yoga is an eastern tradition which is becoming increasingly popular in Western societies. Although the spiritual elements of this ancient Indian practice have partially disappeared in its westernised form, the practice still remains a holistic and multi-dimensional approach to maintaining good health and wellbeing (de Manincor et al., 2015). This is reflected in the meaning of its Sanskrit name: ‘to unite’ or ‘to attain what is previously unattainable’ (Uebelacker et al., 2010). Its main elements include physical postures (asanas), breathing techniques (pranayama) and meditation (dhyana) (Uebelacker et al., 2010). The emphasis on these elements differs between styles, e.g. Iyengar yoga focuses on the alignment of the body in asanas, whilst vinyasa teaches to link breath with movement. In addition, yogis promote positive values and attitudes, as well as lifestyle. Research has shown that it can help with health problems ranging from mental health difficulties to musculoskeletal ailments.

So, is yoga really effective and beneficial for our health and if so, what is its secret?

Meditation is one of the core elements of yoga.
Meditation is one of the core elements of yoga.

Randomised controlled studies of yoga have shown that it can reduce pain and improve functional outcomes for individuals with physical problems such as lower back pain and fibromyalgia (Ward et al., 2013). Some evidence indicates that yoga can not only manage, but also reduce some musculoskeletal problems such as scoliosis – a condition in which the spine curves laterally (Fishman et al., 2014). Scoliosis patients who performed a pose known as the ‘side plank’ for an average of  90 seconds a day, most days of the week for seven months, showed a decrease in the lateral spine curvature by around 32%. The more conscientiously the patients practiced the side plank, the more their spine improved. The authors of the study emphasise the importance of performing the pose on the convex side of the spine only (do not try this without a consultation with a specialist). Such asymmetry of the exercise might achieve its effect by strengthening the weaker side of the vertebral column. The results of this study are very encouraging, however randomized controlled trials with a longer follow-up period are needed to substantiate these findings.

Although other forms of physical activity, such as stretching, can be equally effective in improving daily functioning, in some cases yoga has been shown to be superior to physical therapy. Specifically, when it come to improving quality of life and reducing depression, which often accompanies physical illness (Ward et al., 2013). Indeed, yoga has been shown to help those with mood disorders, including women with postnatal depression (Buttner et al., 2015).

Screen Shot 2016-05-08 at 18.58.53

It can however be difficult to draw clear conclusions from research which examines yoga for health. Specifically because the type of yoga, the intensity and length of practice vary greatly among studies.  Is it possible to formulate a ‘prescription’ yoga practice that would provide clear evidence of its effectiveness? Some yoga experts suggest that, in order to help reduce depression and anxiety, yoga practice not only needs to include certain key elements, but also avoid some of other components (de Manincor et al., 2015). For example, both depression and anxiety might be alleviated with breath regulation, however depressed individuals benefit more from the focus on the inhalation, whilst those with anxiety from lengthening the exhale and ‘humming bee’ (bhramari) technique. Anxious yoga students should avoid rapid breathing techniques, as well as heated and crowded yoga rooms. It is suggested that students with mental health problems should practice for 30-40 minutes 5 times a week for 6 weeks. However, frequency of practice is more controversial among teachers of yoga for musculoskeletal conditions, predominantly because unsupervised yoga sessions can be harmful to those with no previous yoga experience (Ward et al., 2014). However, experts in both areas agree that yoga practice that aims to help with specific problems should be integrated, personalized and taught by those with sufficient experience and training, specifically relating to the condition of their students.

The active ingredients of yoga are thought be mindfulness and physical activity (Uebelacker et al., 2010). Both of these elements are important in other approaches to treating health problems. One of the advantages of yoga, however, is its holistic focus on reaching one’s full potential rather than reducing the symptoms of illness, as well as its emphasis on uniting the mind and body and building self acceptance (Uebelacker et al., 2010). Although it can be difficult to meet the exact requirements for yoga as a treatment for physical and mental health problems, i.e. frequency of practice and structured personlised classes, it still remains a promising adjunct therapy. So, let us hope that the growing popularity of ‘attaining what is previously unattainable’ might increase the access and diversity of classes.

Post by: Jadwiga Nazimek


Buttner, M. M., R. L. Brock, M. W. O’Hara, and S. Stuart, 2015, Efficacy of yoga for depressed postpartum women: A randomized controlled trial: Complement Ther Clin Pract, v. 21, p. 94-100.

de Manincor, M., A. Bensoussan, C. Smith, P. Fahey, and S. Bourchier, 2015, Establishing key components of yoga interventions for reducing depression and anxiety, and improving well-being: a Delphi method study: BMC Complement Altern Med, v. 15, p. 85.

Fishman, L. M., E. J. Groessl, and K. J. Sherman, 2014, Serial case reporting yoga for idiopathic and degenerative scoliosis: Glob Adv Health Med, v. 3, p. 16-21.

Uebelacker, L. A., G. Epstein-Lubow, B. A. Gaudiano, G. Tremont, C. L. Battle, and I. W. Miller, 2010, Hatha yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research: J Psychiatr Pract, v. 16, p. 22-33.

Ward, L., S. Stebbings, D. Cherkin, and G. D. Baxter, 2013, Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: a systematic review and meta-analysis: Musculoskeletal Care, v. 11, p. 203-17.

Ward, L., S. Stebbings, K. J. Sherman, D. Cherkin, and G. D. Baxter, 2014, Establishing key components of yoga interventions for musculoskeletal conditions: a Delphi survey: BMC Complement Altern Med, v. 14, p. 196.

Animal consciousness

When I was a child, living in Poland, we believed that on Christmas Eve animals can speak human language. I waited till the magical time – midnight, and listened, but our dogs and cats did not take the opportunity to tell us what was on their mind. This tradition could have originated from the belief that the spirits of our ancestors could speak through the animals, or perhaps it referred to the presence of animals at the birth of Jesus. Either way, some scientists think that other species of animals have more in common with us than we think.

Bottlenose dolphins hesitate and waver when they are uncertain of the correct answer. Image by NASAs [Public domain], via Wikimedia Commons
Bottlenose dolphins hesitate and waver when they are uncertain of the correct answer. Image by NASAs [Public domain], via Wikimedia Commons

You might not be surprised to hear that dolphins have the skill of metacognition, that is the ability to think about, or oversee, their own thinking (Smith et al., 1995). In humans metacognition is related to self-reflection and self-awareness (Smith et al., 2012) . An example of this ‘thinking about thinking’ is the ‘tip-of-the-tong’ experience (when you are sure that you know something but cannot quite bring it to mind).

Researchers presented dolphins with sounds of different pitch, asking the animals to indicate the pitch of a given sound by touching response paddles (Smith et al., 1995). They increased the difficulty of the task by making some sounds very similar, therefore confusing the dolphins. In recognition that some sounds would be hard to differentiate, the dolphins were given the option to press a paddle indicating that they were ‘uncertain’ of the pitch of the sound. The ability to decline completion of a task due to uncertainty is an important aspect of metacognition. In humans the answer ‘I don’t know’ is thought to be based on the internal reflection: how likely is it that I will respond correctly? The less certain we are of our response, the more we hesitate. The dolphins in the experiment did indeed use the option ‘uncertain’ to decline completing the task when they thought it was too difficult. Moreover, this uncertainty was reflected in their behaviour:  when sure of the response, dolphins swam towards the paddles so fast that the splash sometimes damaged the experimenters equipment. On the other hand, when they did not know the answer, they slowed, wavered and hesitated.

Monkeys know when they do not know. Image by Jack Hynes [CC BY-SA 2.0 (], via Wikimedia Commons
Monkeys know when they do not know.
Image by Jack Hynes [CC BY-SA 2.0 (], via Wikimedia Commons

Other animals also showed the ability to monitor their own thinking. Similar to results seen in dolphins, macaques also show signs of metacognition. Specifically, when asked to decide whether the number of dots on the computer screen was smaller or greater than a value that they had learned before (Beran et al., 2006), macaques showed signs of hesitation and uncertainty when the task was hard. Other researchers asked the monkeys to match currently presented images to previous samples (Hampton, 2001). The more time elapsed between the pictures, the more ‘uncertain’ responses the animals gave. This was interpreted as an example of meta-memory – the ability to monitor our memories and decide whether they are clear enough to give a correct answer.

Does this mean that at least some animals, such as monkeys and dolphins, have consciousness? That depends on the definition of consciousness. Is hesitating and worrying about own performance enough? Do we need more sophisticated tests? Perhaps some of us  (especially those living with pets) need no tests at all to feel that we have a lot in common with non-human animals and that we share our existence with them.

Post by Jadwiga Nazimek

The theory of feeling good

Psychology, especially in the context of health care, is usually associated with treatments for mental illness and attempts at relieving misery and suffering. There is, however, an area of psychology that looks beyond what goes wrong in human mind, instead focusing on understanding and enhancing good things such as happiness and positive emotions. You might ask: why would anybody concern themselves with studying something that stems naturally from good fortune and achievements? Well, some research suggests that it is the other way round: that happiness itself can lead to blessings such as good relationships and financial security (Lyubomirsky et al., 2005)

Enjoying time with others can lead to valued relationships. Image courtesy of panuruangjan at
Enjoying time with others can lead to valued relationships. Image courtesy of panuruangjan at

One theory which attempts to explain the link between happiness and good fortune is the ‘broaden –and –build’ theory of positive emotions (Fredrickson, 2001). According to this stance, feelings of joy, pride, contentment, love and interest help us build long-term resources such as health and job satisfaction by broadening of our thoughts and actions. You might have noticed that stressful situations focus your thoughts on the immediate problem. On the other hand, joy is often associated with playfulness and creativity, interest and exploration, contentment, pride, dreaming about future success, playing, exploring and savouring experiences with those close to you. Further, curiosity can become expertise, whilst affection and enjoying time with others might turn into valued friendships. These resources can increase our resilience, helping us to deal with the difficulties of life.

Resilience can be thought of as the ability to find opportunities, adapt to limitations and recover from misfortune (Cohn et al., 2009). According to some research, this skill of living through changing circumstances is an important link that connects positive emotions and life satisfaction. In other words, joy, pride, gratitude and other good feelings might increase life satisfaction indirectly, through strengthened resilience. And remember that happiness or satisfaction do not equal the absence of negative feelings (Cohn et al., 2009). We can experience sadness or anger during one part of the day and joy or enthusiasm during another. For example, when a loved one dies, resilient people still experience positive emotions amidst their longing and grief (Bonanno et al., 2005). Evidence also suggests that the strengthening effect of good feelings on resilience is stronger than the weakening effect of negative emotions (Cohn et al., 2009). So we don’t have to avoid feeling bad; we just need to also feel good.

Happiness may increase activity and well-being. Image courtesy of nenetus at
Happiness may increase activity and well-being. Image courtesy of nenetus at

Not all studies conclude that the link between positive emotions, resilience and happiness is definitely causal. Some researchers found that when they asked participants to write down their feelings at different points in time, they could see a correlation between positive emotions and resilience. This approach raises the question of causality. However, another study showed that people can influence their own wellbeing by practicing certain approaches to life. For example, after ten weeks of counting their blessings participants slept better, exercised more and felt physically better (Emmons and McCullough, 2003). This suggests that experiencing positive emotions such as gratitude can actually improve wellbeing. It remains to be seen, however,  whether these effects apply to people with mental illness, e.g. depression, those with extremely high negative emotions or extremely low positive emotions, or those affected by a long-term, intensely stressful events (Cohn et al., 2009).

Post by: Jadwiga Nazimek


Bonanno, G. A., J. T. Moskowitz, A. Papa, and S. Folkman, 2005, Resilience to loss in bereaved spouses, bereaved parents, and bereaved gay men: J Pers Soc Psychol, v. 88, p. 827-43.

Cohn, M. A., B. L. Fredrickson, S. L. Brown, J. A. Mikels, and A. M. Conway, 2009, Happiness unpacked: positive emotions increase life satisfaction by building resilience: Emotion, v. 9, p. 361-8.

Emmons, R. A., and M. E. McCullough, 2003, Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life: J Pers Soc Psychol, v. 84, p. 377-89.

Fredrickson, B. L., 2001, The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions: Am Psychol, v. 56, p. 218-26.

Lyubomirsky, S., L. King, and E. Diener, 2005, The benefits of frequent positive affect: does happiness lead to success?: Psychol Bull, v. 131, p. 803-55.

Aromatherapy: what is it and does it actually work?

ET_essential_oil_candleWe all know that smells can affect the way we feel. Indeed, essential oils are used regularly in Ancient Egypt and India as an adjunct to improve health and well-being. These oils are usually extracted by steam distillation from fragrant plants such as lavender, rose, orange, cinnamon or peppermint, to name just a few. The oils can be inhaled, used during massage, or even ingested.

It is theorised that the effect scent has on mood may be mediated by the architecture of the olfactory system. The areas of the brain that process scents are directly connected with areas involved in processing emotions, memories and autonomic responses.

Let’s start from the beginning, i.e. the nose. Here the receptors on olfactory neurons detect odorants (chemicals which form a scent) and transform these  particles into electrical signals. These signals travel along the olfactory nerve to the olfactory bulb in the central nervous system (Kadohisa, 2013). The olfactory bulb forms connections with other brain areas such as amygdala (the center of emotions) (Wilson-Mendenhall et al., 2013) and the entorhinal cortex (important in memory) (Takehara-Nishiuchi, 2014). The amygdala, in turn, is connected to the hypothalamus, a part of brain that regulates physiological states, e.g. controlling the release of stress hormones. This is one reason why smells can have an impact on our mood and why they evoke such strong memories. Can you think of any smell which conjures up a memory for you? – If so, let us know in the comments below!

The_Soul_of_the_Rose_-_WaterhouseA number of people find that essential oils can affect their mood but these are not the only odorants can which have this effect. If you like spending time in nature you probably noticed that being surrounded with vegetation can reduce stress. One study suggests that the “green odour” (the scent of leaves and vegetation) changes the electrical signals in our brain in a way that brings about a sedative-like action, reflected in a feeling of relaxation (Sano et al., 2002). Studies on rats have shown that this effect could be due to the action of the green odour on the brain circuit which release adrenaline and cortisol (the hypothalamic-pituitary-adrenal axis) (Nakashima et al., 2004).

Another botanical scent, the essential oil of rose, may have a similar effect on the brain’s stress circuitry (Fukada et al., 2012). Women who carried a test paper soaked in rose essential oil for several days during exam period showed no change in their cortisol levels, while those students supplied with a jasmine aroma patch or nothing at all, had increased amount of cortisol around their exams. One suggestion raised by this study is that rose essential oil could prevent the release of stress hormones. Further, in another study essential oil extracted from orange peels reduced the activity in the prefrontal cortex, part of the brain involved in integrating information, planning and making decisions (Igarashi et al., 2014). After barely ninety seconds of inhaling these oils participants felt more “comfortable”, “relaxed” and “natural”.

Have you ever noticed that in times of stress your skin becomes dry or you are plagued by eczema? Stress causes shrinking of the lipids that form the protective skin barrier, increasing transepidermal water loss (TEWL) – the escape of moisture from the skin. Some studies suggest that inhaling the “green odour” or rose essential oil can reduce this water leakage and prevent the stress-related drying of the skin (Fukada et al., 2007).

Aromatherapy is based on a holistic approach to the patient, considering both their physical and psychological needs (meaning that any effects of aromatherapy may be person-specific). Scientific studies have shown evidence both for and against the effectiveness of aromatherapy but with many individuals reporting benefits further research is certainly required.

This article is for informational purposes only. Always use essential oils as instructed by the manufacturer or a therapist.

Post by: Jadwiga Nazimek

Fukada, M., E. Kano, M. Miyoshi, R. Komaki, and T. Watanabe, 2012, Effect of “rose essential oil” inhalation on stress-induced skin-barrier disruption in rats and humans: Chem Senses, v. 37, p. 347-56.

Kadohisa, M., 2013, Effects of odor on emotion, with implications: Front Syst Neurosci, v. 7, p. 66.

Nakashima, T., M. Akamatsu, A. Hatanaka, and T. Kiyohara, 2004, Attenuation of stress-induced elevations in plasma ACTH level and body temperature in rats by green odor: Physiology & Behavior, v. 80, p. 481-488.

Sano, K., Y. Tsuda, H. Sugano, S. Aou, and A. Hatanaka, 2002, Concentration effects of green odor on event-related potential (P300) and pleasantness: Chemical Senses, v. 27, p. 225-230.

Takehara-Nishiuchi, K., 2014, Entorhinal cortex and consolidated memory: Neurosci Res, v. 84, p. 27-33.

Wilson-Mendenhall, C. D., L. F. Barrett, and L. W. Barsalou, 2013, Neural Evidence That Human Emotions Share Core Affective Properties: Psychological Science, v. 24, p. 947-956.

Suicide: killed by depression?

Please note that, due to its content, readers may find this article distressing.

I had been kidnapped by depression and killed.

Gwyneth Lewis

A couple of months ago my friend died by suicide. A vivacious, kind and gentle guy, he was one of the six thousand people who kill themselves every year in the UK (Samaritans, Suicide Statistics Report 2015). Every such death affects on average 10-15 people, including family, friends, neighbours and work colleagues (Dyregrov, 2011). Even though the poet Gwyneth Lewis, cited at the beginning of this article, did not attempt a suicide, depression is a major contributor to lethal self-injury. In fact, suicidality is one of the symptoms of this illness. Most of us can probably imagine how loss of hope and prolonged despair can make us want to escape life. However, not all depressed people desire death; among those that do, only about half will attempt to take their lives (May et al., 2012).

Depression and hopelessness are major predictors of suicide.  Image courtesy of David Castillo Dominici at
Depression and hopelessness are major predictors of suicide.
Image courtesy of David Castillo Dominici at

Why is it then that people kill themselves? According to the interpersonal theory of suicide it is because of the combination of three factors: thwarted belongingness, perceived burdensomeness, and the capability for lethal self-injury (Joiner, 2005; Van Orden et al., 2010). Thwarted belongingness is a subjective feeling of being disconnected from others, loneliness and lack of mutual care: “I have no one to turn to”, “I am not a support for others”. For example, prisoners kept in single cells are more likely to attempt a suicide. Thwarted belongingness does not necessarily mean that we truly do not belong; it could just be the case of interpreting the behaviour of others as rejecting.

The second factor, perceived burdensomeness, is the feeling that we are a burden to others. It arises from self-hatred and from the belief that we are inadequate, that we let others down and therefore our family and friends will be better off without us: “I make things worse for the people in my life”, “I am useless”. Perceived burdensomeness plays an important role in suicides of terminal cancer patients. Of course, the subjective feeling of being a burden, or being ‘expendable’ does not mean that others also see us as a burden; often it is part of a distorted view of the self and others. Such bias towards negative signals and the perception that we are ‘stuck’  can be remedied with cognitive-behavioural therapy, which helps us to restructure the way we interpret information, how we make sense of the world and how we approach problems.

I dreamt about a creature, a cross between a beaver and a rabbit had landed between my shoulder blades, biting in so deeply that it hung there. Whenever I moved to try and catch the creature its weight would make the flesh gape even more, as if it were unzipping my back. (…)  Of course, the creature on my back was me and it was pointless trying to get away. (…) If you met me you’d think I was perfectly nice, but (…) it’s what you are at two in the morning when you’ve been pushed off a cliff again and have nothing to hold on to as you fall.’

Gwyneth Lewis

Thwarted belongingness and perceived burdensomeness, accompanied by loss of hope, together create the desire to die (suicidal ideation). However, in order to complete a suicide we also need the capability for lethal self-injury. In other words, people kill themselves not only because they want to, but also because they can; after all, suicide is painful and violent, and therefore very difficult to carry out. The interpersonal theory proposes that self-killing becomes easier if we lose our fear of death and if we are less sensitive to pain. This is why previous attempts, as well as previous experience of violence make us more likely to die by suicide. However, the capability for lethal self-injury also increases with increased access to information about suicide and the means to complete it. For example, military people, when choosing a mean of suicide attempt, opt for the method they have been exposed to: members of the army prefer guns, those in the navy  – hanging and air force individuals – falling from heights. Consider also the phenomenon of suicide contagion (Wray, 2012). It has also been termed the Werther effect after the suicide of the main character in the famous novel by Goethe led to a wave of copy-cat deaths.  Golden Bridge in the US attracts suicidal people from all over the country and from abroad. Kevin Berthia was one of the two hundred people coaxed back from its railings by a police officer. He chose the bridge for the ease of death it offered. He also admitted that erecting a suicide net under the bridge would definitely discourage him from jumping.

Van Orden et al., 2010. Assumptions of the Interpersonal Theory of Suicide.
Van Orden et al., 2010. Assumptions of the Interpersonal Theory of Suicide.

The interpersonal theory of suicide can help explain the links between lethal self-injury and age, as well as some personality aspects. Loss of health and independence, sometimes combined with limited financial means puts older people at greater risk of ending their lives (Jahn and Cukrowicz, 2011). This is because having to rely on the help of others, especially children and grandchildren, makes older people feel that they are a burden. Perceived burdensomeness also appears to be important in linking perfectionism with suicidal tendencies (Rasmussen et al., 2012). Perfectionist individuals tend to set themselves standards which are so high that it is often impossible for them to reach their own expectations. As a result they may fall prey to feelings of incompetence, self –blame and inadequacy, and start to see themselves as a burden on others.

On the other hand, it has been shown that mindfulness as a personality trait can help prevent suicide in veterans (Serpa et al., 2014). Mindfulness is an awareness of present moment with non-judgemental attention, almost the opposite of rumination and worry. It makes it easier to cope with negative emotions, alleviates the severity of mental illness and reduces the risk of suicide.

The interpersonal theory of suicide provided me with a partial explanation for my friend’s death. Ending one’s life is said to be the permanent solution to the temporary problems; the sense of hopelessness blinds us to the fact that no matter how bad things are, nothing lasts forever. Sometimes it takes a while to find the right treatment or the right approach to help those in despair. However, mindfulness and cognitive-behavioural therapy are only some of the treatments that can be tried and that work for many people. Perhaps we should also come up with effective ways to teach ourselves and our children how to better manage our emotions, look after our psychological selves and how to find meaning in life.

In memory of Stephen

If you or someone you know needs help, contact Samaritans at 0845 790 9090.

Post by: Jadwiga Nazimek

Other sources of help:


Dyregrov, K. (2011). What do we know about needs for help after suicide in different parts of the world? A phenomenological perspective. Crisis, 32(6), 310–318.

Jahn D.R., Cukrowicz, K.C. (2011) The Impact of the Nature of Relationships on Perceived Burdensomeness and Suicide Ideation in a Community Sample of Older Adults. Suicide and Life-Threatening Behavior 41(6) 635-49

Joiner, T.E. (2005) Why people die by suicide. Cambridge: Harvard University Press.

Lewis, G. Sunbathing in the rain. A cheerful book about depression.

Rasmussen, K.A., Slish, M.L., Wingate, L.R., Davidson, C.L., Grant, D.M. (2012) Can Perceived Burdensomeness Explain the Relationship Between Suicide and Perfectionism?

Suicide and Life-Threatening Behavior 42(2): 121-128.

Serpa, J.G., Taylor, S.L., Tillisch, K. (2014) Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Medical Care 52(12 Suppl 5):S19-24. doi: 10.1097/MLR.0000000000000202.

Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S.R., Selby, E.A. & Joiner, T.E. (2010). The interpersonal theory of suicide. Psychological Review 117, 575–600. doi:

10.1037/a0018697 accessed 17/06/2015

Wray, M.  (2014) When it comes to suicide, how may be just as important as why. accessed 17/06/2015

Samaritans ‘Suicide Statistics Report 2015’ accessed 18/06/2015

Hearing voices: more common than you might think

I remember being woken up from one of my daily naps by the familiar melody of the ice cream van that comes round our estate every day in summer. True, it was slightly odd that I could hear it so vividly despite wearing ear plugs; nevertheless I leaped out of bed, grabbed my purse and ran outside. Imagine my disappointment when I realized that there was no ice cream van in sight!

Voices can be loud and clear, or barely distinguishable from thoughts.  Image courtesy of stockimages at
Voices can be loud and clear, or barely distinguishable from thoughts.
Image courtesy of stockimages at

Auditory hallucinations are more common that we might think, and they do not only happen to people with mental health problems. The example I described above is a form of hypnopompic hallucinations, i.e. those experienced upon awakening from sleep, and familiar to just over 12% of the population (Ohayon et al., 1996).

Let’s take a moment though to consider what we mean by a ‘hallucination’. The word itself comes from the Latin ‘allucinari’ meaning ‘to wander in the mind’, ‘to dream’ (Choong et al., 2007). It is a perception that occurs in the absence of an external stimulus, when we are fully or partially awake, and is not to be confused with an illusion, which is a misperception of a real stimulus. Hallucinations are one of the cardinal symptoms of schizophrenia; indeed, 70% of people with this illness hear voices. However, they are not the only ones. In some studies 10% of men and 15% of women in the general population described hearing voices at some point in their lives (Tien, 1991). It is not uncommon to experience hallucinations when we are drifting off to sleep (hypnagogic) or  when we are waking up (hypnopompic). Hearing voices might affect us even more after we lose a loved one; nearly half of recent widows and widowers hear the voice of their dead spouse (Carlsson and Nilsson, 2007).

What is it then that people hear? Hallucinations could be fragments of memories or stream of consciousness, often related to worries, and are more likely to occur in times of stress or tiredness.  The voices could be loud and clear, as if someone in the room has just spoken, or they could be barely distinguishable from our thoughts.

“I hear a mixture of men and women, but no children. They usually tell me to do things, but not dangerous things. Like they’ll tell me to take out the garbage or check the lock on the window or call someone. Sometimes they comment on what I’m doing and whether I’m doing a good job or what I could be doing better.” (Woods et al., 2015).

Since hallucinations affecting healthy people have a similar form to those that torment patients with schizophrenia, scientists think that they are on the continuum of normal perception. Where, then, is the line between ‘normal’ and ‘psychotic’ hallucinations and if we hear voices, does it mean we are at risk of a mental illness? Hallucinations that lead to, or are part of a disorder tend to be more negative and intrusive, and are associated with more anxiety and depression. For example, a healthy person might find spiritual or religious explanation for their voices and is more likely to ‘go along’ with them, whereas a person with psychosis is more likely to think that the voice belongs to a real person and try to resist it. The distress that the voices can cause might create a vicious cycle, where the more the individual fears and tries to avoid the voices, the more intrusive and frightening they become.

Voices in mental illness tend to be more negative and associated with more depression.  Image courtesy of David Castillo Dominici at
Voices in mental illness tend to be more negative and associated with more depression.
Image courtesy of David Castillo Dominici at

“Starting when I was about 20 years old, I heard the voices of demons screaming at me, telling me that I was damned, that God hated me, and that I was going to hell… The voices were so frightening and disruptive that much of the time I was unable to focus or concentrate on anything else.”

The physiological underpinnings of hallucinations are not clear. We know that hearing sounds and voices that are not there activates the auditory cortex in a similar way  to ‘real’ auditory stimuli. The content of hallucinations are probably best understood in the context of the individual’s life, personality and experiences. A simple melody produced by the auditory cortex in response to your craving for ice cream is harmless enough. Similarly, hearing the voice of a dead loved one might be comforting; their voice is imprinted on your brain – no wonder it can be reproduced when you long to hear it. Perhaps the derisive commentary is your internal critic that harnessed the auditory cortex to torment you? One thing is certain: whilst voices can be very distressing and coping with them often requires professional help, they are not always dangerous or a sign of mental illness.

Post by: Jadwiga Nazimek


Carlsson, M. E. & Nilsson, I. M. (2007) Bereaved spouses’ adjustment after the patients’ death in palliative care. Palliative and Supportive Care, 5, 397-404.

Choong, C., Hunter, M. D. & Woodruff, P. W. (2007) Auditory hallucinations in those populations that do not suffer from schizophrenia. Current Psychiatry Reports, 9, 206-12.

Johns, L., Kompus, K., Connell, M. et al. (2014) Auditory Verbal Hallucinations in Persons With and Without a Need for Care. Schizophrenia Bulletin 40 (4): 255-264

Nayani, T. H. & David, A. S. (1996) The Auditory Hallucination: a Phenomenological Survey. Psychological Medicine, 26, 179-192.

Ohayon, M. M., Priest, R. G., Caulet, M. & Guilleminault, C. (1996) Hypnagogic and hypnopompic hallucinations: pathological phenomena? British Journal of Psychiatry, 169, 459-67.

Tien, A. Y. (1991) Distributions of hallucinations in the population. Social Psychiatry and Psychiatric Epidemiology, 26, 287-92.

Woods, A., Jones, N., Alderson-Day, B., Callard, F., fernyhough, C. (2015) Experiences of         hearing voices: analysis of a novel phenomenological survey. The Lancet. Psychiatry

Dementia: hanging on

“I am, along with many others, scrabbling to stay ahead long enough to be there when the Cure comes along’ said Terry Pratchett when donating to research on Alzheimer’s disease (AD). The writer had been suffering from a rare form of dementia, which starts at an unusually young age (he was diagnosed at the age of 59).

Social interactions are very important for the wellbeing of people with dementia. Image courtesy of graur razvan ionut at
Social interactions are very important for the wellbeing of people with dementia.
Image courtesy of graur razvan ionut at

Why is the number of people with dementia increasing? The simple answer is: because we live longer. Some older people experience hardly any changes in their memory with age; many may become more forgetful and think more slowly, but otherwise their mind will remain intact. Age, however, is the greatest risk factor for dementia, an illness that affects 850 000 people in UK and gradually destroys our ability to remember, think, interact with others, live independently and look after ourselves.

Alzheimer’s disease, similar to the early-onset illness that affected Terry Pratchett, is the main culprit in dementia. It is responsible for 60–70% of cases and manifests in the brain as accumulations of sticky protein, which form plaques in the brain. The protein, called beta amyloid, kills the nerve cells and causes the brain to shrink. On the other hand, in vascular dementia (VaD) – the second most common killer – symptoms are caused by problems with blood vessels in the brain. Doctors diagnose the type of dementia on the basis of the pattern of symptoms and the brain images, which show them the areas of damage.

Accumulations of beta-amyloid protein is thought to be the main culprit in death of neurons in AD. Image courtesy of National Institute on Aging, via Wikimedia Commons
Accumulations of beta-amyloid protein is thought to be the main culprit in death of neurons in AD. Image courtesy of National Institute on Aging, via Wikimedia Commons

At the moment there is no cure for dementia. Some medications, if taken early, help to slow down the progress of AD. Medicine can also help with problems that accompany the illness, such as anxiety, agitation and depression. Finding a cure for dementia is, therefore, the great challenge for today’s research. So how far have scientists got when it comes to tackling it?

One of the questions that researchers are looking into is: why and how exactly do the sticky proteins accumulate in the brain? Here, Down syndrome has shed some light on the events in the brain. People with Down syndrome have an additional copy of chromosome 21. Apart from having some level of intellectual disability, they also suffer from increased risk of AD. By the age 65, 75% of individuals with Down syndrome have symptoms of dementia. It seems that the extra copy of chromosome 21 might be responsible for reduced level of a protein called sorting nexin 27 (SNX27). SNX27 lowers the level of beta amyloid by curbing the activity of an enzyme (gamma secretase) which produces the sticky protein.

Beta-amyloid is a sticky protein that forms plaques in the brain. Image courtesy of National Institute on Aging, via Wikimedia Commons
Beta-amyloid is a sticky protein that forms plaques in the brain. Image courtesy of National Institute on Aging, via Wikimedia Commons

Whilst gamma – and beta – secretases increase the production of beta amyloid, their sister alpha secretase, an enzyme called ADAM10, has the opposite effect. It blocks the growth of the sticky protein, whilst protecting the nerve cells. Scientists have discovered that a drug for psoriasis (skin problem) increases the activity of ADAM10 in brains of people affected by AD. However, before this medication can be used to treat AD, it has to be tested in extensive and lengthy clinical trials.

Other areas of science are focusing on the influence of diet and lifestyle on the risk of dementia. Researchers have found that older people who have a deficiency of vitamin D (the sunshine vitamin) are more likely to develop dementia. The greater the deficiency, the greater the likelihood of the illness: the risk for those with low levels of vitamin D was 53% higher, and for those with severe deficiency was 125% higher. This could be because vitamin D is not just a building block for our bones, it contributes to clearing the amyloid plaques in the brain and protecting the neurons. Lack of vitamin D can also cause problems with blood vessels, thus increasing the risk of vascular dementia.

Exercise reduces the risk of dementia. Image courtesy of Sura Nualpradid at
Exercise reduces the risk of dementia. Image courtesy of Sura Nualpradid at

Finally, some scientists investigating whether exercise can help us keep our brains healthy. Exercise fanatics will welcome the news that even if we carry a gene in which may predispose us to AD, a decent amount of exercise can protect our brains to some extent from shrinkage. ‘Decent’ in this study was equivalent to jogging, walking or swimming for at least 30 minutes a day, as well as playing sports, e.g. tennis, for at least an hour, but also – and this is good news for those of us who do a lot of housework – 45 minutes a day of fairly intense chores.

No ground-breaking news on the dementia front yet then. However, while we wait for scientists to find the cure, we can certainly look after ourselves and if nothing else, give ourselves a better chance of keeping dementia at bay with healthy lifestyle, good diet and exercise.

Post by: Jadwiga Nazimek


Littlejohns, T.J., Henley, W.E., Lang, I.A. and Annweiler, C. (2014) Vitamin D and the risk of dementia and Alzheimer disease. Neurology 2:920-928.

Flier, W.M. and Scheltens (2005) Epidemiology and risk factors of dementia. Journal of Neurology, Neurosurgery and Psychiatry 76:(Suppl V):v2–v7. doi: 10.1136/jnnp.2005.082867

Smith, J.C., Nielson, K.A., Woodard, J.L. et al. (2014) Physical activity reduces hippocampal atrophy in elders at genetic risk for Alzheimer’s disease. Frontiers in Aging Neuroscience 6:1-7

Endres, K., Fahrenholz, F., Lotz, J.  et al. (2014) Increased CSF APPs-a levels in patients with Alzheimer disease treated with acitretin. Neurology 83: 1930-1935.

Wang X., Huang, T., Hong, W., and Xu, H. (2014) SortingNexin 27 Regulates Aβ Production through Modulating γ-Secretase Activity. Cell Reports 9: 1023–1033

Neurofeedback – or how the mind trains the brain

There is no lack of advertisements  for devices, games and tasks that are meant to train our thinking and memory, just as exercise trains muscle. And, wouldn’t it  be great if we could increase our brain power like Lucy in Luc Besson’s movie? Whilst the claim that we ‘underuse’ our brains is controversial, scientists are developing techniques which allow us to regulate our own brain activity and improve our performance.

Image courtesy of ddpavumba at

Neurofeedback has been around for a while and has developed in ways that fill us with enthusiasm and hope. It involves a brain-machine interface which measures brain activity and provides the participant with real-time feedback. The feedback might take the form of coloured shapes shown on the screen, with colours ranging from blue (low activity) to red (high activity). Depending on the task, participants are instructed to change the colour of the square using only their mind. For example, if the aim of the training is to increase activity in a part of the brain, participants need to try to change the colour of the square to red. If the aim is to decrease activity, they should aim try to turn it blue. Often it is up to the participants how they achieve the change in colour – as long as it works, it doesn’t matter!

This fun-sounding method of training our brain can improve our ability to think, often impaired in depression. Such difficulties include problems with working memory, i.e. holding and manipulating several pieces of information at the same time. In a study which used EEG to measure electrical activity of the brain, after eight training sessions patients with depression were better at the tasks that required working memory than patients who were not trained. They were also able to think faster.

Another target for neurofeedback training is the ability to regulate our feelings. A small part deep in the brain, called the amygdala, plays a major role in emotions. In people with depression and anxiety, the amygdala is hyperactive and its responses to sad objects or events can be exaggerated. This activity can normalize after therapy, however the treatment sometimes takes a long time.  Is it possible to speed up the process with the use of neurofeedback training?  Researchers scanned the brains of healthy participants (using fMRI) whilst presenting them faces with negative emotional expressions. Such images usually increase activity in the amygdala. Here too, participants saw the activity in the emotional center of their brain as colours. In this case, however, they used more specific strategies to reduce the activity in their right amygdala, which included thinking: ‘these are pictures, this is a study, these are actors’, or by distracting themselves. After 4 training sessions they were much better at down-regulating the activity in their brains than the participants who just looked at the faces without the instructions.

The task and the colour scheme of the feedback on the activity in the amygdala.  Brühl, AB. et al. (2014) Real-time Neurofeedback Using Functional MRI Could Improve Down-Regulation of Amygdala Activity During Emotional Stimulation: A Proof-of-Concept Study. Brain Topography 27:138–148.
The task and the colour scheme of the feedback on the activity in the amygdala.
Brühl, AB. et al. (2014) Real-time Neurofeedback Using Functional MRI Could Improve
Down-Regulation of Amygdala Activity During Emotional Stimulation: A Proof-of-Concept Study. Brain Topography 27:138–148.

Perhaps one day the standard treatment for mental illness will include scanning peoples’ heads and providing them with online feedback. Would it not be great if we could regulate activity in our own brains? Only, who is regulating who exactly? Neurofeedback certainly gives a different meaning to the expression “mind over matter”…

Post by: Jadwiga Nazimek

Getting older, getting wiser?

For some of us the New Year was  the time to reflect on past experiences, and to consider  what we have learned from them. Have we become wiser or more mature? Have these lessons helped us to live the rest of our lives as better and happier individuals? Many of us would like to think so, but what does it actually mean to be ‘more mature’, and does wisdom really come with age?

Maturity can offer greater contentment and satisfaction.  Image courtesy of Dr Joseph Valks at
Maturity can offer greater contentment and satisfaction. Image courtesy of Dr Joseph Valks at

Psychology offers various views on personal maturity. Some researchers understand it as personal growth, i.e. the development of our personality as we acquire deeper knowledge of ourselves, connect to others, and become more able to express ourselves.

How much can our personality change as we mature? McAdams (1996) proposes that there are different levels in personality: dispositional traits, personal concerns and self-concepts. The main traits of our personality consist of five broad dimensions: extraversion, neuroticism, conscientiousness, agreeableness and openness to experience. For example, some of us are extraverts, others – introverts, we also differ in our degree of conscientiousness. The second level of personality includes our goals, life tasks, motivations and plans. Finally, our identity, or how we see ourselves and our past, present and future form the third tier of personality. These basic traits do not tend to change. However, our personal concerns and goals do, depending on where we are in life.

Mature people are more able to express themselves in their goals and focus more on connections with others. Image courtesy of khunaspix at
Mature people are more able to express themselves in their goals and focus more on connections with others. Image courtesy of khunaspix at

Research by Sheldon and Kasser (2001) showed that as we mature we set ourselves goals that better fulfill our psychological needs, i.e. the need for self-acceptance, to further develop connections  with others that are close to us, and to contribute to the community. These new goals replace those with external motivations, such as popularity or financial status. Moreover, we learn to pursue these goals because we truly believe in their value, rather due to the pressures of our  societies or cultures.

Maturity can also be defined as becoming more adept at regulating our emotions and to experience more positive feelings, which in turn is related to finding meaning in life. All of us regulate our emotions by influencing the way we feel about other people or events, e.g. cheering ourselves up by giving ourselves a treat when we feel low, or calming ourselves down when we get anxious. Better regulation of our emotions also helps us to achieve goals, by protecting us from becoming easily discouraged. Whilst maturity does not have to correlate with chronological age, it seems that older people focus more on interactions with people who are emotionally close to them, and prefer not to spend their energy on wider social networks of acquaintances (Carstensen, Fung and Charles, 2003). They also experience fewer negative emotions than younger people, with such changes thought to result from different coping strategies. Younger people put more effort into solving their problems, which can benefit them in the long term. Their elders, in turn, might instead try to change the way they feel about the situations, for example by focusing more on positive experiences, and selectively remembering more positive memories.

As we age, we try to deepen our connections with our loved ones. Image courtesy of photostock at
As we age, we try to deepen our connections with our loved ones. Image courtesy of photostock at

The evidence would therefore suggest that we do indeed become happier as we mature: we stick to our own values, get better at fulfilling our psychological needs, get more control over our emotions, and learn that worrying about the opinions or approval of others does not give us the satisfaction that we crave. Something that we can all look forward to as we continue to age.

Post by: Jadwiga Nazimek


McAdams, D.P. (1996) Personality, modernity and the storied self: A contemporary framework for studying persons. Psychological Inquiry 7:295-321

Carstensen, L.L., Fung, H. H. and Charles, S.T. (2003) Socioemotional Selectivity Theory and the Regulation of Emotion in the Second Half of Life. Motivation and Emotion 27 (2):103-123

Sheldon, K.M. and Kasser, T. (2001) Getting Older, Getting Better? Personal Strivings and Psychological Maturity Across the Life Span. Developmental Psychology 37(4): 491-501