The New Male Sexuality by Bernie Zilbergeld

Resurrecting Sex by David Schnarch & James Maddock

The Sex-Starved Marriage by Michele Weiner-Davis

Rekindling Desire by Barry McCarthy & Emily McCarthy

Getting It Right The First Time – Creating a Healthy Marriage by Barry McCarthy & Emily McCarthy

Becoming Orgasmic by Heiman & LoPiccolo

Sexual Awareness by Barry McCarthy & Emily McCarthy

The New Love and Sex After Sixty by Butler & Lewis

Sex-Life Solutions by Janet Hall

The New Joy of Sex by Alex Comfort and Susan Quillan

When Your Sex Drives Don’t Match by Dr Sandra Pertot

Coping with Erectile Dysfunction by Michael Metz & B McCarthy

Women’s Sexual Health by Gilly Andrews

Exposure to severe conflict between parents increases the likelihood that children themselves will exhibit high levels of aggressive behaviours in various interpersonal relationships (for example with their peers, teachers or parents). In fact, a large body of research demonstrates that conflict between parents is associated with an increased risk for psychological problems among children in all families, whether the parents are together or apart. In our work with the Family Court, where the care of children is being disputed between parents or other caregivers, we see a lot of anxious children who are caught in the middle of intense conflict between the adults who are meant to be taking care of them. This conflict is usually born of longstanding relationship problems between the adults. Children will go to extraordinary lengths to try and stop the conflict – they may lie to the first parent about the second parent if they think this will make the first parent happier (and vice versa); they will behave badly simply to interrupt the parents’ battle, and would rather be getting into trouble from the parents than have the parents fighting with each other; they will withdraw from one or other of the parents in an attempt to avoid the distress of the anxiety caused by the conflict; they may behave very strangely in order to draw the parents’ attention away from each other; and they may try and keep everyone happy by being incredibly obedient and compliant (which isn’t normal all the time!). In any case, parents owe it to their children to protect them from severe, unresolved conflict, and children have the right to grow up in environments unmarked by violence of any kind.

Dr Fran Vertue is a clinical psychologist specialising in Child and Family Psychology. Learn more about Fran and about Child and Adolescent Psychology at www.christchurchpsychology.co.nz. where we also welcome comments on this column.

The spate of celebrities, such as Brooke Shields and Courtney Cox, who have publicised their experiences, has been very positive in that it has helped women realise that ‘it can happen to anyone’. However, there are still a number of barriers that prevent women from seeking help. Often women realise something is not right, but find it difficult to distinguish between normal levels of distress or tiredness and distress that warrants help. Women also don’t want to say that they are having difficulty coping, and therefore struggle on alone.

Maintaining good mental health in the postnatal period can help both prevent, and recover, from postnatal depression or anxiety. It’s important to plan regular weekly time without the baby. Often things reach crisis point before everyone rallies to help. It’s much better to take a preventative approach. Often just knowing that you have, for example, a couple of hours break each Sunday morning, can keep you going. Physical activity is also a helpful way to manage low mood and anxiety even if this is just a short morning walk with the baby. Usual household chores and outings can feel overwhelming, so by planning activities for specific times in advance, most important things get done. The more social support you have from friends and family, the less vulnerable you will be to anxiety and stress. Mothers’ groups can be a good way to connect with other mothers. But it is important to seek out like-minded others who are willing to be honest. If you’re in a mothers’ group where everyone is saying things are perfect, you won’t relate to them. Develop a list of what works best for you for those times when you feel down or anxious. Your list might include; going for a walk, a bath, being outside in the sunshine, or putting on some music. Most importantly tell someone, such as your partner, a family member, midwife or GP if you are finding it difficult to cope. There is well researched treatment available for Postnatal depression and anxiety that does not necessarily include medication. There are also a number of support agencies and health professionals in Christchurch who work in this specific field. Further information about postnatal depression and anxiety can be obtained from www.mothersmatter.co.nz

Dr Michelle McCarthy is in private practice. She can be contacted at The Anxiety Clinic and Centre for Cognitive Behavioural Therapy.

Myths
NOT TRUE Children with ADHD are deliberately naughty or bad children.
NOT TRUE ADHD is just youthful high spirits.
NOT TRUE Every child who displays some symptoms of ADHD has it.
There may be other reasons for children having symptoms which mimic ADHD. For example, children who have been abused either sexually or physically, or whose parents have recently separated often display some of the above behaviour. That’s why it is extremely important for the assessment and diagnosis to be thorough and done by qualified professionals who, as much as possible, try to rule out any other causes for a child’s symptoms
NOT TRUE Children with ADHD are incapable of concentrating at all.
Most children with ADHD are often able to concentrate for quite long periods of time on specific activities or hobbies – for example, watching videos they enjoy. In some, this ability to hyperfocus is extraordinary and has led some experts to comment that attention deficit might more accurately be called attention inconsistency.
NOT TRUE Everything that is wrong with the child is ADHD (e.g., all learning and behaviour problems are part of the ADHD).
NOT TRUE If you have ADHD you are not responsible for your behaviour and therefore can be excused for it (i.e., don’t have to face the consequences).
Causes of ADHD
Even though a lot of research into ADHD has gone on around the world, its exact cause is still unknown. It is likely that there are not one, but several causes, which, when they occur together, become ADHD.
Studies of computerised tomography or CT brain scans show that children with ADHD seem to have brain circuits which are wired a little differently from other people’s. This results in the brain having trouble processing the messages it receives – a little bit like a telephone exchange which gets overloaded with calls. This may happen to the infant’s brain in pregnancy, in babyhood, or it may just be an individual variation which has received more notice in the last 40 years. It does not seem to be caused just by a poor diet, yeast infections, allergies or food colourings as some people have thought, although these may be factors in the overall ADHD picture. It is also not caused by bad parenting although often a child’s behaviour will have earned plenty of negative attention in and outside of the family or whanau by the time ADHD is recognised.
Risks factors for developing ADHD
There is thought to be a genetic element to most ADHD, that is, it runs in families. Studies have shown that brothers or sisters of children with ADHD have two to three times the risk of having it as well.
ADHD often occurs with other child mental health problems. These may exist alongside or develop as a result of ADHD. For example, some children with ADHD will have Oppositional Defiant Disorder, Conduct Disorder or experience anxiety or depression. Learning difficulties which are unrecognised also present a risk for serious mental health problems, as they affect progress at school and self-esteem.
ADHD and its associated problems are serious if untreated because they can put young people at risk for accidents, drug or alcohol abuse problems, or suicide.
Living with Attention Deficit / Hyperactivity Disorder
The most important thing to remember about having a child with ADHD is that, like all children, they need love, affection, nurturing and clear rules. Sometimes this is hard to remember when whole days of nagging seem to be the rule rather than the exception at home and everywhere else.
A child with ADHD may have chalked up quite a lot of frustrations and failures before his/her problem is recognised. Some parents worry about the label ADHD and wonder if they have caused it to happen, or failed their child in some way. They may feel anger that this has happened to their family or whanau, or upset that other family or whanau members have dismissed the child’s behaviour as being normal. Others will be relieved that the problem they’ve lived with over a number of years finally has a name.
For the child, knowing he/she has ADHD can be a relief. Often though, children feel there is something really wrong with them. ADHD needs to be carefully explained to them in a way that they can understand and learn to handle. Brothers, sisters and friends, too, may need an explanation that can help them to stop teasing or provoking the child with ADHD.
Some children who have to take medicine to help their symptoms say it is like admitting that something scary is wrong with them and worry that they are retarded or crazy – labels they’ve probably heard before.
In two-parent homes it is important for parents to support each other with managing their child’s behaviour. Consistency is essential. Often one parent will say that the child is “perfectly all right when he is with me.” This can be infuriating for the other parent. For single parents, having a child with ADHD is even more difficult. Have at least one supportive friend outside the family or whanau that you can confide in.
Treatment of Attention Deficit / Hyperactivity Disorder
Summary of treatment options
There is no magic pill to make ADHD disappear, and medication should not be used as a substitute for other appropriate interventions, including educational and psychosocial. It is a complicated condition generally best managed by a mixed treatment programme which may include the following components.
Medication
The main kind of medication are used in the treatment of ADHD are stimulants; antidepressants are only very occasionally prescribed. The same medications are used for both children and adults. It is important that the progress of a child on medication for ADHD is checked and the treatment reviewed regularly with regular weight and height checks if stimulants are taken. You are entitled to know the names of any medicines prescribed; what symptoms they are supposed to treat; how long it will be before they take effect; how long they will have to be taken for and what their side effects (short and long-term) are.
Psychosocial treatments
Psychosocial treatments are non-medical treatments which look at the child or young person’s thinking, behaviour, relationships and environment, including their culture. The main psychosocial treatments for ADHD include behaviour management and social skills training to ensure encouragement and support for the child at home and at school. Other psychosocial treatments may include individual psychological therapy or family therapy to help young people and their families and whanau understand the condition and to make positive changes in their lives and relationships.
All types of therapy/counselling should be provided to children, adolescents and their families and whanau in a manner which is respectful of them, and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.
Complementary therapies
Complementary therapies that enhance the young person’s life may be used in addition to psychosocial treatments and prescription medicines.

This article is an excerpt from www.mentalhealth.org.nz

Bulimia normally starts with the person – most often, but not exclusively, a young woman, becoming worried about their weight and shape. This often happens around the time that puberty causes the normal changes to the body shape and weight. Dieting may cause a dramatic weight loss – about half of those who begin this process reach a low enough weight to have anorexia nervosa. The person then loses control of the dieting and begins the pattern of bingeing and purging. Weight gradually rises since the bingeing and purging does not usually keep it down. Many people with bulimia have normal weight but some are underweight and may continue to have anorexia as well – and some are overweight. About half of all cases of bulimia start before the age of 19, and almost all before the age of 45. Ninety percent of people with bulimia are women. Twenty three percent of women report bingeing quite often and 11 percent report purging. In about five percent of women this occurs often enough to be diagnosed as bulimia nervosa.

Outlook
There is no clear information yet on the long-term outlook for those with bulimia. What we know at the moment is that after 10 years about 50 percent of people who have had bulimia are fully recovered; about 20 percent still have ongoing problems with bingeing and purging and 30 percent relapse from time to time. Studies which have been done so far have found that the death rate is three per 1000 people with bulimia, but many of the studies are so short that this figure is probably too low. Suicide can be a cause of death particularly for those people who have an associated depression. It is also known that people with bulimia stand a higher risk of developing depression, anxiety problems or alcohol and drug problems.

Signs of bulimia
Early signs of bulimia include:
• extreme concern about being too fat
• increasing isolation from others
• food disappearing from the house, especially high calorie foods
• spending long periods in the toilet especially immediately after meals, sometimes with the tap running for long periods
• shoplifting food
• swollen cheeks (a little like mumps) caused by swelling of the parotid gland
• excessive tooth decay – vomiting causes damage to tooth enamel
• a callous at the base of the index finger caused by repeatedly using the finger to vomit.

While bulimia does not appear to affect the person’s physical health, over a long period there are a number of serious complications which can occur:
• Repeated vomiting can lead to loss of tooth enamel, damage to the gullet and disturbances in body chemistry. At worst, low potassium levels can cause sudden death from cardiac arrest.
• Laxative abuse can lead to loss of normal bowel function which can cause enlargement of the large bowel and chronic constipation. It can also contribute to low potassium levels.
• Periods do not usually stop, but may be irregular.
Risk factors for developing bulimia
There are a number of groups who are at particular risk for developing bulimia:
• those whose career or sport requires them to be thin – dancers, gymnasts, models or body builders
• those who are overweight
• those with a number of different problems including childhood sexual abuse or neglect, drug or alcohol problems and unstable relationships
• people with diabetes
• those with problems of self-esteem and identity.

Causes of bulimia
We do not know what causes bulimia. There is no clear difference between those who get anorexia and those who get bulimia and they are best thought of as different forms of the same condition. Bulimia develops in certain situations.

Social situations. Bulimia has mainly become a problem for the western world in the last few decades. It does not occur in countries in which food is scarce, or in countries where women are not encouraged to be thin. In the west women have been given the message that they need to be thin to be considered beautiful. Since a thin shape is normal and healthy for only a very few women, others must either struggle with feelings of not being good, perfect or self-controlled enough or begin to diet.

Family and whanau situations. Those who develop bulimia have a higher than normal chance of having a close family or whanau member who has an eating disorder, depression, obsessive-compulsive disorder or alcohol problems. This may mean that there is a genetic aspect to bulimia, or that these families and whanau have emotional or other problems which make them more vulnerable to social pressures, or both. There may also be an increased chance of broken families and whanau and/or abuse within the families and whanau.

Individual situations. A number of writers have described emotional difficulties which they believe are common amongst those who have bulimia. Some stress the struggle people with bulimia have to feel in control of their lives. They turn to dieting as something they can feel completely in control of. Others have suggested that bulimia can be related to difficulties in growing up. People with bulimia often believe they developed it because things have gone wrong in their lives – it could be abandonment, sexual or physical abuse, being in an unhappy family whanau or not living up to people’s expectations. Other people with bulimia may agree with the view that there is genetic or biological aspect to their condition. A lot of people believe it is a combination of these things. Sometimes people think their problem is a punishment for their moral or spiritual failure. It’s important to remember that it is not your fault you have bulimia.

Families and whanau, especially parents, can worry that they caused their relative to develop bulimia. Sometimes they feel blamed by mental health professionals which can be very distressing for them. Most families and whanau want the best for their relative. It is important for them to understand what has contributed to their relative’s problem and to be able to discuss their own feelings about this without feeling guilty or blamed.

Living with Bulimia
Bulimia differs from anorexia in that it is much more able to be concealed. Sometimes people with bulimia say that they have had it for many years without family whanau or partners knowing anything about it. Generally the person feels very ashamed and disgusted by the vomiting. This leaves them feeling very isolated and vulnerable to depression and despair.

For family whanau bulimia is very puzzling and frustrating. They tend to feel helpless and find it hard to know how much to watch over the person with bulimia and how much to leave them alone. Often they feel lied to and sometimes they are angry about the amount of food that is ‘lost’. They may worry that the person with bulimia will die. Mothers, in particular, often feel guilty, responsible and angry with the child with bulimia for being difficult. Fathers often feel frustrated, closed out and unimportant.

Frequently, the parents cannot agree about the seriousness of the problem or what to do. Often one wants to be tougher while the other feels this will only make things worse. Brothers and sisters may feel ignored by parents whose attention is entirely taken up by the person with bulimia.

People with bulimia who are in a sexual relationship often report that the relationship is not satisfactory. Quite commonly, people with bulimia report having a number of unsuccessful relationships. It can be very important for the partner to understand the problem in order to be helpful. It is also important that the partner participates in dealing with the problem. This can be just as stressful for the partner who will need to make sure that they get plenty of support from family whanau and friends.

Treatment of Bulimia

Summary of treatment options
Overall the treatment of bulimia will depend on the severity of the symptoms and any associated emotional problems, such as depression, anxiety or alcohol abuse, the age of the person and the quality of their interpersonal relationships. A key issue in any psychological treatment is the person being able to work well with the clinician. In general, it is not helpful to combine different treatments or to have more than one therapist helping at any one time although it is common for people to try a number of
therapies. This can be useful since no treatment is clearly better than others and recovery is most likely where the patient mostly likes and understands the therapy. However, it is important to let the therapist know how you are feeling about the therapy and whether you are in another therapy.

Psychosocial treatments
These address the person’s thinking, behaviour, relationships and environment, including their culture.

Psychological therapies (often referred to as therapy or psychotherapy) involve a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people understand what has happened to them and to make positive changes in their lives. They may involve the use of specific therapies such as family therapy or individual therapies including cognitive-behavioural therapy (CBT), psychodynamic therapy, interpersonal therapy (ITP) or narrative therapy. Some therapists use feminist theories to encourage the person to become more aware of the importance of social pressures on her to be thin. More research is needed before one type of psychological therapy is necessarily preferred over another.

Psychoeducation is a process whereby the person is given information about their eating disorder and the complications of bulimia. This can be extremely important to help family whanau and friends to understand the person better and to aid improvement of the disorder.

Counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem solving and information giving. All types of therapy/counselling should be provided to people and their families and whanau in a manner which is respectful of them and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.

Medication
Antidepressants have been found to be helpful in the treatment of bulimia. If you are prescribed medication you are entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long you will have to take them for and what their side-effects (short and long-term) are. If you are pregnant or breast feeding no medication is entirely safe. Before making any decisions about taking medication at this time you should talk with your doctor about the potential benefits and problems associated with each particular type of medication in pregnancy.

Hospitalisation
Hospitalisation may be suggested where there are serious concerns about the person’s physical health.

Complementary therapies
Complementary therapies which enhance the person’s life may be used in addition to psychosocial treatments and prescription medicines.

This article is an excerpt from www.mentalhealth.org.nz

Further Information
Websites
The Mental Health Foundation’s website has information about the mental health sector and mental health promotion, news of upcoming conferences both here and overseas, links to other sites of interest and the Foundation’s on-line bookstore. It contains the full text of all the MHINZ booklets which can be downloaded as pdf or Word files.
www.mentalhealth.org.nz

The Eating Disorders Association (UK)
www.edauk.com

Eating Disorders Foundation of Victoria
www.eatingdisorders.org.au

Something Fishy
www.something-fishy.org

Anorexia Nervosa and Related Eating Disorders
www.anred.com

www.mentalhealth.org.nz

Suggested reasons for a high rate of smoking include the stress of coping with a diagnosis of mental illness and in some cases, enforced unemployment. Some people smoke to control weight gain caused by their medication, or to self-medicate. Others believe that smoking will prevent relapse or reduce symptoms such as depression, anxiety or poor concentration. In inpatient units the lack of meaningful activity may be a reason that people smoke.

Studies of smoking patterns and attitudes among people with a mental illness indicate that tobacco plays a very important role in their lives. Cigarettes are rated as a ‘core need’ – often rated as being more important than food.

A recent study by the mental health charity Mentality in the United Kingdom found that although around half of people with a diagnosis wanted to quit smoking, smoking is often condoned by the mental health system. Mentality reported a general failure by health authorities to support service users who wanted to quit. Smoking has traditionally been used as a ‘pacifier’ in psychiatric settings where many of the staff smoke as well. (Friedli, 2001)

Why People Smoke

The tobacco plant, nicotiana, was introduced into France by Jean Nicot in 1556. Christopher Columbus had observed its use by Native Americans who smoked it for ceremonial and medicinal properties. During the seventeenth century, religious leaders and statesmen in many countries condemned the use of tobacco. The Catholic Church excommunicated smokers with some allegedly condemned to death and executed. Despite all this, the tobacco smoking habit spread rapidly all over the world. Captain Cook is credited with its introduction into New Zealand.

In the 21st Century, with indisputable evidence that smoking can kill, people continue to smoke. Although worldwide trends show a decrease in the number of adults smoking, smoking rates amongst adolescents have increased in recent years. In New Zealand in 2003, the ASH survey of Year 10, 14-15 year old, students bucked that trend by showing a slight decrease in youth smoking. Overall, an estimated 25 percent of the New Zealand population smokes.

Many and various reasons for smoking have been recorded. These include:

• To relieve stress
• To celebrate
• To relax, calm down
• To stay awake
• To get to sleep
• To look sexy
• To be ‘cool’
• To be seen as ‘adult’ or mature
• To get energy
• To concentrate
• To think better
• To ‘reward’ themselves for doing something
• To be sociable
• To feel confident
• To stay thin
• To accompany food, drink, fun, games, sex
• In response to advertising that promotes smoking as glamorous, cool and sophisticated
• To emulate a role model – an admired teacher, pop star, sporting hero or a television character who smokes can influence others to smoke
• Because they feel unhappy, bored, lonely, anxious, tired or frustrated
• Because their parent/parents or siblings smoke
• Because of peer pressure – wanting to fit in with group
• Because they have low self-esteem
• Because of social and economic deprivation – social deprivation is linked to smoking levels
• Because of major problems like unemployment, breakup of a relationship, financial pressure or illness
• Because it’s a habit – an almost unconscious act
• Because they feel indestructible or immortal – some people, especially young people, do not think smoking will affect their health despite knowing the risks
• Because they know its dangerous, but feel it is too late as the damage has already been done.
• Because smoking is still acceptable in many public places

For people with a mental illness, starting to smoke can sometimes be directly related to their contact with mental health services or welfare organisations

“I did not smoke at school. I became a state ward and lived in a girls’ home. Everyone smoked. A packet of smokes was given to all the girls by social workers on our 15th birthdays.”
“When I lived in the psychiatric hospital I worked on the grounds and we were paid in cigarettes.”
“Peer pressure in hospital. When I was in hospital I felt stressed and anxious and felt a sense of hopelessness. There was nothing to do… all I could do was smoke.”

(Quotes from Kites focus group research, 2004)

“In New Zealand’s past inpatient service users were rewarded or “paid” with a daily quota of cigarettes. Cigarettes are used as prizes during organised games in some supported accommodation. In the current inpatient environment the room that is warmest and friendliest, a gathering point, is the smoking room, a fact that helps foster addiction.”

(Handisides, 2004)

Regular smokers get used to a certain level of nicotine in their system and only feel better by lighting another cigarette. For most people, the reason they continue to smoke is because they are addicted to nicotine.

How Nicotine Works

Nicotine is one of more than 4,000 chemicals found in the smoke from tobacco products such as cigarettes, cigars and pipes. Smokeless tobacco products such as snuff and chewing tobacco also contain high levels of nicotine. Recognised as one of the most frequently used addictive drugs, nicotine is a naturally occurring colorless liquid that turns brown when burned.
Cigarette smoking is the most common form of nicotine intake. Through inhaling smoke, the average smoker takes in one to two milligrams of nicotine per cigarette.
Nicotine is absorbed through the skin and mucosal lining of the mouth and nose, or by inhalation in the lungs. Depending on how tobacco is taken, nicotine can reach peak levels in the bloodstream and brain rapidly. Cigarette smoking results in rapid distribution of nicotine throughout the body, reaching the brain within 10 seconds of inhalation. Cigar and pipe smokers, on the other hand, typically do not inhale the smoke, so nicotine is absorbed more slowly through the mucosal membranes of their mouths. Nicotine from smokeless tobacco also is absorbed through the mucosal membranes.
Once nicotine reaches the brain it begins to act on specific neurons or working cells. Each neuron has receptors to which brain chemicals called neurotransmitters can attach themselves. Nicotine fits into one of the receptors acted upon by a neurotransmitter called acetylcholine and causes the brain to release two other brain chemicals – noradrenaline and dopamine. These act as stimulants.
Although nicotine is a stimulant, paradoxically, the smoker may feel either stimulated or relaxed. This depends on their mental and physical state and the situation in which smoking happens. An after-dinner cigarette is likely to be experienced as more relaxing than one smoked prior to sitting a university exam.

Nicotine’s addictive effect is linked to its capacity to trigger the release of dopamine – a brain chemical that is associated with feelings of pleasure. Nicotine has been shown to have effects on brain dopamine systems similar to the effects of drugs such as heroin or cocaine. Recent research has suggested that in the long term, nicotine actually depresses the brain’s ability to experience pleasure and that smokers therefore need greater amounts of nicotine to achieve their former levels of satisfaction. Smoking is therefore a form of self-medication. Further smoking alleviates the withdrawal symptoms, which set in soon after the effects of nicotine wear off.
Withdrawal effects of nicotine

Typical physical symptoms following cessation or reduction of nicotine intake include craving for nicotine, irritability, anxiety, difficulty concentrating, restlessness, sleep disturbances, decreased heart rate, and increased appetite or weight gain. The fact that these symptoms can be attributed to nicotine, rather than behavioural aspects of tobacco use is shown by the finding that withdrawal symptoms are relieved by nicotine replacement therapy such as gum and patches, but not by placebo – i.e. products that do not contain nicotine.

Stress

Many smokers say they smoke to relieve feelings of anxiety and stress. The stress-reducing properties of nicotine may however be more illusory than real. As mentioned in the previous section, nicotine stimulates the release of dopamine in the brain. Smokers quickly develop regular smoking patterns and eventually need increased levels of nicotine to feel ‘normal’. As the nicotine level in their blood drops, they begin to crave a smoke and feel ‘stressed’ until the craving is relieved. The relief of this craving by replenishing the nicotine supply is what makes the smoker feel ‘relaxed’. They are in fact merely ending the withdrawal. One physiological consequence of stress is that it makes the urine acidic. This makes the smoker’s body excrete nicotine at an accelerated rate, so when the smoker encounters a stressful situation he/she loses nicotine and goes into drug withdrawal.
Genetic influence

Certain smokers may be predisposed to nicotine addiction through the effects of a gene responsible for metabolising nicotine. Scientists have found that non-smokers are twice as likely as smokers to carry a mutation in a gene that helps to rid the body of nicotine. Smokers who carry this mutation are likely to smoke less because nicotine is not rapidly removed from their brain and bloodstream. In contrast, smokers with an efficient version of the gene (known as CYP2A6) will tend to smoke more heavily to compensate for nicotine being removed more rapidly.
Defining addiction

In 1988 the US Surgeon General published a landmark review that concluded that cigarettes and other forms of tobacco are addicting and that nicotine is the drug in tobacco that causes addiction. In February 2000 the British Royal College of Physicians published a report on nicotine addiction with the conclusion that: “Cigarettes are highly efficient nicotine delivery devices and are as addictive as drugs such as heroin or cocaine.”

Despite the weight of such authoritative research, there has been some debate about the extent to which the smoking habit is controlled by physiological addiction. The debate has arisen because there is no universally accepted definition of addiction. The World Health Organisation’s definition of addiction is:

“A state, psychic and sometimes also physical, resulting in the interaction between a living organism and a drug, characterized by the behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absences. Tolerance may or may not be present.”

On the basis of this definition, it is possible to demonstrate a scientific basis for defining nicotine as an addictive substance.

The Effects of Smoking on Mental Health

The effects of cigarette smoking on physical health such as cancers, cardiovascular and respiratory diseases are widely reported. Researchers are now beginning to look at the effects of smoking on mental health. Nicotine dependence itself has been classed as a psychiatric disorder, although it should be stated that not all smokers are nicotine dependent. Nicotine dependence is said by some to be the most prevalent, the most costly, the most deadly but the most treatable of all the disorders. Health professionals, particularly in the mental health sector where there has been a strong culture of smoking among professionals and clients alike, often overlook it.

Cigarette smoking is linked with a wide range of psychiatric diagnoses including depression, anxiety, panic disorder, post-traumatic stress disorder, and illnesses such as schizophrenia and bipolar affective disorder where psychosis is part of the condition. Researchers don’t yet understand what these links are. They don’t know whether tobacco smoking directly causes any of the mental illnesses or whether having a mental illness makes people more likely to smoke. There is however, some evidence that smoking may increase vulnerability to some mental conditions. In general a greater severity of mental illness seems to be associated with higher rates of smoking. Prenatal exposure to nicotine or cigarette smoke may be a causal factor in mental health problems later in life.

While the literature on smoking and mental health is comparatively new, it is important as it conveys information that is pertinent to helping smokers with a mental health problem to quit or cut down their smoking should they chose to do so. Conversely, in assisting people to give up smoking, GPs or those conducting smoking cessation programmes need to be aware that some people may have underlying mental health problems that need attention and may be in the way of successful quitting

Studies on smoking and mental health tend to focus on diagnostic categories with most of the information to date on depression and schizophrenia. Below is a sample of what the literature says on links between smoking and some common diagnoses.
Anxiety and panic disorder

Many people smoke in the belief that it lessens anxiety but there is some evidence that smoking can cause anxiety. Smoking may be a risk factor for developing panic disorder and it may also be a contributing factor to higher cardiovascular risk in people with panic disorder. A gender effect that links smoking behaviour with higher levels of panic disorder in women has also been found.
Post-traumatic stress disorder

Studies of Vietnam veterans who smoke show that they are more likely than non-smoking veterans to report higher levels of PTSD symptoms, depression and anxiety.
Depression

Many studies have linked smoking to depression and vice versa. Some have concluded that the effects on the brain of poverty, deprivation, childhood trauma, personality, low self-esteem, poor coping strategies and genetic factors may predispose a person to both smoke and to develop major depression. There are a number of studies which link regular smoking with an increased risk of either depressive symptoms or major depression. Just to complicate matters, for some smokers nicotine seems to act as an antidepressant, which may help to explain why some individuals with a history of depression use smoking as a form of self-medication.
Schizophrenia

People with schizophrenia are estimated to have twice the mortality rate from smoking-related diseases than the general population. Smoking behaviour in schizophrenia is a complex process. It may be that the release of dopamine caused by nicotine alleviates some symptoms of schizophrenia. People with schizophrenia are thought to have a lower number of nicotinic receptors than others and this makes them more vulnerable to becoming heavy smokers should they begin smoking. In addition they may consume higher doses of nicotine from their cigarettes.

There is evidence too, that people with schizophrenia who live in institutions including boarding or ‘halfway’ houses or are homeless, have a higher rate of smoking than the general population. This could be attributed to social or environmental factors such as poverty or unemployment rather than to their particular brain chemistry.

Nicotine interacts with the drugs commonly used to treat schizophrenia by reducing the levels of such drugs in the person’s blood. This may lead to the need for higher doses of anti-psychotic medications, which in turn, can lead to increased side effects. One study has shown that people smoke more when treated with the antipsychotic drug Haliperidol than during a medication-free state. In some instances smoking may reduce side effects of medication though evidence for this is not conclusive. The use of the newer ‘atypical’ antipsychotic drugs has been reported to reduce heavy smoking as well as improve outcomes in tobacco addiction treatment programmes.
Bipolar affective disorder

Data about smoking and bipolar disorder (manic depression) is limited but seems to show that as for schizophrenia, heavy smoking is associated with a history of psychosis. Once again, smoking may be related to dopamine transmission.
Alzheimer’s disease

Studies done in the early 1990s suggested that smoking had a protective effect against Alzheimer’s disease. It was hypothesised that nicotine may compensate for the loss of nicotinic brain receptors in Alzheimer’s disease and therefore postpone its onset.
Recently that theory has been challenged. Even if smoking were ‘protective’ against Alzheimer’s, it could never be advocated for this purpose. This is because the known health risks of smoking far outweigh any possible reduction in risk of getting Alzheimer’s disease in later life.

(Sources for studies quoted in this section: Ziedonis, Douglas M. & Williams, Jill M. (2003). Management of Smoking in People with a Psychiatric Disorder.
McNeill, Dr Ann (2001) Smoking and Mental Health – a review of the Literature).

Harm Reduction

Programmes that target smokers in the general population are aimed at helping them to quit. Quitting is also the most desirable outcome for smokers with mental health problems. But given the high rates of smoking in this group a ‘harm reduction’ approach in parallel with encouraging people to eventually stop smoking, may be more pragmatic in some instances. If some cigarettes were replaced with less harmful forms of nicotine delivery such as nicotine patches or gum, there might be an overall benefit to the person’s health. Using a less harmful form of nicotine delivery may in turn encourage the smoker to quit. There is an argument too that smokers who are unwilling or unable to quit should at least be given the choice of which form of nicotine delivery to use.

Clinicians in the United States have been concerned about whether tobacco abstinence will worsen mental illness or jeopardize recovery from other substance abuse. Although this area has received limited study, reports to date indicate that nicotine dependence treatment for people with a mental illness is safe and usually well tolerated. However there have been reports of some increases in mental illness symptoms during the acute detoxification phase.

Inpatient treatment units and other mental health settings are increasingly required to be smoke free. Nicotine replacement medications can be helpful in these settings in preventing nicotine withdrawal during periods of forced or temporary abstinence.

International studies tracking the process of treatment units becoming tobacco-free have been positive. They report no significant increases in the rates of disruptive behaviour, ‘Against Medical Advice’ discharges, additional seclusion and restraints, or the use of ‘as needed’ or emergency medications when tobacco use is prohibited.

Quitting

Why quit?

A healthier and longer life

Quitting smoking gives people the possibility of a healthier and longer life.
Because of their smoking habits deaths from respiratory disorders are 60 percent more likely amongst people with a mental illness compared with the general population, and deaths from heart diseases are 30 percent more likely. Chronic illnesses such as strokes and the drawn-out suffering of emphysema severely affect the quality of a person’s life.

Lower doses of antipsychotic medication

Quitting is likely to reduce the levels of antipsychotic medication needed to be effective People with schizophrenia who smoke tend to require larger doses of antipsychotic medication to gain a therapeutic effect than their non-smoking counterparts. Smokers tend to have lower plasma concentration and clear their antipsychotics from the body at faster rates than non-smokers. There is some research to show that people on newer antipsychotic medications (such as clozapine) may smoke less than those taking the more traditional antipsychotics.

A sense of achievement

Even small steps towards quitting raise self-esteem. Self-confidence can soar as people realise they can take control over their lives.

Improved income

Quitting can help to achieve or restore financial independence.
It has been estimated that smokers with mental illness spend an average of 30 – 50 percent of their income on cigarettes and tobacco products. This can have an enormous impact on the person’s finances and their overall quality of life.

Breaking down the barriers to socializing or getting work

Heavy smoking may affect socializing or getting work. (For example, there are now fewer places where smoking is socially acceptable).

Increased opportunities to develop effective coping strategies

Quitting provides an opportunity to develop new and effective coping strategies.
While people use smoking as a coping strategy to deal with stress, they miss the opportunity to develop more effective coping strategies. Some people with a mental illness have had limited opportunities to develop positive coping strategies because they developed the illness early in adult life. This can be made worse by the amount of time and money they must devote to smoking, creating a vicious cycle.

Enjoying ordinary smokefree activities

Cutting down or quitting promotes access to ordinary community activities.
Many heavy smokers cannot take part in community activities because of smoking bans at many public venues.

Reducing fire hazards

There is a real risk of accidental fire caused by cigarettes. Smoking less and quitting reduces fire dangers.

(Above section adapted with permission from the SANE SmokeFree Kit)

• Within one day of quitting, the chance of a heart attack decreases
• Within two days of quitting, smell and taste are enhanced.
• Within two weeks to three months of quitting, circulation improves and lung function increases by up to 30 percent
• Former smokers live longer: after 10-15 years’ abstinence, the risk of dying almost returns that of people who have never smoked
• Women who stop smoking before or during the first trimester of pregnancy reduce risks to their baby to a level comparable to that of women who have never smoked

National Health Committee Revised Guidelines for Smoking Cessation, 2002)

What helps?

Quitting smoking is a big challenge. Some people can go ‘cold turkey’ and never smoke again. For most smokers, quitting is a process. No one should feel discouraged if they have to make several attempts. Smokers cycle through the stages of contemplating quitting, actually quitting and relapsing on an average of three to four times before achieving permanent success. The message is, “don’t quit trying to quit”. There is good evidence that the following options for quitting are effective:

• Brief advice from health professionals (personal, non-judgmental advice on quitting to smokers repeated in different forms from different sources. Frequent and consistent interventions over time are more important than the type of intervention).

• All forms of nicotine replacement therapy (NRT). NRT products include patches, gum, nicotine nasal spray and nicotine inhaler. A doctor’s prescription is needed for the nasal spray and the inhaler is available only from a pharmacist. Subsidised nicotine patches and gum are available in New Zealand for people smoking more than 10-15 cigarettes a day through the national Quitline (0800 778 778), smoking cessation providers who are part of the Quit Cards programme and Aukati Kai Paipa providers.

• Self-help materials (e.g. books, pamphlets); adding follow-up telephone calls from a health professional improves effectiveness.

• Organised group programmes. These are better than self-help materials but no better than intensive health professional advice.

• Counselling and self-help materials for pregnant women who smoke.

• Specific counseling for men at risk of ischaemic heart disease.

• Some interventions provided in specialist smoking cessation clinics. (The mental health consumer organisation SANE Australia, has produced a SmokeFree Kit containing a quit programme designed to meet the needs of people with a mental illness. Often consumers/tangata whaiora do not wish to reveal their illness in more general groups or may prefer facilitators who understand mental illness.)

• The use of antidepressants nortriptyline or bupropion (Zyban) as second-line pharmacotherapy. (n.b.bupropion is not publicly subsidised in New Zealand and the Medical Adverse Reactions Committee has recommended that it should only be considered as a second-line intervention after unsuccessful trial with other smoking cessation treatments, including nicotine replacement therapy.)

The national Freephone Quitline 0800 778 778 offers confidential support and advice for people wanting to quit smoking. Quit advisors are expertly trained to help smokers gain the required skills to address problems with quitting. Maori and Pacific quit advisors are also available.

Aukati Kai Paipa is one of the services of Te Hotu Manawa Maori. The focus of the service is to provide quality training, support and advice to kaimahi Maori who will then provide free smoking cessation services and support using Nicotine Replacement Therapy, Cognitive Behavioural Therapy and support over a period of 8 weeks to twelve months

Medications and quitting

Nicotine, hydrocarbons and tar-like substances in tobacco products can alter the way drugs are metabolized in the body. When a person no longer inhales hydrocarbons, the liver enzymes take about a month to return to normal levels. During this time the body may build up increased concentrations of a particular medication.

If you are on medication and decide to stop smoking, it is extremely important that you tell your doctor. Your medication needs to be monitored and the dosage may need to be reduced. This is particularly important if you are taking medications used to treat mental illness (also for heart or diabetes medications).

(Source: National Health Committee Revised Guidelines for Smoking Cessation, 2002)

Smoking and caffeine

Nicotine masks the effects of caffeine so that coffee, tea and cola drinks can make you feel jittery and irritable. Reduce or monitor your caffeine intake to minimize these effects. Do not drink acidic liquids such as coffee, orange juice or Coke before chewing or during the use of nicotine chewing gum.

Dealing with obstacles to quitting

Withdrawal

The body reacts when it stops getting nicotine and all the other chemicals in tobacco smoke. For some people this can produce withdrawal symptoms and sensations that can feel unpleasant. However unpleasant, they are actually positive signs that the smoker’s body is recovering.

Emotional symptoms such as anxiety or irritability can be closely related to the physical reaction of the body as nicotine leaves the system. Some symptoms such as upset digestion, constipation and sore throat last only for a few days, while others, such as coughing and sleep disturbances, last longer. However most symptoms become less intense or completely disappear within two to three weeks.
Common signs of withdrawal include:

• Cravings for tobacco – these usually last less than five minutes. Initially they can be very strong, but with time they become less frequent and less intense.

• Feelings of irritation, anxiety or depression – these should lessen over one to three weeks. The may be a result of chemical changes in the body, inadequate means of coping with these feelings without cigarettes or a grief reaction to losing cigarettes.

• Tingling sensation in the fingers or toes – this is due to an improvement in blood circulation.
• Coughing or tightness in the throat – coughing means that the cilia (the small hair-like structures that line the lungs) are working again and are sweeping out the tar and mucus. This should be a temporary effect.

• Change in sleep patterns – some people complain about unusual or strong dreams while others find they sleep better. The use of nicotine patches can sometimes lead to very vivid dreams or nightmares. These should pass with time. Use of 16–hour patches (instead of 24-hour patches) may be more appropriate to lessen this effect.

• Difficulty concentrating – use lists or other methods to help. Reduce the demands you make on yourself as you readjust.

• Occasional headaches or dizziness – this is a sign that the brain is receiving more oxygen. These feelings should pass. Consult your doctor if they persist.

• Changes in appetite – there is often a temporary increase in appetite because nicotine in the cigarettes can suppress appetite. In addition, within a couple of days of quitting, the taste buds become more sensitive and people can taste things better. Be prepared by keeping healthy foods at hand. (See section below on weight gain.)

Weight gain

Weight gain is a side effect of some antipsychotic medications, so concerns about putting on more weight are especially valid. Not everyone who quits smoking puts on weight, but for those who do, the average weight gain is about two kilograms, which people usually lose within a couple of months. The health benefits of quitting are much greater than the effects of gaining this amount of weight. Weight gain can be minimized with very little exercise (for example, 20 minutes of brisk walking, three times a week). There is also some evidence that using nicotine gum can delay weight gain.

Some people put on weight because they eat more when they quit. Some have an increased appetite and a preference for sugar when they quit. Other people eat more as a replacement strategy for cigarettes or to comfort themselves. Eating can be associated with pleasure, relaxation or dealing with different emotions. Try sugar-free sweets and healthy snacks, or use non-food rewards such as buying flowers, having a bath or telephoning a friend.

Depression

It is common for anyone who quits smoking to feel down at some stage of an attempt to quit. Coping strategies such as positive self-talk, phoning a friend, doing favourite activities, exercising, meditating or having a massage can be effective in lifting a depressed mood.

People with a history of depression are more likely to be smokers than those who don’t have such a history. They are also more likely to experience a relapse of depression when they quit smoking. It is important that such people feel reassured and supported in their efforts to stop smoking. If you have experienced depression and want to quit smoking, talk to your doctor and work out ways of managing quitting that will minimise any chance of relapse.

Changing your thoughts and beliefs about quitting smoking

Your style of thinking may get in the way of successfully quitting smoking. Challenging negative thought patterns and replacing them with positive ones can be powerful. On the following page are some common examples of ‘faulty’ thinking and some suggestions for countering them:

Style of thinking Negative thought Suggestions for countering
Black and white thinking
You look at things in absolute, all-or-nothing terms “If I don’t quit now, I never will.” “I will give it a go. I know a lot of people don’t succeed the first time they try – quitting successfully might take some hard work but I can do it.”
Overgeneralisation
You view each negative event as a never-ending pattern of defeat “Every time I try to stop smoking I fail.” “ I haven’t managed to quit so far, but that doesn’t mean I never will.”
Selective thinking
You dwell on the negatives and ignore the positive “Quitting is too hard. You get crabby, eat too much and then fail.” Quitting is hard, but you have more money, better health and a sense of achievement.”
Fortune telling
You predict that things will turn out badly “I know I won’t be able to quit no matter how hard I try.” Where’s the evidence for this prediction?
Magnification or minimisation
You blow things up out of proportion or you shrink their importance inappropriately “Quitting is the hardest thing in the world,” OR “I only quit for three hours, that’s pathetic.” “Quitting is tough, but it’s not impossible. I could start by challenging myself to quit for half a day.”
Personalisation
You blame yourself for something you are not responsible for “I shouldn’t nave gone to that smoker’s house” How were you to know that person was a smoker?

This article is an excerpt from www.mentalhealth.org.nz

How to identify problems with tranquilliser use
Any of the above problems – having side effects like feeling sedated, being controlled by your drug or being stoned by your drug – can lead to other life problems. Reactions can be slowed and this can cause accidents. Relationships of all kinds can be strained because the person is now essentially different. Work performance may decline especially if the person feels sedated and slowed. If people become disinhibited, they can do impulsive things and end up in all kinds of trouble.
The first step is to recognise that you might have a problem. This can sometimes be difficult – it is often easier to carry on taking a drug than it is to try and stop it. Apart from those people who abuse benzodiazepines for particular effects, people start taking benzodiazepines because they have another underlying problem. They often blame the problems caused by benzodiazepines on the underlying problem instead. It is sometimes hard for people to accept that benzodiazepines are causing problems, for example, not functioning properly at work or being more irritable and moody than they used to be.
You need to honestly look at any problems that might be caused by your benzodiazepine use and decide for yourself whether or not a problem exists. In particular, you need to think about signs of being hooked or addicted. You need to allow others to be able to tell you if there is a difference in you or if your behaviour has changed.
The problems that your benzodiazepines can cause you can be distressing for your family or whanau and friends and those people should have the right to be able to tell you that they think there is a problem. If they do this, it is not that they do not love you, understand you or care for you. Pointing out problems is more helpful than keeping quiet about them and hoping that they will go away.
People often do something about their drug problem when it becomes important enough for them to do so.
If you are considering giving up or cutting down on tranquilliser use, draw up a list of the good things and the less good things that you experience with taking benzodiazepines. Write down all the good things that you can think of, for example, that taking the drugs make you feel better, that it means you have a good time with your friends, or whatever. In terms of the less good things, consider any of the negative effects that might be influencing your life. Consider what your family or whanau is saying about your taking benzodiazepines. Consider the effect that this may have on them. Consider any effects that benzodiazepines might be having on your health. Look at the balance of the good things and the less good things. Is your drug taking a problem for you or for other people? Do you need to change something about it? If taking benzodiazepines is causing problems in your life are you ready to do something about it?
Treatment of Problems with Tranquilliser Use
Getting help
The best place to start seeking help is to see a doctor (for some people who may have been prescribed tranquillisers before their addictive qualities were commonly known, issues of anger that a trusted professional allowed a situation to develop to the point where you became addicted to your medication will need to be dealt with).
Almost always you will need a plan to wean you off your pills and a doctor needs to set this in place with you. The doctor should also know about local drug and alcohol services and be able to refer you there.
These services can give you information about your drug problem and are able to help you find counselling, group support or other programmes which can help you make the change away from taking pills. You can discuss with either your family doctor, or your drug and alcohol counsellor, whether or not you may need to see other people such as a therapist, a psychologist or a psychiatrist to help you with any other problems you might have to deal with in making positive changes in your life.
Warning against suddenly stopping tranquilliser use
If you have a problem because you take benzodiazepines, the obvious answer would be to stop taking them. However it can be unpleasant and dangerous to suddenly stop taking them. In addition to this, if the benzodiazepines were initially taken to help an underlying problem – and the underlying problem has not been attended to – suddenly stopping the benzodiazepines might make you feel worse again.
Despite this, some people take the cold turkey option and abruptly stop benzodiazepines with the decision to tough out any withdrawal symptoms that come along. Because of the different lengths of actions of the different benzodiazepines, withdrawal symptoms can last for variable lengths of time (up to months and years) and they can come on up to weeks and months after you stop taking the drug. The incidence of serious side effects (for example fits and hallucinations) is not high, but when they occur these are serious and dangerous problems. There is no clear way to predict whether or not any one person will have these serious complications of withdrawal or not.
Summary of treatment options
The safest option is to wean yourself off benzodiazepines gradually in what is referred to as detoxification. While you are coming off your benzodiazepines, any other problems that exist need to be attended to. If problems such as depression or anxiety emerge you may need to seek support and help from a counsellor, psychologist or psychiatrist. If you have other problems in your life which benzodiazepines have been helping you to cope with, you will need to increase your efforts to deal with these problems and, again, you might need to seek the help of a therapist. If you do not attend to any co-existing problems, and if these co-existing problems cause you distress, it is more likely that you might again seek the comfort of benzodiazepines.
Whether or not you decide to give up or cut down your tranquilliser use it is important that you have support to help you stick to your decision. It is also important to try and manage stress, maintain good physical health, and, if desired, take advantage of a range of complementary services or treatments to help you either give up or reduce your dependency on benzodiazepines.

This is an excerpt from www.mentalhealth.org.nz

This post is an excerpt from www.mentalhealth.org.nz