Haynes Brain Manual 1844253716, 9781844253715

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Haynes

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_ The step-by-step guide for men to achieving and maintaining

mental well-being

and not forgetting... We don’t just publish manuals, you know! In addition to the hundred million plus car manuals we have sold worldwide, Haynes also produce a wide range of practical books and manuals on subjects such as home DIY, computing, caravanning, cycling and driving tuition — and there’s our innovative and highly successful Family Series as well. No matter what the subject, our essential no-nonsense, easy-to-follow approach remains the same.

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We also publish and distribute hundreds of books and DVDs covering general motoring and transport subjects, including all aspects of motorsport, classic cars, sports cars, motorcycling, military vehicles, aviation, model cars, cycling, golf, history and much, much more. Washing Machine Manual

Paul Frére

Check out our website at www.haynes.co.uk to find your nearest stockist or to view or download our online catalogue. All Haynes publications are available variously through car accessory shops, book stores and mail order outlets.

Haynes Publishing, Sparkford, Yeovil, Somerset BA22 7JJ, England Telephone (01963) 442030 ¢ E-mail [email protected] ¢ Website France

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www.haynes.co.uk

613 9763-8100

Illegal Copying It is the policy of Haynes Publishing to actively protect its Copyrights and Trade Marks. Legal action will be taken against anyone who unlawfully copies the cover or contents of this Manual. This includes all forms of unauthorised copying including digital, mechanical, and electronic in any form. Authorisation from Haynes Publishing will only be provided expressly and in writing. lllegal copying will also be reported to the appropriate statutory authorities in whichever jurisdiction the offence takes place.

This book should be returned to any branch of the Lancashire County Library on or before the date shown

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lan Banks Cartoons by Jim Campbell

LANCASHIRE COUNTY LIBRARY

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© lan Banks 2006

All rights reserved. No part of this publication may be reproduced or stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission in writing from Haynes Publishing. Haynes Publishing Sparkford, Yeovil, Somerset BA22 7JJ, England Haynes North America, Inc 861 Lawrence Drive, Newbury Park, California 91320, USA

Editions Haynes 4, Rue de |'Abreuvoir

92415 COURBEVOIE CEDEX, France Haynes Publishing Nordiska AB Box 1504, 751 45 Uppsala, Sweden

British Library Cataloguing in Publication Data: A catalogue record for this book is available from the British Library

ISBN 1 84425 371 6 Printed in Britain by J. H. Haynes & Co. Ltd., Sparkford. The Author and the Publisher have taken care to ensure that the advice given in this edition is current at the time of publication. The Reader is advised to read and understand the instructions and information material included with all medicines recommended,

and to

consider carefully the appropriateness of any treatments. The Author and the Publisher will have no liability for adverse results,

inappropriate or excessive use of the remedies offered in this book or their level of effectiveness in individual cases. The Author and the Publisher do not intend that this book be used as a substitute for medical advice. Advice from a medical practitioner should always be sought for any symptom or illness.

Dedication To Edna Small, who stepped in at just the right time to stop the Mother & Father of all computer crashes.

Photo Credits: Haynes Edition cover: © Bettmann/CORBIS & iStockphoto.com: Peeter Viisimaa, Alan McCredie, Wouter van Caspel, James Benet Men's Health Forum Edition cover: © iStockphoto.com: Peeter Viisimaa, Trudy Karl, Alan McCredie, Wouter van Caspel, James Benet

Other photos courtesy Em Willmott, Paul Buckland, Carole Turk, lan Barnes, Graham Phillips and Tracey Robertson

Illustrations by: Matthew Marke, Mark Stevens, Roger Healing and Pete Shoemark. Numskulls

© D C Thomson & Co on pages 1, 63, 90 and 98

Contents Dedication

ii

Acknowledgements

iv

Author’s introduction

Vv

Sponsors

vi

Myths and statistics

XIV

‘A

@

Stress

63

Dealing with stress

64

Stress and work Long hours, stress and depression Socially excluded men/men in prison

67 72 76

The Ageing Brain

80

Age Concern

81

Alzheimer’s and dementia

90

98

The Brain

1

Common Problems

The brain

2

Mental problems

The brain and the body

6

The emotional brain

8

Mental health and physical health Mental health and diversity Agoraphobia

99 107 116 120

Epilepsy

123

Hard drive Generalised Anxiety Disorder (GAD) Obsessive Compulsive Disorder (OCD) Post Traumatic Stress Disorder (PTSD) Social phobia/social anxiety disorder Men and stroke

127

Brain chemicals

S

Brain injury

11

The Healthy Brain

13

Digestive health & diet

14

Nutrition and mental health

15

Diet and mental health facts Top tips for healthy eating

Lg 20

Water, mental health and mental

well-being

21

131 133 135 142 144

25

Reference

32

Grieving and coping with bereavement

148

Man and other animals Take a walk on the wild side... The arts and mental well-being

34 39 41

Suicide

149

Access your pharmacist!

152

158 166

Relationships

45

When things need fixing Complementary medicine Meditation, happiness, personality and

A user’s guide

46

Dads have feelings too!

52

Use your brain when you use the net

My RAMs bigger than your RAM! Gay, bisexual and transgender men

56 61

Further reading Contacts

Physical activity

and mental health

The biophilia effect

the brain

147

168 170 172 172

Acknowledgements If you will, get your head around this, over 50 human brains contributed to this manual. That’s the equivalent of over one million PCs. If you put all these computers end to end they would cause a terrible queue at the Technical Support department in your local computer super store. Their brains shared a common program; to guide men towards the very best way of improving their mental well-being. Some academics would say we are reinforcing the male mechanistic stereotype but while we wait for the victory from social engineering these are the people at the laser edge of changing men’s health for the better, right now. Special mention of: Matthew Minter, Jim Campbell, Matthew Maycock, Peter Baker, Steve Boorman, Ben Mee, Victoria Aldridge, Jenny Bywaters, Amo Kalar, Michael Reece, Rodney Elgie, Simon

Gregory.

Contributors & Advisors Alex Pollard Allison Marshall Andy Cale Angela Conoly Anthony Leeds Bill McLoughlin Brian Brockwell Catherine Witfield

Chris Manning D Farrington David Haslam David Peters David Sallah Deborah Hart Declan Fox Ewan Gillon

Graham Phillips Guy Dominy Hind Khalifeh Ingrid Burns Jane McCleneghan Jason Saw Jen Banks Jenny North Jessica Peters Jim Pollard

John Banks John Henderson Justine Varney Kathy Barstow Louise Carver Louise Diss Mark Jennet Martin Wakeland Mary Alabaster Mitch Counsell Mona Freeman Nick Ellins Nicky Lidbetter Pam Prentice R MacQueen Rosemary Anderson Samantha Harding

Sandra Gidley Sarah Hawksworth Sarah Nelson Tara St.John Toby Williamson Tracey Reid Vanessa Ashby Veronique Okafor Victoria Lehmann

Computres r a wste of tmie

Tehy wuoldn’t hvae a clu Waht I’v wirtten in tihs Ititle ryme

UlInike me and yoo!

Author’s introduction Ever sat in front of a computer when it crashed? How do you feel when ERROR flashes in its little black box? Can you remember when you last saw YOU ARE RUNNING OUT OF MEMORY? Chances are you experience all of these things in real life, let alone on the computer. Infinitely more complex but often slower than your average desk top, the human brain still beats the best mother of all motherboards when it comes to life with the mother-in-law, although there is no CTRL-ALT-DELETE to re-boot. Human brains created computers, but paradoxically we have

something to learn from our electronic offspring and it can be invaluable, not to mention fun, making comparisons.

Processing power and clock ‘As fast as the speed of thought’ is not quite as good as it sounds. Take a look at the back of the Highway Code for reaction times in an emergency stop. But it’s not just a matter of how fast a signal travels down a wire or nerve, it is the number of junctions it has to pass. The processing power of an average brain is 100,000,000 MIPS (Million computer Instructions Per Second). 2006's fastest Intel PC processor chip on the market was 3.8 giga Hz, performing only 2700 MIPS. Speed is not everything; it is the complexity of data management coming from multiple sources. Even so, Super-computers are rapidly approaching the brain’s handling capacity.

Memory At the World Memory championships human brains routinely recalled the sequence of a randomly shuffled deck of cards within 60 seconds. Some neurophysiologists reckon there is no limit to the brain’s memory capacity and dispute the need to ‘clear out’ memories to make room for more. Their argument is that most people are bad at ‘filing’ memories. It is all matter of usage. Regularly used memories, home telephone numbers, home address, are most easily accessed. Memories associated with

significant life events also remain ‘fresh’. Best guess of brain memory capacity lies around 100 million megabytes, but it could be much greater and varies from person to person. There do seem to be two types of memory, short and long term. Computers use primary and secondary memory. Primary memory is used for calculation processes and storage of temporary values, and disappear when the power is turned off — ‘You will lose any unsaved data’. Most word programs use an automatic save function which can recall the data up to the last Save episode. ‘| really must remember that telephone message’ is generally a prompt to write it down. Primary memory is important when executing programs; bigger programs require more primary

memory. Secondary memory provides storage and transfer of most of a system’s data, programs and other permanent data. PC hard drive memory is already routinely greater than 400 gigabytes and getting larger all the time, driven by ever more memory-hungry programs. Learning to play the piano is not a million miles from modern computer games in terms of the space needed. The more you run the program the better it is handled. Practice makes perfect.

Performance People’s performance varies enormously. Although the computer appears to win hands down when it comes to speed of calculation, and chess lost its last human champion in 2005, it is not a level playing field, sorry chess board. Humans get tired, need a cup of tea, daydream, have a wee, while all the time the

brain is being bombarded with information from eyes, ears, tongue, nose, skin, joints, muscles and internal organs. Even the most super computer doesn’t need to worry about a lack of toilet paper before sitting down.

Learning Learning is different from memory, although they are linked. Reflexes are different again. Grabbing a red hot pan handle triggers a reflex reaction. Memory recalls what happened last time a hot handle was grabbed, but the brain can learn that whilst the heat may be painful, the pan contains that night’s dinner, and eating it off the floor is never a good idea. Babies’ brains learn fastest through sheer necessity. This involves trial and error combined with previous experience (memory). Habits are the result of continued reinforcement, doing the same thing

over. Computers can also learn: voice recognition engines and optical character recognition (OCR) are good examples. Some smart programs are capable of learning by trial and error, learning from their mistakes and recording the best solutions to any problems found. Engineering robots work on this principle. But thankfully, people are not yet robots. Just to prove it...

Click on START

GE

Sponsors MHF MEN'S HEALTH FORUM The author, the publisher and the Men’s Health Forum would like to thank the following organisations for their contributions to the content, production and distribution of this manual.

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THE AFIYA TRUST

The Afiya Trust A Black and Minority Ethnic (BME) led national organisation working to reduce inequality in health and social care provision for racialised groups through networking, partnership working, user involvement, consultations, research and information dissemination and community engagement. Afiya Trust's work covers the following inter-related areas: @ Influencing policy makers and service providers. @ Addressing Carers Issues through National Black and Minority Ethnic Carers and Carers Workers Network (NBCCWN). @ Mental Health issues through National Black and Minority Ethnic Mental Health Network (NBMEMHN). @ Cancer — In partnership with Cancer Equality, the provision of Information Services for Black and Minority Ethnic grouips. Tel: O20 7582 O400 Website: www.afiyatrust.org.uk Age Concern The UK’s largest organisation working for and with older people to enable them to make more of life. In England, we are a federation of over 400 independent charities which share the same name, values and standards.

AGE

We believe that ageing is a normal part of life, and that later life should be fulfilling, enjoyable and

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Mental problems Introduction

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1 Just as our physical health is linked to our genes and our lifestyle, so too is our mental health. For instance, through their genes, some people may be more susceptible to anxiety or depression. Others may develop a mental health problem as a result of child abuse, substance misuse or experiencing a traumatic event. All of us are vulnerable when it comes to major life changes — a death in the family, divorce or losing our job. Even positive changes, such as having a new baby or moving house, can be stressful and have a negative impact on our mental well-being. 2 Experiencing a mental health problem should not be a cause of shame any more than having pneumonia or breaking a leg. In

fact, mental health problems are extremely common. Indeed, 1 in 4 of us will experience one at some point in our lives. 3 Although mental health problems affect both men and women, men are much less likely to seek help from their doctor. Men traditionally expect themselves to be competitive and successful, tough and self-reliant. They can find it very difficult to admit that they are feeling fragile and vulnerable. If they do see their doctor, they are more likely to talk about their physical symptoms than the emotional and psychological ones. As a result, many men do not get the help they need and make their problems worse by abusing alcohol and drugs. 4 Mental health problems include a wide range of conditions. Some affect our sense of well-being, such as anxiety and mild depression. Other mental health problems can be more severe, such as schizophrenia, where a person can at times lose contact with reality. 5 Many mental health problems respond very well to treatment, So it is important to seek professional help. If you are feeling wretched, don’t hold back — talk to your GP, a family member or friend.

Anxiety 6

We all feel anxious when faced with situations we find

threatening or difficult. In fact, fear and anxiety can be useful, as

they help us to avoid dangerous situations, and give us the motivation to deal with problems and make necessary changes to our lives. 7 Sometimes it is obvious what is causing the anxiety, for instance worries about work or family. Anxiety can also be caused by using street drugs or even by the caffeine in coffee. Usually, when the source of stress disappears, so does the anxiety. However, if the feelings of fear and anxiety become too strong, or go on too long, they can stop us doing the things we want to do, and make our lives miserable.

8 A phobia is an extreme fear of particular situations — a social phobia is a fear of being in social situations — or particular things like spiders, which most people do not find troublesome. Sudden unexpected surges of anxiety are called panic and usually lead to the person having to escape as quickly as possible.

Physical symptoms Palpitations. Sweating. Muscle tension and pain. Breathing heavily. Faintness and dizziness. Indigestion and diarrhoea.

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Mental symptoms Constant worry. Tiredness.

Difficulty concentrating. Feeling irritable. Problems sleeping. Easily startled by unexpected sounds. Treatment 9 Although 1 in 10 people suffers from anxiety and phobias at some point in their lives, most do not seek treatment. Effective treatments include psychotherapy, group therapy, medications such as tranquillisers and anti-depressants, and learning relaxation techniques (see Jreatments and how they work). 10 The important thing to remember is that having anxiety, and seeking help, is not a sign of weakness.

Post Traumatic Stress Disorder (PTSD) 11 Any one of us can have an experience that is overwhelming, frightening and beyond our control. We could find ourselves in a car crash, witness a terror attack, or be a victim of violence. Most people, with time, get over the experience without needing help. In some, however, the traumatic experience sets off a reaction that can last for many months or years. Symptoms 12 In addition to the common symptoms of anxiety, people with PTSD may also: @

Have vivid memories, flashbacks and nightmares. Feel emotionally numb. Be constantly ‘on guard’. Avoid places and people that remind them of the trauma. Have to keep busy to cope.

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People don’t like to talk about upsetting events

more likely to go to their doctor about the physical symptoms which accompany PTSD — palpitations, headaches and diarrhoea — than to seek help for the psychological symptoms such as depression and being ‘on edge’. If a person has these symptoms for more than 6 weeks, it is important to see their doctor. Treatment 16 Anti-depressants can reduce the strength of PTSD symptoms and relieve any depression. Other effective treatments include

Cognitive Behavioural Therapy (CBT), group therapy and complementary therapies (see Jreatments and how they work). A newer technique, Eye Movement Desensitisation and Reprocessing (EMDR) uses eye movements to help the brain to process flashbacks and make sense of the traumatic experience.

Depression

@ Feel depressed. 13 These symptoms are a normal reaction to narrowly escaping death, and nearly everyone will have them for the first month or so. They actually help the person to come to terms with the traumatic experience. 14 For 1 in 3 people the symptoms do not go away, and they have problems coping with what has happened. This is more likely if the event was:

17 Depression is a common illness which causes a huge amount of mental pain. At some point in their life, 1 in 10 men will suffer from depression. Men who live alone, have no friends around, are stressed, have other worries or are physically rundown are more at risk. Depression is responsible for high rates of sick-leave and can be a potentially fatal disorder — most people who kill themselves have been depressed. 18 Everybody, at times, feels down and unhappy. Usually there is

@

a good reason, often more than one reason. At other times,

Sudden and unexpected. Went on for a long time. Was man-made. Caused many deaths. Caused mutilation and loss of limbs. Involved children.

@ The person was trapped and could not get away. 15 Because people do not want to be thought of as weak or unstable, PTSD is often unrecognised and untreated. Men are

unhappiness can come ‘out of the blue’. Generally these feelings don’t last longer than a week or two, and don’t interfere too much with our lives. However, if they don’t go away, become severe or Start to interfere with life, you may have a ‘depressive illness’. You may not realise how depressed you are because it has come on gradually. You may be determined to struggle on and cope with feelings of depression by keeping yourself very busy. 19 Depression has nothing to do with being weak or unmanly. Even powerful people can become depressed. Winston Churchill

called his depression his ‘black dog’. Depression can also run in families. If one of your parents was severely depressed, you are 8 times more likely to become depressed yourself. 20 Gay teenagers and young adults may be more vulnerable to depression because of the stress of ‘coming-out’, victimisation and bullying. Psychological symptoms 21 You may: @ Feel unhappy most of the time (particularly in the morning but you may feel a little better in the evening). Lose interest in life and can’t enjoy anything. Find it hard to make decisions. Find it hard to concentrate. Feel restless and agitated. Feel tense and anxious. Feel irritable. Feel worthless and hopeless. Feel guilty. Feel utterly tired. Lack motivation. Cry for no apparent reason. Physical symptoms 22 You may: @ Have difficulty getting to sleep, and/or wake early or during the night. @ Lose your appetite and therefore weight. @ &xperience physical pains and constant headaches. @ Lose interest in sex.

Treatment 23 Treatment can include, psychotherapy, counselling and antidepressants. 24 The organisation Relate offers relationship counselling, and Cruse offers bereavement counselling. A small number of people may need more specialist help and will be referred by their GP to a psychiatrist or member of the community mental health team. How to help yourself 25 There are also many ways you can help yourself: @ Don't bottle things up — talk to someone about how you are feeling. This is the mind’s natural way of healing. Keep active and exercise. Eat properly. Avoid drugs and alcohol — they actually make depression worse. Learn relaxation techniques. Make life-style changes. Try to do something you enjoy. Keep hopeful — depression can be a useful experience. You may come out stronger, see situations and relationships more clearly, and be able to make important decisions and changes in your life which you had been avoiding.

Eating disorders 26 Everyone has different eating habits and there are a large number of ‘eating styles’ which can allow us to stay healthy. However, some eating habits can actually damage our health.

These are called ‘eating disorders’, and the most common Anorexia Nervosa and Bulimia Nervosa.

are

27 Although girls and women are 10 times more likely to suffer from anorexia and bulimia, boys and men seem to be getting eating disorders more often. Anorexia is a serious illness which can damage your heart, lungs and bones. It has the highest death rate of any psychological disorder. 28 Anorexia usually starts in the teenage years and affects around one 15 year-old boy in every 1,000. Bulimia often starts in the mid-teens, but people don’t usually seek help for it until their early to mid-twenties because, unlike anorexia, they are able to hide it. Symptoms (for men in particular) @ Eating less and less. @ Worrying more and more about your weight. @

Using harmful ways to get rid of calories, such as vomiting and using laxatives.

@ @

&xercising more and more to burn off calories. Using slimming pills, or smoking more to keep your weight down. @ Losing interest in sex. @ Erections and wet dreams stop, your testicles shrink. @ Binge eating. 29 The symptoms of anorexia and bulimia are often mixed. The pattern of symptoms can change over time — someone

may start

with anorexic symptoms, but later develop those of bulimia. 30 Another eating disorder has recently been recognised — binge eating disorder. It involves dieting and binge eating, but not vomiting. It is much less harmful than bulimia and sufferers are more likely to become overweight.

Possible causes @

@ @

@ @

@

@

Social pressure — occupations which demand a low body weight (or low body fat) — body building, wrestling, ballet, swimming and athletics — seem to make eating disorders more common. Control — your weight may be the only part of your life that you feel you can control. Puberty — anorexia can reverse some of the physical changes of becoming an adult — pubic and facial hair for example. This may help you put off the demands of getting older, particularly sexual ones. Family — saying ‘no’ to food may be the only way you can express your feelings or have a say in family affairs. Depression — people with bulimia are often depressed. Bingeing may start as a way of coping with feelings of unhappiness. Self-esteem — people with anorexia and bulimia often don’t think much of themselves and compare themselves unfavourably with other people. Emotional distress — anorexia and bulimia can develop as a result of sexual abuse, physical illness, and important life events.

Treatment 31 Most people with a serious eating disorder will end up having some sort of treatment, as the condition does not appear to get better on its own. Bulimia can sometimes be tackled using a self-help manual and some guidance from a therapist. However, anorexia usually needs more organised help from a clinic or therapist.

Although half of people with anorexia make a recovery, on average they will be ill jor five ip six years. A full recovery can happen even afier20 years. About 1 in 5 of the mosi senously ill may die.

32 Although Cognitive Behaviour Therapy and Interpersonal Therapy have been jound to be beneficial for bulimia, many patienis have responded io other iherapy approaches, pariicularty forms of family therapy. In the case of anorexia, no particular therapy has advantages over others.

Bipolar disorder (manic depression) 33 About 1 in 100 adulis has bipolar disorder (manic Gepression). This means thai they have periods of bad depression aliemating with periods of feeling ‘manic’. The manic episodes can be jusi as harmiul as the periods of depression. The paiiem 07 mood swings varies considerably from person io person, with some people experiencing high and low swings, others only manic episodes, and some mainly depressive episodes. 34 Bipolar disorder mosi commonly siarts in the laie teens or early iweniies and aifecis nearly as many men as women.

Research has shown that it does mun in families. There is a problem wiih ihe pari of the Drain thai conirols the general level

of how we feel emotionally. This is why medication can control the sympioms.

Symptoms of manic mood episodes 35 You may feel @

Very happy and exciied.

@

Full of new exciting ideas.

@

irriiaied with other people (who don’t share your opiimistic outlook). Full of energy. Sure that there is no problem.

Thai you don?t need io sleep. Thai you wani io ialk io people much more. Thai you are very imporiant. Less commonly, you may hear voices that other people don’t. 36 When you are having a manic episode, you may not realise any thing is wrong. Others may noiice that you: Behave in a bizarre way. Speak very quickly. Make odd decisions on the spur of the moment. Spend money recklessly. Are less inhibited about your sexual behaviour. Make plans which are grandiose and unrealistic to other people. 37 When someone recovers from a manic mood episode, they often regret the things that they did and said whilst *high’. Without the right help, the condition can destroy your family, your relationships or your work. Therefore, it is important to recognise the signs that a manic episode is about to start. You can then get help before you are feeling so good that you don't see that there is a problem.

Treatment 38 One of the main treatments for bipolar disorder is lithium, a natural substance found in the earth. Mood stabilising medications such as carbamazepine & sodium valproate can also help control manic and depressive mood swings. Psychotherapy and anti-depressants can be used to treat the depression.

Psychotherapy and counselling can be helpful in the periods beiween mood swings.

Schizophrenia 39 Schizophrenia is a serious and complicated mental health Gisorder that affects around 1 in 100. It affects men and women equally and seems io be more common in city areas and in some minority ethnic groups. Ii is rare before the age of 15, but can start ai any time after this, most often between the ages of 15 and 35. 40 I in 10 people has a parent with the illness. Research Suggesis thai genes account for about half of the risk of developing the disorder. The use of some street drugs, including cannabis, ecsiasy, LSD, amphetamines and crack seems to increase the risk of developing schizophrenia in some vulnerable people. Suicide is also more common in people with this illness. 41 Ii is imporiani io undersiand that: @ Schizophrenia is noi a ‘split personality’. @ People with schizophrenia are not necessarily dangerous. @ 1 in 5 people will recover compleiely. Symptoms are often described as ‘positive’ and ‘negative’ 42 Positive symptoms: @

Hallucinations — you hear, smell, feel or see something that others cannoi.

@ @ @ 43

Delusional ideas that make you feel persecuted or harassed. Muddled thinking and difficulty concentrating. Feeling that you are being controlled. Negative sympioms. You:

@ @ @ @ @

ose Lose Feel Lose Feel

inierest in life. interest in your personal appearance. uncomfortable with other people. insighi. depressed.

Treatment 44 The longer schizophrenia is left untreated, the greater its impact on your life. Antipsychotic medication should be started as soon as possible. This can help the most disturbing symptoms and make it possible for other kinds of help to work. Talking therapies include Cognitive Behaviour Therapy (CBT), counselling and supportive psychotherapy. You may not need to go to hospital, but will need to see a psychiatrist and a community mental health team.

Possible causes of malfunction Genes 45 There is evidence that some people, through their genes, are more susceptible to certain mental health problems, including schizophrenia, bipolar disorder and depression.

Relationships 46 Wve all need to feel loved and appreciated. It has been shown that, for men, relationship difficulties are the most common cause of mental health problerns. Men are less able to cope with disagreements than women, and arguments can make men feel physically uncomfortable. By withdrawing, they avoid difficult discussions and confrontations. This can lead to his partner feeling more upset and ignored, and the problem escalates. The vicious circle can easily destroy a relationship.

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Mid-life 53 Some men appear to experience a crisis of confidence at midlife (most commonly in the 40s to 50s), which may be accompanied by depression and other mental health problems. Alcohol and drugs 54 People use and misuse many different substances. These can be legal, such as alcohol, tobacco and solvents, or illegal such as

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develops a physical and/or psychological dependence, and has withdrawal symptoms if they do not use the substance.

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especially amongst young people. According to the Department of Health, around 1 in 8 men is physically addicted to alcohol. 56 Alcohol acts on the brain like many other drugs. If you drink regularly, you will find that you need to drink more and more to get the effect you want. This is called ‘tolerance’ and is a powerful part of becoming addicted to alcohol. 57 Alcohol and drug misuse can lead to serious and permanent mental health problems: @ Dementia — memory loss like Alzheimer’s disease. @ Psychosis — you may start to hear voices. @ Dependence — if you stop using the substance you get withdrawal symptoms such as shaking, nervousness and

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sometimes seeing things that aren't there. Schizophrenia — there is evidence that the use of cannabis is linked to the development of this serious mental illness in some vulnerable people. @ Suicide — 40% of men who try to kill themselves have had a long-term alcohol problem. 58 Some facts about drinking too much alcohol: @ Alcohol increases the risk of depression. @ Regular drinking causes social problems — family arguments, domestic violence and poor work. @ Anxiety and depression will become worse if you drink alcohol. @ Binge drinking seems to be connected with an increased risk of death in middle-aged men.

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Using street drugs can seriously damage your health

Street drugs 59 Using street drugs like cannabis (hash), speed (amphetamines), ecstasy (E), cocaine and heroin can seriously damage your health, and in some cases be fatal. Some facts: @ Mixing ecstasy and alcohol can lead to dehydration, coma and death. @ Cannabis can make you feel panicky, confused, tired and hungry. Smoking cannabis causes lung disease. @ Young adolescent men who smoke cannabis on a weekly basis are more likely to become dependent later on in life. @ ‘Skunk’, a particular strong form of cannabis, is particularly dangerous. @ Cannabis can trigger schizophrenia in vulnerable people. @ Amphetamines affect the heart and can cause death. @ Amphetamines can make you feel scared and anxious. @ LSD can cause terrifying experiences. @ Cocaine and crack cocaine can cause chest pain, difficulty breathing and are highly addictive. @ Heroin is highly addictive and can be fatal. ® Steroids can cause breast development in men, depression and hormonal problems. @ Serious infections, such as HIV and hepatitis, can be spread by sharing needles or ‘equipment’. 60 The most common sign that you have a drug problem is that you find you need more and more of the substance to get the same effect and you cannot cope without it. If you think you have a problem speak to your doctor. Physical illness 61 A serious physical illness can affect every area of your relationships, work, spiritual beliefs and how you socialise other people. Being ill can make you feel sad, frightened, or angry. You will be particularly vulnerable to depression

life — with worried if the

illness returns, for example, a recurrence of cancer or a second

heart attack. 62 The emotional impact of a serious physical illness can be overwhelming. 63 You may feel out of control of your body and your situation generally. You may be uncertain about what exactly is wrong, anxious about the pain of surgery, the effectiveness of the treatment and the side-effects of medication. You may feel lonely and isolated from family and friends, because you may find it difficult to talk about the illness with those close to you. You may fear death. 64 Some drug treatments, such as steroids, and some physical illnesses, such as an under-active thyroid, affect the way the brain works and can cause anxiety and depression directly. Symptoms of depression can be similar to those caused by the physical illness. 65 Health professionals can help identify whether it is the illness, or the depression, which is causing the symptoms and what treatment is needed. They can explain your illness and its treatment, and help you to talk about your feelings.

Self-harm 66 Self-harm is linked to emotional distress in people who have been struggling with difficulties for a period of time. Often there are problems with relationships, particularly in young people who feel that they are not heard, are powerless, and are bullied. 67 About 10% of young people harm themselves. Although selfharm is more common in females, men may be more likely to disguise it as accidents. Once someone has started to harm themselves, they tend to do it again quite quickly and 30% will repeat it during the following year. Self-harm is not an attempt at suicide. People who use violent methods to harm themselves, who are socially isolated, or have a psychiatric disorder, should be seen by a healthcare professional. 68 Self-harming can include: @ Overdosing. Cutting yourself. Burning your body. Banging your head. Throwing your body against something. Punching yourself. @

Sticking things in your body. Swallowing objects.

Suicide 69 Many people who kill themselves have been depressed. Men are 3 times more likely to kill themselves than women. Suicide is commonest amongst men who are separated, widowed or divorced and is more likely in someone who is a heavy drinker. 40% of men who try to kill themselves have had a long-standing alcohol problem. Men between the ages of 16 and 24, and 39 and 54, are particularly vulnerable.

70 We know that: @ 2 out of 3 people who kill themselves have seen their GP in the previous 4 weeks. @

Nearly 1 in every 2 people who kill themselves will have seen their GP the week before they take their lives.

@

2 out of 3 people who kill themselves have talked about it to friends or family. 71 As most men have to pluck up the courage to tell someone about the way they are feeling, it is very important to take anyone who talks about suicide seriously. If you are feeling so bad that you have thoughts of suicide, it is essential to talk to

someone. 72 Most studies suggest that treatment is difficult. Talking about the problem can help clarify the problem areas. There are also a number of internet sites and telephone organisations for people who prefer to talk anonymously.

Treatments and how they work Anti-depressants 73 These are drugs which relieve the symptoms of depression and other mental health problems, and have been used since the 1950s. The main types of anti-depressants available today are: ® @

Tricyclics. SSRIs (Selective Serotonin Re-uptake Inhibitors).

@ MAOls (Monoamine Oxidase Inhibitors). @ SNRIs (Serotonin and Noradrenaline Re-uptake Inhibitors). 74 Anti-depressants can take between 2 to 6 weeks to work. They are not addictive, although one third of people who stop taking SSRIs and SNRIs have some withdrawal symptoms (upset stomach, flu-like symptoms, and anxiety). They can have sideeffects, particularly at the start of treatment, and you may be advised to avoid certain foods. Anti-depressants are not licensed for use in people under the age of 18. 75 Anti-depressants are used to treat: @ Moderate and severe depression. Severe anxiety and panic attacks. Obsessive compulsive disorders. Chronic pain. Eating disorders. Post Traumatic Stress Disorder (PTSD). Tranquillisers 76 These are drugs used to reduced anxiety and they can also help you to sleep. Common tranquillisers are diazepam, lorazepam and temazepam. Tranquillisers should not be used for longer than a couple of weeks, as they can become addictive. Antipsychotics 77 These are drugs used to treat the symptoms of the most severe mental illnesses such as schizophrenia and psychotic depression. Psychotic symptoms may include hallucinations and delusions. Newer antipsychotic drugs have fewer side-effects.

Psychotherapy 78 Many men are reluctant to consider psychotherapy or counselling. But, these are powerful ways of relieving depression and anxiety and work well for many men. 79 There are many different types of psychotherapy. Some focus on feelings you have about other people and involve discussing past experiences. Others focus on changing problematic patterns of behaviour directly. Family and relationship therapy will try to include all the people involved in a relationship problem. Cognitive Behaviour Therapy (CBT) 80 Research shows that CBT is as effective as anti-depressants for many forms of depression, and is also one of the most effective treatments for anxiety. It can help you to make sense of overwhelming problems by breaking them down into smaller parts. CBT helps you change how you think and what you do, to make you feel better. It focuses on the ‘here and now’ problems and difficulties, and looks for ways to improve your state of mind now. It has been found to be helpful in: Anxiety, panic, phobias.

Post Traumatic Stress Disorder. Depression. Bulimia. @ Schizophrenia. 81 CBT can be done individually, within a group and also from a self-help book or computer programme. Individual therapy may involve meeting a therapist for between 5 and 20 weekly, or fortnightly, sessions, each lasting between 30 and 60 minutes. Complementary therapies 82 Physiotherapy, osteopathy, massage, reflexology, acupuncture, yoga, meditation and Tai Chi can help relieve symptoms of anxiety and depression. St John’s Wort is a herbal remedy, available from chemists, which has been shown to be effective in mild to moderate depression. If you are taking other medication, consult your doctor before taking St John’s Wort.

Here are some tips to help you maintain mental well-being Don’t @ Bottle up your feelings. @ Resort to using alcohol and drugs. @ Feel ashamed if you have a mental health problem. Do @ @ @ @ @ @ @ @ @

Eat healthily. Exercise. Spend time with family and friends. Learn how to relax. Do things you enjoy. Take a break. Keep a check on your lifestyle. Have a purpose — work, volunteer, practise a hobby. Be patient with yourself if you have suffered a major loss.

Mental health and

physical health 1 We often take our mental well-being for granted. That we will be able to function like we always have, that we will have successful relationships with partners, friends and family, hold down a job, socialise and feel good... ‘normal’. So what happens

when our mood and behaviour changes and we don’t know why? 2 Everyone will experience highs and lows in how they are feeling, often in reaction to what’s going on in our lives and what's happening around us. But when these feelings don’t go away and start to impact on everyday life, then it may be time to address whether you have a mental health problem. Some mental illnesses are more common than others — depression and anxiety type disorders are among the most common.

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All mental illnesses are serious, but severe mental people .

illnesses are usually classified as those in 9 mental health conditions through which sion will affectfe: and ue Depress ti thelt \ a ane people are likely to experience a disconnection with reality — psychosis. During psychotic of the ge" mci degrees © episodes people experience and respond ed expene i ~ anxiety disorder: differently to the world that others experience, often evident through symptoms like soca hallucinations and delusions. There is a huge amount of stigma attached to severe mental illnesses — mostly through ignorance, misinterpretation and sensationalism within the national press. If you are worried about yourself or someone close to you, give yourself the opportunity to make up your own mind by becoming more informed about what mental illness is, and what can be done to treat and

manage it. This next paragraphs will outline some of the basic information about severe mental health conditions, and the impact these can have on your mental well-being and your physical health.

Schizophrenia 4 Schizophrenia is a mental illness which is experienced in terms of ‘acute episodes’, where a person’s mental experience and thinking become distorted. 1 in 100 people will experience at least one such episode during their life and the highest incidence is during the late teens and early twenties. One quarter of people with schizophrenia will recover fully and most will have long periods with good ability to function, but with occasional

problems and relapses. Recognising symptoms of schizophrenia 5 People with schizophrenia become disconnected from the reality that others around them experience. This will often be detected through showing a combination of symptoms which can include hallucinations and delusions; some people will also have depressive type episodes, sometimes referred to as ‘negative’ symptoms, which may include withdrawing into themselves and self neglect.

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Hallucinations are experiences through the senses (sight, smell, taste, touch or hearing) that seem to come out of

nowhere, the most common voices’. @

taking the form of ‘hearing

Delusions are ‘strange’ or unfounded beliefs that someone with schizophrenia commonly develops, often as a way of rationalising and justifying the hallucinations that they are experiencing. Some of the more common types of delusions include believing that they are being watched, cheated or harassed (persecution), or a grossly inflated sense of own importance and abilities (grandeur).

What causes schizophrenia? 6 Research has shown that there are many interacting factors and triggers which can lead to someone developing a mental health problem. @

Our biology; brain chemistry appears to be one important factor. There are two chemical ‘messengers’

(neurotransmitters) that have been found to be particularly linked with mental illness: Serotonin and Dopamine. When their levels are too high, too low or are imbalanced, they can

lead to neurological symptoms such as psychosis; affect (mood) problems or subtle changes in behaviour. Pregnancy and birth complications, or a traumatic head injury (particularly during childhood) have been found to be significant risk factors in the development of schizophrenia, although the risk is small compared to genetic heredity. @

Significant life events and stressful environments are the main psychological trigger for schizophrenia for those who are predisposed to the condition. These include any major event, like losing a job or experiencing a significant trauma.

@

Some substances may cause a brain disturbance that can trigger a first episode, especially LSD, cannabis and amphetamines.

Bipolar disorder (manic depression) 7 Bipolar Disorder (manic depression) is a mood (affective) disorder that causes unusually severe shifts in mood, energy and ability to function. It typically develops in late adolescence and early adulthood, and can be treated, so it’s possible to lead a full and productive life with the condition. Recognising symptoms of bipolar disorder 8 Bipolar disorder is characterised by dramatic mood swings from overly ‘high’ (mania) through to sad and hopeless (depression), often with normal mood periods between. @

@

Mania: \ncreased energy/activity, restlessness, excessive ‘high’ or euphoric mood, extreme irritability, racing thoughts, talking very fast, lack of concentration, needing little sleep, unrealistic belief in own powers, poor judgement, spending sprees, increased sexual drive, misuse of drugs and stimulants, provocative or aggressive behaviour, often a denial that anything is wrong. Depression: Lasting sad, anxious or empty mood, feeling hopeless or pessimistic, feelings of guilt, worthlessness or helplessness, loss of pleasure in once enjoyed activities including sex, decreased energy, fatigue or feeling ‘slowed down’, difficulty concentrating, remembering things or making decisions.

9 For some people, symptoms of mania and depression can occur together in a ‘mixed bipolar state’, which can make a person feel very sad and hopeless whilst at the same time extremely energised. Severe episodes of mania or depression can also include psychotic symptoms (hallucinations and delusions). Therefore, people with bipolar disorder are sometimes incorrectly diagnosed as having schizophrenia. What causes bipolar disorder? 10 Like schizophrenia, possible genetic causes of bipolar disorder are related to the neurotransmitter system in the body. Also similarly, the main psychological cause thought to be able to trigger symptoms, is stressful life events.

Personality disorders 11 Someone may be described as having a ‘personality disorder’ if their personality characteristics cause them long term and regular problems with the way they interact with others, cope with life or respond emotionally to things. People who are given this diagnosis often feel that they are being blamed or criticised for their problems. This type of disorder is more common in men than women and is particularly evident in institutional settings such as prison. ion \s

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Recognising symptoms of personality disorders 12 In personality disorders, symptoms remain relatively constant and tend to be long lasting, if not permanent, due to the supposed ‘ingrained’ nature of personality disorders. Symptoms experienced will depend on the type of personality disorder diagnosed. Types of personality disorders 13 Personality disorders are grouped into 3 main types or ‘clusters’. These are the odd/eccentric paranoid cluster (cluster A); the dramatic/erratic cluster (cluster B) and the anxious/inhibited cluster (cluster C). There is also a classification of Dangerous and Severe Personality Disorder (DSPD) although this as a separate classification iS Somewhat controversial within the mental health field.

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Persona ); 49% o f

Prisoners in the UK What causes personality disorders? 14 As personality disorder is directly linked to traits and characteristics in our personality, it is likely to be the case that there is a strong genetic basis to what causes it — which is possibly why personality disorder often runs in families. The environment that we grow up in may also affect the way we develop our personality, which may explain why there are high rates of people with personality disorder who have experienced abuse.

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15 Everyone feels down sometimes but when this is a prolonged experience which begins to have an impact on your ability to function normally, it’s an illness. Depression can affect the way you eat and sleep, how you feel about yourself and how you think and how you can function within your family. Having depression is not a sign of weakness and it is not possible to simply ‘pull yourself together’ when you have clinical depression.

21 Some people may experience anxiety, worry, fear or panic at a greater level than is normal. For some this anxiety is triggered by particular things (phobias) whilst others cannot pinpoint a specific trigger (generalised anxiety). These problems can have a significant effect on someone’s quality of life.

Recognising symptoms of depression 16 You may experience some of these symptoms: feeling helpless and hopeless, feeling useless and inadequate, self-hatred, being vulnerable and over-sensitive, feeling guilty, loss of energy and motivation so that simple tasks and decisions feel difficult, selfharm, loss or gain of weight, difficulty sleeping or excessive sleeping, agitation and restlessness, loss of sex drive, difficulty concentrating, sense of unreality, physical aches and pains.

17 People with severe depression may have suicidal thoughts (suicidal ideation) and self-harm; but they may also show more severe signs of self neglect such as not eating for prolonged periods. In some of these extreme cases people may also start to experience psychotic symptoms like hallucinations and delusions if treatment is not used or is ineffective. Types of depression 18 Depressive illnesses come in different forms, which can be characterised by certain patterns of symptoms or triggers. Types of depression include: @

Major depression: a series of symptoms which interfere with life and functioning. Such a disabling episode can occur once but more often several times in a lifetime.

@

Dysthymia: less severe, long term symptoms that do not disable but keep you from feeling good and functioning well.

@

Postnatal depression: not the same as ‘baby blues’, postnatal depression occurs from about 2 weeks to up to 2 years after the birth.

@

Seasonal affective disorder (SAD): a type of depression which coincides with start of winter and lasts until the days grow longer and there is more sunshine in spring.

What causes depression? 19 Some types of depression have specific triggers; for example changes in hormones after giving birth (post natal depression), and SAD is linked with lack of light in winter which affects brain chemicals. Genetics can make people more predisposed through the make-up of the neurotransmitter system which regulates our brain chemicals that make us feel good or low in our mood. 20 Social and psychological stressors are often found to be key triggers for depression, and these can include significant life events such as divorce or bereavement, losing your job or finding out that you have a chronic illness or condition.

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Symptoms of anxiety disorders 22 Constant worrying, feeling tired, difficulties concentrating, being irritable, problems sleeping, heart palpitations, sweating, tension and pains, heavy and rapid breathing, dizziness, fainting, indigestion, diarrhoea, stomach aches and sickness, dread.

Types of anxiety disorder 23 There are several different types of anxiety-related disorder. Most of them are dealt with in detail later in this Chapter. @ @ @

@ @

@

Generalised anxiety disorder (GAD) Obsessive-compulsive disorder (OCD) Panic disorder: abrupt episodes of intense fear or discomfort often experienced in the form of ‘panic attacks’ which include sudden physiological symptoms and can often lead to people developing a fear that they are dying during these attacks. Post-traumatic stress disorder (PTSD) Social anxiety disorder (social phobia) Separation anxiety disorder: this refers to anxiety when away from home or parents, at a level greater than is normal for a child’s age. Phobias: excessive fear of an object or situation, the most common being fear of specific animals.

What causes anxiety? 24 Anxiety disorders running through families may be due to our genetic make-up which determines our physiological and psychological responses to stress. Some drugs and substances can also lead to symptoms of anxiety, including caffeine, alcohol, nicotine, cocaine, amphetamines and cold remedies.

Eating disorders 25 Eating disorders involve serious disturbances in eating behaviour such as an extreme reduction in eating, or severe

overeating, as well as distress or extreme concern about body shape or weight. Although eating disorders are typically thought of as a female issue, there are growing numbers of men being recognised as having one of these eating-related conditions.

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There is help out there — effective and successful treatments are available for the majority of mental health conditions — more than 80% of people can be treated successfully with medication and social support for clinical depression.

@

Giving yourself the best chance of recovery — research into the long term effects and potential for recovery from mental illness has indicated that the earlier help is sought and treatment started, the better your chances in overall recovery.

@

The network: help and reassurance for your family and significant others — the experience of symptoms related to mental health can be very distressing, but for many people they are not alone in their fear and emotional turmoil about the illness as family, partners and close friends often go through this with them. The early stages of mental illness are a confusing time — you may be acting differently, not as sociable or talkative, or may even be experiencing psychotic symptoms. For family members such changes can be difficult to explain (they may even feel guilty or that it is their fault in some way) and come to terms with. Through seeking help and information about what you are experiencing, families too can be informed, and in situations where they may be taking on extra caring responsibilities, they may be entitled to help and assistance for their own needs.

@

Minimising the risk to yourself — coming to terms with the fact that you are experiencing difficulties with your mental health, and dealing with the symptoms these often involve is not easy. The way that someone deals and reacts to such a situation Is very personal; aggression is one reaction that a number a men experience during these times. An aggressive

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Types of eating disorders @

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Anorexia Nervosa — people with anorexia nervosa see themselves as overweight even if they are dangerously thin.

Strange habits might be noticeable and other methods for weight loss may be used such as laxatives or excessive exercise. @

Bulimia Nervosa — men and women

who live with bulimia

often eat large quantities of food (binge) and then take laxatives or induce vomit (purge). Purging techniques can differ between men and women: excessive exercise is more common in men and laxative use more common for women. @

Binge eating disorder — men and women with this disorder binge in the way that people with bulimia do, but they won't purge or use other methods to get the food out of their bodies so they are often overweight.

Causes of eating disorders 26 Eating disorders are likely to result from a combination of factors which have made someone feel out of control or unable to cope. Factors such as relationship difficulties, problems at work/college/university, low self-esteem, bereavement or trauma, or physical, sexual or emotional abuse are commonly reported. As these kinds of issues can be experienced by anybody, men as well as women are at risk of developing an eating disorder as a way of coping. It is not uncommon for men who are experiencing questions about their identity and sexuality to develop eating disorders as a way of coping with this internal crisis.

GETTING HELP FOR MENTAL HEALTH PROBLEMS 1 No one is expected to be able overcome mental health problems without support. Asking for help is not a sign of weakness. On the contrary, it takes courage to confront a problem and look for a way to get better.

reaction does however have a number of risks; there is a risk

to the individual from the aggression (harm to self, consequences of causing damage such as criminal damage) and the effects of the aggression on others (physical harm and damage to personal effects/property for example).

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Seeking help — taking the first step 2 To actually tell someone else, whether this be your partner, a family member or even your doctor that you are feeling unwell or ‘not yourself’ is a big first step that many men struggle with. Whether this is due to feeling generally uncomfortable talking about your emotions, or feeling worried about what the symptoms you are experiencing mean; acknowledging that you need some help does not make you any less of a man. Going to the doctor if you are experiencing mental health difficulties is no different to seeing the physio for old sports injuries or the GP if you have put your back out — mental health problems are valid and real conditions and are no different from physical problems. There are a number of reasons why it is important that if you think you are experiencing mental health problems that you try to access help as soon as possible.

3 In severe cases and stages of mental illness people may selfharm or even be thinking about taking their own life. Young men are four times more likely than women with mental illness to commit suicide — so seeking help in less severe stages of illness may ultimately save your life.

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You can talk to your GP and what you discuss will be kept confidential — it may also be helpful to check at your doctor’s surgery whether there is a doctor that has experience with mental health problems (the receptionist or secretary should

be able to tell you this). @

itis helpful to GPs for you to tell them as much as you can about how you are feeling and the impact this is having on your life so they can understand your experiences and discuss the most effective methods of treatment and recovery with you. This can be quite difficult for some people to talk about, or there may be so much to say that you are worried about remembering it all. If this is worrying you why not spend some time before your initial appointment and make a list of what you want to cover in the appointment?

@

Many GP appointments are too short to cover what you might want to discuss in these types of situations, when booking your appointment you could ask to see whether it is possible to get a double slot so that you don’t feel rushed.

@

You don't have to say you are ill or know specifically what the problem is, you can just say ‘Il have been feeling and/or acting in a way l’m worried about’ and try to explain what has been happening. If you can give examples of what you have experienced this may help. For example saying ‘I’m feeling depressed’ may not give the full impact of your situation, instead try describing what you go through on a daily basis such as ‘Il don’t want to get out of bed anymore. When | do finally get up | find it difficult to motivate myself to even get dressed or eat something.’

GP, or they may present with symptoms or issues that relate to a mental illness they are unaware of — for example feeling very low in mood or have started to hear ‘things’. 6 From this it would be standard practice for a full medical history to be taken. This would include factors such as whether certain conditions have run in your family, what changes you have noticed and when, and also maybe looking at other areas of your life and how these may be impacting on your mental wellbeing. A period of observation is also likely to follow — your doctor is likely to want to organise a follow-up consultation in the near future, and may even ask you to complete something like a mood chart or to keep notes of how you are feeling and noticing whether you can identify any triggers for particular problems you are experiencing. It may also be helpful if you are willing for the doctor to hear from close family members or significant others about any changes that they may have noticed in you. 7 Following this observation period, a doctor may refer you for a psychiatric assessment, where you will meet with a psychiatrist who will assess your pattern of symptoms and whether these match up to different conditions. Diagnosis is not always a straight-forward process as many conditions will overlap in the types of symptoms they will demonstrate. Because of this it is not uncommon for it to take some time for a diagnosis to be reached, or even that a diagnosis may be changed over time as someone's

condition becomes better understood. 8 Upon getting a diagnosis, care and treatment plans will be constructed that take into account the problems related to a particular mental illness, and other personal factors. This process is not always easy, and it is not uncommon to have difficulties in either getting it recognised that you do have a mental illness, getting access to help and treatment or that you may feel you

@

Don't put it off. Sometimes people feel that their concerns aren't serious enough to ‘bother’ anyone, but it’s important to seek support as early as possible to increase chances of recovery.

have been given a misdiagnosis. In these cases there are a number of mental illness organisations that will be able to advise you on what to do next.

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Support services exist because nobody should have to cope with mental health problems on their own. No one expects you to struggle on without help.

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Getting help — what happens through the diagnosis process? 4 Mental health problems are not diagnosed in the same way that many physical illnesses are — at the moment there is not a ‘test’ for checking for mental illness, although there is hope in that in the future brain scans or other tests may be able to confirm a mental illness diagnosis. 5 So what happens? Many people that have started to experience symptoms of a mental health problems will be unsure of what the problem is and may find it hard to explain to their

1 The main treatments for mental illnesses are medications such as antipsychotics, antidepressants or mood stabilisers, and ‘talking therapies’ (psychological treatments). For each of these types of treatment there are a number of different types or options, and what you are given will depend on your own individual factors and assessed needs. 2 Treatments are important in the management of mental health problems as they are used to help alleviate the symptoms of the illness during crisis, but may also be crucial towards a successful recovery through identifying potential triggers in order to action plan to avoid relapsing (where possible) and changing damaging coping strategies or behaviour patterns which may be contributing to the overall problem.

Medication and drug treatments Antipsychotics 3 The natural chemicals in the brain (neurotransmitters) called serotonin and dopamine carry ‘messages’ around the brain about thought, emotions, behaviour and perception. If these chemicals

are under or over-active, they can produce ‘psychotic’ symptoms

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such as hallucinations and delusions. There are many types of antipsychotics available, the older ones are called ‘typical’ antipsychotics and the more recently developed ones are called ‘atypical’. It may take a number of attempts (a process known as switching) for doctors or psychiatrists to find the most suitable (maximum benefits with minimal impact from side effects) medication for you. Antidepressants 4 Serotonin and noradrenalin are important chemical messengers involved in mood and thinking. They are less active in people who are depressed, and antidepressants are therefore used to boost these chemicals to improve mood. There are several kinds of antidepressants available: tricyclic antidepressants, selective serotonin re-uptake inhibitors (SSRIs) and mono-amine oxidase inhibitors (MAOIs). Mood Stabilisers 5 People with psychotic illness (like bipolar depression) often have to cope with extreme mood swings. There are several drugs used to stabilise mood: @

Lithium is used to treat mania, but your blood levels have to be monitored regularly as high levels can be toxic.

@

Semisodium valproate also treats mania and can make people hungrier, leading to weight gain.

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Carbamazepine is used for treating mood disorders and has to reach a certain level in the blood to work, which can take several months. 6 If you are on any of these types of medication treatments for a mental health problem, there are often consequences if you suddenly stop taking your medication — it is usually only in the cases of an extreme reaction or a drug-related problem that is of threat to your health that medication is stopped suddenly. Most of the medications described need to be reduced in their dosage, often over periods extending from weeks to months, in order to prevent a sudden return of symptoms (relapse) and to avoid withdrawal effects in certain drugs. This is also a process that you are recommended to advise your doctor of, and where possible to complete with the supervision of a doctor.

Talking therapies 7 Talking treatments are generally not taken up by as many men as women with a mental illness. This falls in line with general stereotypes of men not wanting, or being able, to talk about their feelings and emotional experiences. But using a ‘talking’ therapy goes far beyond simply having someone you can talk to — treatments like CBT and CAT are ways of identifying ways our thoughts, behaviours, reactions and habits are impacting on current or reoccurring problems, and developing strategies from these to change. Many people prefer to try a nondrug option for treatment, whilst others experience the benefits of a combination of treatments (medication and psychological therapy) that tackle many of the problems faced during periods of mental illness. Psychological therapies form the basis of new and developing self-management practices that people can use to start to take back, and maintain, control over their lives and mental health. 8 Cognitive behaviour therapy (CBT) aims to help people identify, and then change, patterns of thinking or behaviour that

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are causing them problems. CBT has been found to help depression, anxiety panic attacks, phobias, OCD and some eating disorders (primarily bulimia), and it is now been used as a treatment in the management of some long term health problems like chronic pain or fatigue. CBT programmes usually involve a number of sessions with a psychologist.

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Cognitive analytic therapy (CAT) involves working with a

therapist to identify past behaviour, and how this may have hindered past attempts to change. Looking at past experience is used in order to help people understand how they can move forward by understanding how the difficulties they have experienced may be made worse by habitual coping strategies. CAT has been used effectively in the treatment of depression, anxiety, personal and relationship problems, and, more recently, has shown some early signs of being of benefit to people with personality disorders.

10 Dialectical behaviour therapy (DBT) is therapy based on cognitive and behavioural therapy predominantly used for people with borderline and other personality disorders. This type of therapy was designed from the perspective that people who were brought up in certain types of environments during childhood, and potentially due to (currently unknown) biological and genetic factors, may react abnormally to emotional stimulation. DBT often involves attending therapy for a minimum of a year, and has been found to reduce self-harming behaviours and inpatient hospital stays. 11 Psychotherapy is a treatment based on a formal relationship between a therapist and a client in order to explore difficult emotions and experiences in order to help people become more independent and able to solve problems they come up against in a constructive way. 12 Family intervention helps families deal with a family member coping with drug, alcohol or gambling addictions, eating disorders or other self-harming behaviours. This has also been adapted to help families cope with schizophrenia. 13 Counselling is an opportunity for someone to talk about their problems with someone who is not there to tell them what to do, but to listen without being judgemental.

PHYSICAL HEALTH Mental illness and our physical health 1 Traditional medical health theories and therapies have focused on the mind and the body as existing as separate entities — but more recent research has shown the way that the mind has the ability to have a direct physiological effect on the body and vice versa. The way we think and feel can cause us to become more prone to illness and disease; people that are highly stressed often find that they have more colds and other minor illnesses;

this is because stress over long time periods reduces the ability of our immune system. 2 During episodes of severe mental illness, people may also struggle to look after themselves and their health in the same way that they would when well. This may include eating patterns and diet, not taking medication as prescribed (commonly through forgetting) and trouble with sleeping, amongst other things. So the way we are feeling emotionally can have a direct impact on our health. Our mental well-being also has the ability to influence the way we act and react to situations; you may hear this referred to as coping mechanisms or strategies.

Looking after our physical health during mental illness Diet 3 Many of us do not have a particularly healthy diet at the best of times. We often fail to have enough fruit and vegetables in our diets, and ‘food on the go’ often means that we are not getting

the vitamins and minerals our body needs. This situation is often made even worse during mental illness, as research suggests diets become characterised during crises by high fat content, low fibre and too much processed foods and soft drinks, alcohol and caffeine. In some extreme cases people will become unable to plan and organise healthy meals and so stop cooking and rely on snacks like crisps and chocolate, or because of delusions radically modify their diet to only eat certain foods.

4

Our diet is important as what we eat does have the potential

to affect our mental well-being — deficiencies in zinc and vitamin B6 amongst others have the ability to cause neurological symptoms like those experienced in mental illness and so may be contributing to symptoms. It is also the case that some people with certain types of conditions have a genetic predisposition to be lacking certain substances within the body that are needed for good mental and physical health; a high percentage of people with schizophrenia and ADHD (attention deficit hyperactivity disorder) show reduced levels of omega-3, a type of fatty acid, in their blood. Supplements are therefore sometimes useful for people experiencing mental illnesses. You can ask your GP about what supplements you may benefit from.

Sleeping 5 Experiencing changes to normal sleep pattern is a common feature of many mental illnesses. Many people experience poor

sleep, or may find that they are unable to sleep for as long as they used to. This may be as a result of symptoms like excessive energy or rumination of thoughts causing you anxiousness. But it may also be due to surrounding factors such as if some recreational drugs have been taken, or as a side effect of the prescribed medication for the mental illness. 6 Tips for improving sleep: @

Avoid caffeine based drinks in the evening, remember a

number of soft drinks contain caffeine. @

Ignore the clock; don’t go to bed until you feel sleepy — lying awake if you are not tired is only likely to make you feel anxious or stressed.

@

Avoid any day time naps; set your alarm and get up at the same time every day; doing this helps you body re-establish its internal clock. 7 For others, extreme tiredness and an increase in number of hours of sleep is the problem. During depressive type episodes many people will find that they are sleeping more, and are experiencing more tiredness symptoms during the day. There are a number of prescribed medications used for treating mental health problems that have a sedating effect. Try to make yourself aware of whether your medication is affecting you in this way, and also try to avoid alcohol when on these drugs as this will make the sedation effect even stronger. 8 If you are experiencing disturbances to your sleep this is something that you could raise with your doctor to see whether options are available for helping with this.

Activity and exercise 9 During times of crisis our mental health can change our motivation, energy levels and ability to plan, organise and make decisions. Because of this people often experience disruptions to their normal routines, and many report feeling unable to function normally. During such times, and especially for people with disorders that involve depressive episodes, activity and exercise can fall by the wayside. When we don’t get enough exercise this can lead to weight gain and long term health problems with blood pressure and cardiovascular diseases. 10 Exercise also has a number of positive benefits for our mental, as well as physical, health. The release of endorphins in the brain during physical activity can lift mood and so is particularly good for people suffering depression and low mood. Exercise is now generally accepted within the medical profession as an important

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people may go on to develop dependencies on the substances they are using, which in itself will become problematic; so-called ‘dual-diagnosis’. 14 Misusing substances can be potentially very damaging for people with mental illness or those with a predisposition to mental illness (such as those with a family history of mental health problems) as some substances can trigger psychotic episodes. Along with this, dependency on a substance like alcohol or drugs also brings another set of health concerns linked with the particular substance such as liver disease from longterm alcohol use.

part of good health, and it is possible to be ‘prescribed’ exercise on the NHS which can help towards the costs of getting fit. Ways of coping and its affect on our physical health 11 In situations where we are feeling stressed out and emotional (angry, upset, scared) or during periods of experiencing mental health problems, people often develop ‘coping strategies’ — ways that we tend to deal with things. Some people feel the need to tackle problems head-on; others may deny or be unable to recognise that there is even a problem. Through these pressures and times of difficulty, there are a number of common behaviour patterns that people use to deal with how they are feeling, all of which, in some way, will influence our overall health.

12 Being aware of how you react to things can put you in a strong position to make changes or to seek help for those habits or tendencies that are having a negative effect on your health, and putting you at a higher health risk than you need to be. It can be hard through difficult times or during mental illness to look at the way you are reacting in an objective and evaluative way. This type of evaluation is an important component of psychological behavioural therapies like CBT. Over the following paragraphs a range of common health behaviours that are used for coping will be discussed and the way that these impact on your physical and mental health highlighted, in order to help you begin to evaluate your own way of responding to difficulties and in times of stress or illness.

Substance misuse/dual diagnosis 13 Using alcohol or drugs is a way that some people try to manage and deal with the symptoms they are experiencing during mental illness. Whether it is to feel happier, calmer or

Smoking 15 Evidence exists that smoking is more common for people who have a mental illness than in the general population, for example it is estimated that up to 70% of people with schizophrenia smoke. Smokers regularly report that the habit works in a stressreducing manner, and thus alleviates some symptoms of mental illness. However, smoking has a number of very serious health outcomes which mean that every effort should be made to help people who want to, stop. Smoking is also a very expensive

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habit, and this can add to the financial difficulties that many people with severe mental illness face, who often cannot work and may be reliant upon welfare benefits.

Distraction 16 Many people may try and distract themselves in order to avoid dealing with the fact that they may have a problem. For men in particular, one way of doing this is often through work; working long hours, taking extra shifts, or even putting symptoms down to ‘work-stress’ are ways for people to not think about, or address, how they are feeling. Absorbing yourself into other

activities could mean that it takes longer to get round to seeking help, or even recognising that there is a problem. This may potentially also lead to further problems where further stresses may result from these distraction and avoidance coping strategies. Self-harm 17 There are a number of reasons why someone may be selfharming. Some of the more common reasons reported include: @

Affect (mood) regulation: in the way that people can deal with emotions or feelings. People may start to self-harm in order to try and prevent themselves becoming overwhelmed by powerful, unsettling and turbulent emotions.

@

Communication: when people feel that they are unable to express their feelings in words. People who self-harm for this reason have often tried other more acceptable means of communication, but have been ignored or received an inappropriate response — this is not attention seeking.

@

Control or punishment: self-harm may be used for people who are dealing with their feelings towards abuse they have experienced, and the emotions that this causes them. Sometimes people report self-harm as a way of preventing

future acts of abuse (‘magical thinking’) or as a way of dealing with guilt surrounding the abuse which some people describe experiencing.

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Mental illness medications and our

physical health 18 For many people with mental illness, physical health also becomes an important issue as a result of the health problems and side effects of psychiatric treatment on our bodies. Physical side effects can be immediate such as movement disorders and sedation, but it is increasingly coming to light that there are a number a long term health conditions that may be associated with taking some medications for mental illness. Side effects of medication on our body 19 Some of the more common side effects of antipsychotics are: sedation, movement disorders such as shakiness, muscle spasms, excessive movement of face, effects on heart function,

sexual problems such as impotence, and weight gain. 20 Different people will experience different side effects on antidepressants. When taking tricyclic medications, the most common side effects are: dry mouth, blurred vision, drowsiness, weight gain or loss, skin rash, constipation. Side effects associated with SSRIs include: headache, nausea, diarrhoea, abdominal pain, inability to have an erection, inability to reach orgasm (men and women), loss of libido. 21 Side effects can be extreme and distressing, but in many cases may only be noticed more ‘in the background,’ where they can be frustrating or annoying but not disabling. Many people feel that the side effects from medications are far outweighed by the relief they experience from the alleviation of symptoms of the mental illness being treated by the drugs. But, if you are on medication and are unhappy with the side effects from medication you are experiencing, this is something you should raise with your doctor or psychiatrist. Related long-term conditions 22 There are a number of chronic (long-term) health conditions which appear to be more common for people taking certain types of medications, than for people not on these drugs. This does not necessarily mean that these drugs cause another illness, it may be that they trigger its onset in people who are already predisposed to it, or that the medication is linked to an ‘unknown factor’ and it is this unknown that is related to triggering another illness. However you can do your best to be informed about what effects the drugs you are being recommended or given, could have on your long term health. 23 The main long term health condition related to people taking medication for mental illness is diabetes. This is gaining increasing interest within the field, and more research into why this link exists is needed. There is thought that the diabetes could be triggered through the weight gain that many people experience on some of the more modern antipsychotic treatments over long time periods, or that the treatments in some way are triggering its onset in some people — not everyone on these treatments will develop diabetes. You can discuss what the likely long term effects of your medication are with your doctor, or the internet and local libraries can be useful for doing some of your own research. There is also a medication helpline run by the respected Maudsley Hospital in London which can provide detailed drug specific information.

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Mental health and

diversity Introduction 1 The UK, indeed all of Europe, can be though of as a linked network of high powered computers, running at full speed and playing a key role in economic, social, political and cultural growth. Each computer in this network is unique, it may have a different memory capacity, a different RAM, a different processor speed and be made of microchips from different parts of the world. Each of these components,

however, is central to the

smooth running of the computer and the overall network. In the very same way, each human being in the UK and Europe can be thought of as like a computer. An individual’s ethnic identity can be thought of as their ‘configuration’. Mental conditions affect humans in the same way that viruses affect computers. Certain computers are more prone to viruses because of their configuration, and can protect themselves by using anti-virus programmes. Likewise, certain ethnic groups are more affected by certain ‘viruses’ or mental health conditions. 2 This section on mental health will briefly outline the origins and migration histories of the Black and Minority Ethnic (BME) groups resident in the UK, namely the South Asian and the Caribbean groups. Also, we will try to answer queries as to the key issues around diversity in mental health, and how to get more information or advice on BME male mental health issues

How many people belong to black and minority groups? The UK today is perhaps the most multi-cultural country in the world

3 The United Kingdom today is perhaps the most multi-cultural country in the world, where individuals originating from over 300 countries in the world live and work together in harmony. You

may want to know exactly how many of our neighbours are from BME populations. So here are some amazing facts:

@

The population of the UK in mid 2004 was 59.8 million people.

@

The population of BME individuals was, in total, 4.6 million, or 7.9% of the total population of the UK.

@

The largest BME group in England is the South Asian group, made up mainly of individuals from India, Pakistan and Bangladesh with a total of 2.3 million individuals.

@

The second largest BME group in the UK is the combined Black British and Black Caribbean ethnic group, made up of individuals from Africa and the Caribbean, with a total of 1.1 million individuals.

@

There are also close to 700,000 individuals of mixed ethnic

origin living in the UK. @

45% of the non-white population in the UK are resident in London.

(Office for National Statistics, 2004)

What are the main issues in these groups around anxiety and depression? 4 There is a rich and varied history charting the migration of the main BME groups into the UK. Both South Asian and African-Caribbean groups have been settling in the UK now for close to four hundred years. Their reasons for settling here are at times very similar, and at times varied. The following summaries may give you more information. 5 The relationship between countries in the South Asian peninsula, India, Pakistan and Bangladesh and the UK was primarily based many hundreds of years ago on trade. You may have heard of the East India Company, which built on the initial forays of discoverers and merchants in the 1600s, who discovered the oriental luxuries, spices, cloth and dyes which could be imported to the UK from India though shipping routes. 6 Later on in the Eighteenth Century the British Empire, through the East India Trading Company, sought to expand into India, and eventually brought the country under its colonial rule. This lead a massive expansion in population shifts between the two countries, increased trade and a flourishing of the arts. Queen Victoria was made the Empress of India from 1858. From then India remained under British rule until its independence under Nehru in 1947. This followed a struggle, as you may be aware, under the great Mahatma Gandhi. 7 Although many Indian domestics, servants and ayahs (nannies) travelled to the UK from the 17th Century, and an increasing number of Indians — largely professionals — came to Britain in the mid 1800s, mass migration to the UK from India and surrounding countries did not really commence until after the 1950s. Both the 1948 British Nationality Act and the Commonwealth Immigration Act of 1962 were key historical turning points, as before this most South Asian immigration had been quite small in number compared to Caribbean migration. 8 The 1948 Act allowed free right of entry to British Subjects and Commonwealth Citizens, and the 1962 Act allowed many more, some would say less skilled, individuals into the UK in order to fulfil labour shortages in the post war period. Thus South Asians, as long as they had a resident sponsor in the UK, were

allowed to migrate to the UK. Many chose to work in the Northern textile industries based around areas such as Bradford and Manchester, where they settled and remain to this day. 9 The migration of individuals from the Caribbean has an extended history that stretches back into the beginnings of European colonisation, and once again the British Empire had a large part to play in the influx of peoples towards its motherland. The arrival of Caribbeans in England was largely down to the colonial connections fostered between Britain and the West Indies at the beginning of the 17th century, and since then the inward flow of African-Caribbean people towards the UK has contributed to the vastly diverse and cosmopolitan matrix of contemporary British culture. 10 Initially the first African-Caribbeans arrived in England as slaves between the 17th and 19th centuries. They were brought over by the colonising powers to work in the domestic services of Britain. After the end of slavery during the 19th century, Caribbeans began to arrive as seamen and students, at this time many worked as entertainers, playing on an ideology that would have perceived them as exotic and exciting. Immigration during this time remained relatively stable, and comprised not more than a ‘trickle’. The beginning to the middle of the 20th Century witnessed a massive increase in the rates of movement from the Caribbean to England that can be framed around England’s involvement in the First and Second World wars. Thousands of Caribbeans came to bolster England’s war industries and navy during the First World War. The final phase of Caribbean arrival in England took place after the World War 2, when many war veterans returned having been recruited by the government to supplement Britain’s depleted labour market, as was the case with migrants originating from India and Pakistan. 11 Things have not always been easy, however, for these immigrant groups. It was immediately following the periods of rapid immigration that social and racial tensions flared between the immigrants and their hosts in the UK. Many of the mental health conditions from which BME groups suffer occur in part as the result of poverty, overt racism and discrimination leading to what some may term ‘social exclusion’. What is also clear, however, is that what constitutes or at least is perceived as a mental condition can also vary amongst ethnic groups, and we should be aware that ethnic groups can suffer from mental health issues that our ‘operating system’, i.e., Western psychiatry, cannot readily comprehend.

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12 There may be different symptoms, indeed different conditions which may be prevalent in BME groups, which can exist alongside ‘Western’ disorders. There is diversity not only in how different groups experience mental well-being but also in their ‘operating system’, or how they understand the concept of mental well-being.

Are the BME groups more anxious? 13 When we look at the main anxiety disorders: @ Social anxiety. Agoraphobia. Obsessive Compulsive Disorder (OCD). Post Traumatic Stress Disorder (PTSD). Panic disorder. @ Generalised Anxiety Disorder (GAD). 14 Generally, these are experienced by around 12-15% of the population at any point in time, with a cost to the UK economy of around £6 billion a year. 15 Some of the major symptoms related to depression that can be applied to men in general, but have been highlighted in African and Caribbean men, include:

Changes in appetite and weight. Disturbed sleep pattern. Motor agitation. Fatigue and loss of energy. Depressed or irritable mood. Loss of interest and pleasure derived from usual activities. Feelings of worthlessness and excessive guilt. @ Suicidal thinking. 16 As mentioned earlier, we would expect that ‘social exclusion’ would affect South Asian and African Caribbean groups equally as they both came to the UK at around the same time, and will

have suffered similar types of stresses such as racism and poverty. You would also expect that this would lead to them suffering from similar rates of anxiety and depression, also known as the Common Mental Disorders (CMDs). But we cannot say either way whether this is true or not. 17 For example, some research informs us that Pakistani individuals show similar rates of depression to White British people in the UK, whilst rates among Indian and Bangladeshi groups are lower than both of these groups. The Bangladeshi population are said to show especially low rates of depression, amongst both men and women. The same studies suggest that Pakistani women have lower rates of depression than their White counterparts, while Pakistani men were more likely than White informants to be depressed. 18 Contrary to all of this, others suggest that there are significantly higher rates of CMDs amongst Asian residents compared with those of White or Black ethnicity, who share a broadly similar rate. Why the prevalence of these disorders is higher among Asian residents (nearly twice that found in the other two groups) in both community (37%) and primary care settings (30%) could be down to many factors. Some disagree whether these findings are at all correct, and point to similar

rates (41%) of CMDs among Punjabi patients attending General Practices in South London and among English controls (39%). A very similar prevalence was reported from a study of Pakistani primary care attendees in Manchester.

19 This is just a taste of the thousands of studies which suggest different things, but leads us to conclude that there is inconclusive proof as to whether BME groups suffer from higher

rates of anxiety and depression than the White British population.

Diversity is about a lot more than different rates of mental illnesses 20 That is true, real diversity can also present itself in the way that different ethnic groups approach their first point of contact, the GP, with symptoms of mental distress. There has always been huge debate whether rates of mental illnesses are really lower in South Asian groups or whether they are underreported, or hidden 21 For example, lower rates of both CMDs and mental disorders such as schizophrenia may exist in South Asian, and to an extent African Caribbean, groups because of the existence of robust social and religious support networks in these communities which protect individuals from life stresses and provide practical help. This can take the form of family support, and even housing and financial assistance in times of distress or need. 22 A popular hypothesis exists that suggests that in their very nature, migrant groups to this country underwent a number of stresses and strains to reach their host country, and thus may be ‘protected’ from mental illnesses as they are psychologically more robust. On the other hand, the Migration theory of Psychotic Personality has emerged, which explains the existence of a specific style of individual who migrates, and is more likely to suffer from migration ‘stress’ leading to increased levels of alcoholism and mental illness, especially schizophrenia, when they arrive in the new country. 23 Perhaps more likely, however, is that underreporting characterizes the way that Asians present with mental distress to the health services. For example, there are a number of cultural barriers that many believe prevent Asian individuals from telling their GPs about any mental distress they may be having. 24 An important behaviour shown by this group, and related to notions of the Indian Ayurvedic concept of a mind-body dualism, is called somatization. This can best be described as where underlying psychological symptoms are subsumed under the guise of physical complaints, when patients see their GP. Such is the prevalence of this behaviour amongst South Asian men and women that the Bradford Somatic Inventory has been created, to measure its prevalence. 25 Another possible explanation for the low level of engagement by BME groups with mental health services is that mental illness is highly stigmatized in the groups, perhaps more so than in other populations. There are many stereotypes that exist regarding the ‘pagals’ or mentally ill in the South Asian community. This stigma is said to affect Asian communities, to the point that few families shall admit to having a mentally ill member. Much of the psychosis and depression is therefore hidden, as there is no open discussion, no access to patients for researchers and the services. The label of mental illness cannot be removed, once it has been applied.

Implicit Association Tests (IATs)

What about Black British and Black

Caribbean groups? 26 All of the factors mentioned apply to all BME groups in the UK, especially mental illness stigma and social exclusion. Indeed, much research and thought in mental health has recently turned towards overwhelming findings that have emerged around young African-Caribbean men and rates of schizophrenia. 27 Schizophrenia is an illness in which the chemistry of the brain may be altered, and this affects thinking, emotions and mood. This brings about changes in behaviour as a result. One of the most unfortunate issues around schizophrenia is that it affects people, men, usually in the prime of their lives around the ages of 15 to 45. 28 Several environmental factors may be related to the onset of schizophrenia, the prevalence of which is generally believed to be anything up to 6 to 10 more times more likely in young men of Caribbean origin. Some of these factors are social, others more related to the system of psychiatry itself. The factors include:

@

Migration stressors. Stress imposed by life events or family circumstances. Poverty. Unemployment. Foetal malnutrition or stress.

Alcohol and drug abuse or ‘dual diagnosis’. 29 There is a much higher prevalence of substance misuse amongst African and Caribbean men compared to the general population. @®

@

52% of African and Caribbean men with a history of alcohol abuse also have a mental disorder.

59% of African and Caribbean men with a history of substance misuse also have a mental disorder. 30 Worryingly, African and Caribbean men with severe mental illness commonly exhibit the following complications secondary to substance or alcohol misuse: @ Exacerbation of psychiatric symptoms. Much higher rates of sectioning and hospitalisation. Non-compliance to treatment. Disruptive and often violent social behaviour. Arrest and incarceration. Unemployment. Unsuccessful treatment strategies. Homelessness. @ Loss of custody of children and relationship breakdown. 31 Another interesting fact that has recently emerged which is highly relevant to young men, regards the smoking or taking of cannabis. Scientists have begun to support the idea that smoking or ingesting cannabis may lead to individuals suffering from ‘cannabis psychosis’. Scientists currently think that although taking cannabis may not lead directly to clinical psychotic disorders, the likelihood of developing schizophrenia and psychosis is much higher in at-risk individuals who smoke or take cannabis.

lIATs are specially designed to be very accessible to anybody and help to clarify the various implicit associations people bring to a range of social situations. They are like computer games, are interactive and user friendly. The academic information available via the sites comes as an optional extra. Please try l|ATs yourself, by simply going to the link below for Harvard University’s range of IATs or by doing a search via the internet, that will bring up a broad range of alternatives. It is well known that people don’t always ‘speak their minds’, and it is suspected that people don’t always ‘know their minds’. Understanding such divergences is important to scientific psychology. This website presents a method that demonstrates the conscious-unconscious divergences much more convincingly than has been possible with previous methods. This new method is called the implicit Association Test, or IAT for short. Website: www.implicit.harvard.edu/implicit/

Do we need to change our thinking? 32 We all need to change our thinking. This is the best advice that any of our organizations can give. Firstly, mental illnesses are highly stigmatized, and when this is combined with other social factors mentioned earlier, this can lead to real problems across all groups. We need to provide good, clear information about mental well-being to all groups, that’s why this manual contains this section of diversity. 33 It’s good to talk!! Men need to learn to talk to their friends, their GP, their partner... anyone about mental well-being. This can be really hard, we know, in BME groups because of stigma, so please get in touch with any of the organizations, Destigmatize, SIRI Counselling, etc, mentioned in this manual.

We are here for you, to help you. 34 The mental health services need to change too, because they may have preconceived ideas, and be prone to misdiagnosing BME men, especially Caribbean Men. If psychiatry is based on a patient’s history, their personality, and their current mental state, then a lot of power is in the hands of the psychiatrist and nurses. He or she may unconsciously stereotype a black man as schizophrenic and violent before anything else. There is mutual distrust and hostility between African and Caribbean men in the UK. Psychiatrists may be offering BME men strong anti-psychotic drugs rather than psychotherapy. We need to work together and stop this.

The Robert Carter website This is a very serious and helpful website in regards to racecultural psychology. This African-American website contains a wealth of information. In simple and accessible language, it covers the work of three academic generations producing tools for both black and white people to find a way forward. As well as practice and training, it includes references to research and theory. Website: www.roberttcarterassociates.com

Agoraphobia stigmatize

Contributed by the National Phobics Society 1 Agoraphobia is one of the most debilitating phobic conditions around and aspects of it are often apparent in other anxiety disorders. The aim of this Section is to summarise the main forms of help available for this condition, as well as describing agoraphobia in detail for those who may not be familiar with it and all that it entails.

What is agoraphobia?

National Phobics Society The anxiety disorders cherity

2 The term ‘agoraphobia’ was originally introduced many years ago where It literally meant ‘fear of the market place’. However, these days ‘agoraphobia’ has a much wider meaning and is now taken to include fears not only of open spaces but also of other things such as crowded places, being alone, and anywhere a sufferer might be afraid of having panicky feelings. Indeed, most agoraphobics we have known are very rarely afraid of open spaces and are more commonly afraid of having panicky feelings, wherever these fearful feelings may occur. Many people have felt such feelings at home, while driving, in Supermarkets, and even when sat in the hairdresser’s chair. In fact, the worst scenario for any agoraphobic is one in which they feel psychologically ‘trapped’ and unable to escape with immediate effect. Once again, as with many other anxiety disorders the issue of being out of control seems an important one in the manifestation of agoraphobic ‘avoidance’. Being unable to escape from a potentially panicky situation is the key issue — and fear of this results in avoidance of various situations and places. 3 Here are some examples of situations which can produce panicky and fearful feelings in agoraphobics: @ Travelling on a tube train — and knowing that escape is not possible until the next station. ® Sitting in the middle of a row at the theatre or cinema — escape would not be impossible here but it would create disturbance amongst the audience. @ Travelling as a passenger in a car. The feelings of being trapped results from being unable to stop the car when needed and having to rely on someone else. @

@

Eating out. Once the meal is ordered, the agoraphobic feels trapped knowing they cannot leave — as this would not be socially acceptable.

Having guests round to your home. Once the guests arrive you feel trapped because you may panic and you can’t ask them to leave. @ Travelling any distance from home or other place of safety. @ Standing in queues. @ Travelling over bridges. Once you have entered onto a bridge escape is not possible until the other end is reached. @ Being alone or the fear of experiencing panicky feelings alone. 4 The term agoraphobia therefore refers to an interrelated and often overlapping cluster of phobias. While most agoraphobics can tell you what it is they dread will happen to them if they are placed in their feared environment, some agoraphobics simply do not know what lies at the root of their fear.

Diagnostic guidelines 5 All the following criteria should be fulfilled in order to obtain a definite diagnosis: @

The psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms, such as delusions or obsessional thoughts.

@

The anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public places, travelling away from home, and travelling alone.

@

Avoidance of the phobic situation must be — or have been — a prominent feature.

Differential diagnosis 6 Some agoraphobics experience little anxiety because they are constantly able to avoid their phobic situations. The presence of other symptoms such as depression, depersonalisation, obsessional symptoms or social phobia does not invalidate the diagnosis — providing these symptoms do not dominate the clinical picture. However, if the patient was already significantly depressed when the phobic symptoms first appeared, ‘depressive episode’ may be a more appropriate diagnosis. This is more common in late-onset cases. 7 Many people who suffer with panic attacks go on to develop agoraphobia, which is a severely disabling condition. At its worst, agoraphobia can prevent individuals from leaving a room, rendering them effectively ‘room-bound’. At the other end of the spectrum those suffering with milder versions of agoraphobia may appear to be functioning fairly normally to the outsider when they are actually coping by avoiding potentially fearful situations. For example, they may be able to travel perfectly well within their hometown but cannot travel beyond this psychological boundary. The term ‘city bound executive’ was coined in the United States to describe agoraphobic men who won't take promotion because this would entail travelling beyond their safety zone. This in itself shows the old stories of agoraphobia being a condition that affects only housewives were very wrong. Indeed, while it is true that more women seek medical help for agoraphobia this does not mean that women are any more likely to get the condition than men. Studies in America have shown many male agoraphobics drink to cover up their problems and are therefore more likely to be found propping up the bar than at the doctor’s surgery!

If you suffer with agoraphobia, it is likely that it developed something like this 8 One day you were walking down the road when suddenly you experienced a terrible bout of fear which came on for no apparent reason. You experienced all the physical symptoms of anxiety —

the dry mouth, churning stomach, giddiness, thumping and racing heart, breathlessness, shakiness, etc. These feelings really alarmed you and you became convinced that something dreadful was going to happen to you. At this point many agoraphobics run to the nearest source of help — the doctor’s surgery, A&E department, friends or family, or ask someone to call an ambulance. Once you have been checked out by the medical profession and told that nothing is physically wrong with you, you then go on with your life. However, that nagging fear of ‘what if | get that horrible bout of fear again’ lingers on in the back of your mind. It is quite likely that within a few days/weeks you experience yet another attack of fear/panic. 9 Before long, these panic attacks get more and more frequent. You then start to worry about where you might be should these attacks come on and you naturally start to avoid any situations where immediate escape would be impossible — or where help might be unavailable. In effect, this means you avoid gong anywhere too far from your home where you know where all

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sources of medical help are; you avoid any situation where you might not be able to cope with yourself having ‘a panic’. Before long your life has changed dramatically and many things that you used to do without a problem are now off-limit. 10 Another feature of agoraphobia is dependence by the sufferer on a trusted partner, friend or family member. Usually this person is the one who helped at the time when the panic attacks first began although this is not always the case. These ‘support persons’ however are always considered to be ‘safe’ by the agoraphobic individual. While the agoraphobic feels that they are living life as if in a psychological prison, often the support person feels the same because their life has also had to change to accommodate agoraphobia. 11 It is important at this stage to point out the difference between agoraphobia and social phobia because the net result is the same — j.e., avoidance behaviour with both conditions.

Agoraphobics are afraid of how they will feel in a given fearprovoking situation — of how they will cope with the panicky feelings. Social phobics on the other hand are afraid of the scrutiny of other people who might notice their anxiety. 12 As already mentioned, it is not uncommon to find that agoraphobics take to alcohol in an attempt to control their fears — albeit in relatively small amounts because of the need to avoid being out of control. Sometimes other drugs are abused for similar reasons.

Other features of agoraphobia 13 As with other anxiety disorders, agoraphobia typically starts during the late teens or early twenties. The condition also tends to run in families. Depressive and obsessional symptoms and social phobia may also be present but do not dominate the clinical picture.

Prevalence 14 Marks (1987) carried out much work looking into the incidence of agoraphobia and found out that the condition is actually quite common. He estimated that up to 20% of the population suffers at any one time with some form of agoraphobic avoidance. He also concluded that the incidence of full-blown agoraphobia is between 1.2 and 3.8 per cent with a similar prevalence occurring in Asian and African cultures. This latter observation obviously opposes the view that agoraphobia is a reflection of the stress of modern, urban life.

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(depending on the severity of the agoraphobia). Treatment is as individualised as the condition itself and much of the work, as with any therapy, is done by you. 17 If you have already started to avoid places the most appropriate from of therapy is something called ‘gradual exposure therapy,’ or ‘systematic desensitisation’. This process involves gradually re-entering phobic situations and learning to cope with anxiety and panic as it occurs. It can be beneficial to practise this with a trained behavioural therapist although it is possible to do so on your own. ‘The Anxiety & Phobia Workbook’ by Edmund J Bourne, provides excellent instructions for desensitisation. You can see a behavioural therapist on the NHS via your GP or you can, of course, go privately. 18 For many people, behavioural therapy works quite effectively. However, there are others who cannot even contemplate reentering phobic situations because the level of panic they experience is much too much to deal with. If you are one of those people medication would be suitable here. There are some very good anti-depressants (SSRIs) around now which have anxiety-blocking components, which have been shown to be very useful in such circumstances. You would need to visit your GP to discuss this further. 19 In addition to the above treatments, because agoraphobia essentially develops as a ‘psychological consequence’ of panic attacks, cognitive therapy is also a very effective treatment. A cognitive therapist will actively focus on specific problems occurring in your present daily life. You will be taught how to examine and recognise ‘negative thought patterns’ and ‘negative automatic thoughts’. By identifying these thought distortions you can learn to modify them and so alter your mood. Complementary therapies 20 Some studies have shown that agoraphobia can sometimes be caused by a deficiency of fatty acid called ‘alpha linolenic acid’ more commonly known as ‘flaxseed oil’. A study in the Journal of Biological Psychiatry showed that agoraphobics significantly improved within 2/3 months after taking 2-6 teaspoons of flaxseed oil a day. 21 The Bach Flower Remedy Rock Rose and the Bach Rescue Remedy have been found by some to relieve feelings of terror and panic.

Homeopathy 22 The following remedies may be of use: @

Fear of crowds and public places: Argentum nitrate, Arnica, Aconite, Nux vomica and Pulsatilla.

@

For fear of busy streets: Aconite, Carcinosin or Causticum.

Treatment for agoraphobia 15 Whatever the severity of your agoraphobia one thing is certain — the longer you leave the symptoms to fester the harder it will be to treat. Therefore, it is best to seek help sooner rather than later. So how do you avoid avoidance? 16 The recommended treatment for agoraphobia is a combination of cognitive-behavioural therapy and medication

—(22)

Further reading Edmund J Bourne The Anxiety & Phobia Workbook (New Harbinger Publications, 2005) Claire Weekes Simple, effective treatment of agoraphobia (Angus & Robertson, 1984)

Epilepsy What is it? Kathy Bairstow,

Epilepsy Action Stella Pearson, NSE

1 Epilepsy is the tendency to have seizures that start in the brain. The brain controls all that we do, our consciousness, awareness, movement, and posture. It does this by continually sending messages via electrical impulses to the nerve cells. If these impulses are disrupted, they can misfire, causing unwanted messages to be sent. This confusion of signals causes an epileptic seizure. 2 1 in 20 people have a one-off seizure, but epilepsy is generally not diagnosed until they have had more than one. 3 Epilepsy is the most common serious neurological condition in the world. Current figures suggest 1 in every 131 people in the UK have epilepsy. This means that there are at least 456,000 people with epilepsy in the UK, and approximately 50 million worldwide.

What causes epilepsy?

You can catch it FALSE. Epilepsy is not contagious.

Epilepsy is very rare FALSE. 1 in 50 people will have epilepsy at some point in their life. Epilepsy is a mental illness FALSE. Epilepsy is a physical, neurological condition. It’s when you fall over and shake

TRUE BUT NOT ALWAYS. Not all seizures involve convulsions. You can swallow your tongue FALSE. You cannot swallow your tongue during a seizure, and no-one should try to put anything into your mouth. This could damage your teeth, or their fingers. Flashing lights will always trigger a seizure FALSE. Photosensitive epilepsy only affects 3-5% of people with epilepsy.

4 Anyone can develop epilepsy, at any age. The reasons for developing epilepsy are not straightforward, and sometimes there can be a combination of causes. Epilepsy can develop following a head injury, or because of another condition or illness, for example, a stroke, or an infection such as meningitis or encephalitis. Often, a cause cannot be found. However, we all have a certain level of resistance to seizures, called a seizure threshold. If you have a lower seizure threshold, you may be more likely to develop epilepsy. In most cases, epilepsy is not inherited.

Types of seizure 5 There are many types of epileptic seizure, but they tend to fall into two main categories: partial seizures, which affect part of the brain, and generalised seizures, which affect the whole brain. What happens to someone during a seizure depends on which part of the brain is affected. Some seizures affect consciousness, and some do not. What can happen during different types of seizure? 6 A seizure could be the twitching of a limb, or an odd rising feeling in the stomach. It could be fiddling with clothing or lip smacking. It could be adopting strange postures, or sudden jerking of the arms or head. Or a blank few seconds where you stare into space, and do not remember this happening afterwards. Or collapsing to the ground for a few seconds because your muscles have suddenly gone floppy. Or it can be a tonic clonic seizure where your muscles stiffen and jerk convulsively.

Tonic clonic seizures What happens 7 The person may cry out, become stiff, and if they are standing will fall to the floor. They may bite their tongue or cheek. Their muscles relax and tighten making the body jerk and shake (convulsions). Their breathing may become difficult; and

First aid Often when a person has an epileptic seizure there is no need to call an ambulance.

However you should always dial 999/112 for an ambulance, if:

@ It is the person’s first seizure (as far as you

know). The person has injured themselves badly.

They have trouble breathing after the seizure has stopped. One seizure immediately follows another with no recovery in between. The seizure lasts two minutes longer than is usual for them; or the seizure lasts more than five minutes (if you do not know how long their seizures usually last).

After someone had a seizure, put

them into the recovery position, and monitor their colour and breathing

their skin may turn pale or a blue-grey colour. They may also wet themselves as the muscles press on the bladder. 8 The length of a tonic clonic seizure can vary from person to person, but the average length is 2-4 minutes. How to help someone @

@ @ @

@ @

Stay calm. Time the seizure (see the five minute rule above). Put something soft (like a jacket, or cup your hands) under their head, to stop it hitting the ground. Move objects like furniture out of the way if possible. Only move the person if they are in danger; for example, at the top of stairs or in the road.

Make sure to the body

the egs are straig

Do not restrain them, allow the seizure to happen. Do not try to put anything in their mouth.

Afterwards @ Put them into the recovery position. Monitor their colour and breathing. @ Check their mouth to see that nothing is blocking the airway, like food or false teeth. @ @

Try to minimise embarrassment. If they have wet themselves deal with this as privately as possible. Stay with them, giving reassurance, until they have fully recovered.

Hold the casualty’s hand against the cheek, palm outwards, and raise the furthest leg, keeping the foot on the floor

Epilepsy in men 9 Epilepsy affects approximately 225,000 males in the UK. Research shows that many men are reluctant to visit their doctor, unless they are in great pain, or an illness has become too serious to ignore. However, if you have epilepsy, it is important to see your doctor if you are having any particular problems with your epilepsy or if you believe that you may be experiencing side effects from your anti-epileptic drugs (AEDs).

Treatment of epilepsy 10 An important part of managing epilepsy is the carefully planned use of drugs designed to control seizures. Taking the medicine prescribed by the doctor on a daily basis helps most people to get on with what they want to do — without epilepsy getting in the way too much. 11 There is a wide choice of effective AEDs available in the UK today. They act in several ways and usually come in tablet or capsule form. For four out of five people seizures can be controlled by taking the right dose of the right drug.

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Keeping the hand held against the cheek, pull the raised leg and roll the casualty

Which drug? 12 Once you've been diagnosed as having epilepsy the doctor will try to find the drug that controls your seizures, at a low dose and with few side effects. The doctor will introduce the drug she/he chooses gradually until the best control of your seizures is achieved. During this time you'll have regular check-ups and blood samples may be taken to check on the levels of the drug in your blood.

check that the hand below the cheek helps keep the airway open

13 Some trial and error may be involved before the right treatment is found. Once it is, you will need to consult your

doctor or hospital from time to time. Always seek advice from your doctor if any of the following occur: @

You suddenly start experiencing more seizures than usual.

@

You can’t take your medicine for any reason, eg, stomach upset.

@ Other aspects of your health change. 14 It is vital to take your medicine correctly, as prescribed by the doctor. AEDs work by establishing a constant balance of the drug in your system — missing doses or taking the drugs at irregular times may prevent them having a positive effect on your seizures. @

Inthe UK, if you have epilepsy and require medication, you do not have to pay prescription charges, however, you will need an exemption certificate. NHS Direct, your GP or pharmacist can advise you further.

Side effects 15 All medicines have potential side effects as well as benefits. Balancing the two can be a fine art. Some of us are lucky and don’t experience any side effects — especially with some of the newer drugs. Even if you do get them they may be fairly minor, occur at the start of treatment and settle down after a few weeks.

Coming to terms 16 When you are told you have epilepsy you may worry that it will affect your relationships. Being diagnosed with epilepsy can be a shock and can take a while to come to terms with — not just for you, but for your friends and family as well. 17 There are several common responses to being diagnosed with epilepsy.

@

You may worry about going out on your own in case you have a seizure.

@

Friends and family might become over protective of you.

Most anti-epileptic drugs accomodate an occasional alcoholic drink without any problems

@

Denial. You may find it hard to accept that you have epilepsy. Your friends and family may also find the diagnosis difficult to

accept. @

You may worry about stigma and how others will react to the condition.

Meeting others 18 Having epilepsy can sometimes restrict social activities, for example, losing a driving licence can make it more difficult for people to go out, particularly if you live in an area where transport is poor. Alcohol can be a problem for some people with epilepsy and there can be interactions between AEDs and alcohol. Having said that, many people with epilepsy can and do have an occasional alcoholic drink without any problems. 19 You may feel less confident going out in public in case you have a seizure. You may choose to avoid social situations because you feel uncomfortable talking about your epilepsy. Deciding when to tell others about a medical condition like epilepsy is a personal decision. You may be very open about your epilepsy, or you may prefer to wait until you know people better before talking about your epilepsy.

Sexuality 20 Male sexual development (puberty) is not usually affected by epilepsy. However, there is some evidence to suggest that some teenagers who have taken AEDs since they were young children may not be quite as tall as their friends of the same age who do not have epilepsy. Some teenagers, especially those who take more than one AED, may go through puberty later than other people of the same age. 21 Many men with epilepsy enjoy a healthy sex life and their epilepsy does not affect this in any way, but some men with epilepsy are anxious about having sexual relationships, as they worry that a seizure may occur during sexual intercourse. They fear that this may upset their partner or even ruin the

Lack of interest in sex is more common in men with epilepsy than in men in the general population

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relationship. In fact, a seizure is no more likely to occur at this time than at any other. Having said that, lack of interest in sex is more common in men with epilepsy than in men in the general population. This may be because a man’s testosterone levels are low, which can have the effect of lowering his sex drive and sexual interest. Research suggests that the levels of testosterone in males can be lowered by the effects of epileptic discharges on the part of the brain which is responsible for testosterone production or by the effect of AEDs. 22 Most men experience impotence at some time in their life. Common causes are stress, tiredness, illness, or alcohol. Impotence is not necessarily connected to epilepsy itself. Sometimes, low testosterone levels, caused by epileptic activity or some AEDs, may make it more difficult to get an erection. 23 If you are concerned about a lack of sexual interest or impotence, it would be a good idea to talk things over with your GP. If they feel that this could be connected to your epilepsy or AEDs, they may refer you to see an epilepsy specialist. 24 There is limited information about fertility in men with epilepsy. Some studies have suggested that men with epilepsy may have reduced fertility compared with men in the general population. This may be due to the effect of epileptic activity or anti-epileptic drugs (AEDs) on testosterone levels. Nevertheless, the majority of men with epilepsy have no problems with fertility and father healthy children.

Useful contacts (UK) Epilepsy Action Tel: 0113 210 8800 Fax: 0113 391 0300 Website: www.epilepsy.org.uk National Society for Epilepsy Chesham Lane Chalfont St Peter Buckinghamshire SLO ORJ Tel: 01494 601 300 Helpline: 01494 601 400 Website: www.epilepsynse.org.uk

Hard drive Introduction 1 We would all like to have great sex every time but let’s be realistic. Sex is not always perfect! It is not uncommon for erection problems to occur — for some it will be just on one occasion, but for others it could keep on happening again and again.

Victoria Lehmann, Sex

Therapist and Registered Nurse, Department of

Urology, Brighton and Sussex University Hospital Trust

2 Although all men are different, most would agree that having a healthy sex life and satisfying their partner plays an important role in a successful relationship. Men want their performance to be one they can be proud of and if this is affected by an erectile dysfunction, it can have a considerable personal impact. There are hardly words to describe the distress, shame, and anxiety that

some men and their partners feel when they are confronted with erection difficulties. 3 There is no need to panic or feel embarrassed because many erectile problems can be resolved. The following section is a guide to help you seek the support and advice you need to reboot a healthy sex life. 4 Firstly, it is important to know that you are not alone. Erectile dysfunction (ED), defined as the inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity, affects approximately 1 in 10 of all men.? As men get older, things do change and the prevalence of ED increases with age. When men reach 40 or over, as many as 50% of them will suffer

from ED.? 5 You can experience an erection problem for a variety of both physical and psychological reasons. It is very important that you consult your doctor if you are worried that your erections are not hard enough or don’t seem to last very long as there may be an underlying medical cause which you need to address — the quicker you get help the better. 6 A way to think about erections, and to help men to discuss the problem more openly with a GP, is to grade the erection to help explain what has happened to their sex life. For example a grade 1 erection may mean a penis that is larger but is too soft for sex whereas a grade 4 is fully hard and rigid and may define the type of erection that a man wants to get back. 7 Unfortunately most men still wait between 3-5 years before asking for help. If there is a delay with treatment, it is easy to get into a bad habit of avoiding sex, so you will go to bed worrying about your ED and wake up thinking about it. ED is a difficult subject to address and some men are worried about confidentiality or speaking to their doctor frankly about it. But ED can adversely affect your quality of life and you need to talk to your doctor and get the help you need. 8 It takes an enormous amount of courage to talk about such a personal issue, but men should not suffer in silence.

ED and mental health — cause or effect? 9 How we tune into sex depends on our state of physical and mental health and our partner’s response if involved in a relationship. Despite the common misperception, we know that erection problems are not all in the mind and they can be the

Medicines and alcohol can be a factor

board and so it makes sense that if our brain is not functioning clearly our sexual response will also be affected. It is known that stress, anxiety, depression, substance misuse and alcohol affect

how our brain responds to sexual stimulation. Our senses all become more sensitive when we are Sexually aroused. When we first meet a partner, we often notice how they look, or the sound of their voice makes us want to listen to them talking, or the way they smell or touch, turns us on. Depression and anxiety dampens down these senses, which means that they are not so acute. It is heightened awareness and sensitivity to the other person, that helps the brain to send signals down through our nerve pathways creating warmth and stirring in the loins, sending another message back to our brain saying ‘let’s take this a little further!’ Mood disturbance affects this very delicate circuit, it is as if the circuit becomes bruised or contaminated causing the signal to weaken. If your brain does not send a strong enough signal, very often the penis doesn’t respond. Without that evidence of a hard erection the brain as a sexual organ shuts down.

Impact of ED on mental health first sign of a physical disease such as heart disease and diabetes. In men with diabetes of any age, the prevalence of ED may be as high as 85%.3 10 Other causes can include: @ High blood pressure. Prostate conditions. Spinal cord injury. Multiple sclerosis. Side effects of some medications. Diseases that damage the nerve pathways or affect blood circulation. @ Smoking. @ Excessive alcohol. 11 It is the potential of an underlying medical condition which makes it is so important to see a doctor. You should remember that ED can be a result of a combination of both psychological and physical causes. Psychological causes can include relationship problems, depression, performance anxiety and fear of failure. 12 Imagine a man has a very stressful day at work; he comes home and opens a bottle of wine. His partner tries to give him a cuddle and kisses him and normally, this man would expect to feel aroused. This time he doesn’t feel sexy and his penis doesn’t ‘stir’. He looks down and realises that not only has he had a difficult day at work, but he is also unable to satisfy his partner sexually. He starts to become anxious, depressed and ashamed that he cannot perform. This loss of sexual activity often leads to real sadness and a type of grief similar to when someone close to you suddenly dies. It is important to take your feelings seriously and ask for help, living without touch or intimacy can be devastating to any individual and the couple. 13 The brain is an important component of our sexual circuit

14 Sometimes it is difficult to determine whether an individual is depressed as a result of their ED or their ED symptoms are a catalyst for their depression. In fact, anti-depressants used to manage depression are also recognised as a contributory factor to erectile problems and as such it can be difficult to determine which symptoms were first to manifest. There is, however, a recognised link between ED symptoms and depression which should be acknowledged and addressed. Studies have shown that 90% of men with severe depression will suffer from some

form of ED.* 15 There is no doubt that if a man suffers from ED it will affect his mood, self esteem and confidence. Many men feel ashamed

that they cannot perform and/or satisfy their partner. As well as becoming depressed they may be tremendously anxious, especially in social situations. For example, when a sexual problem occurs you can often find yourself not giving your partner the usual physical contact, and the relationship can become very uncomfortable as a result of the loss of intimacy. 16 It can be especially difficult for men hoping to start a new relationship. Men may become isolated and rarely go out socially as they don’t feel that they have the right to ‘chat up’ a prospective partner or participate in any relationship because they won't be able to engage in any intimacy. It is a very lonely feeling fearing that you may be alone forever. Also, there is the awful thought that if you took a chance and attempted any sexual activity, your partner would be dissatisfied which would be even more hurtful and damaging to your self esteem. 17 The problem is that when a man (or woman) starts a new relationship, we always seem to be on our best behaviour, showing the other person only our good side. It takes time to find a language to talk about sexual matters, even talking about contraception can be difficult, so you can imagine the challenges of discussing erection difficulties.

Relationships 18 ED will affect relationships and partners can respond in a variety of ways. It all really depends on what a person or couple believe is ‘normal’ for their relationship. If a woman is used to her partner waking up with an erection and having sex in the early morning before they rush off to work, and this stops happening, she will either be delighted that she can get up and spend more time getting ready or she may be concerned that her husband no longer finds her attractive and will become anxious that he is having sex elsewhere. We often find it difficult to confront partners when an intimacy issue occurs, so what we frequently do is argue about something completely different to try and get rid of our anger and disappointment. Nobody wants to hear that their partner no longer finds them attractive. Women are fortunate; they tend to talk to their friends when they feel sad and upset, but men traditionally find such communication challenging and you rarely hear of a man saying to his friends in the pub ‘by the way | couldn’t get an erection last night’. Yet many women will say to their girlfriends that there are having problems in the bedroom. This difference in communication affects our relationship and often delays us resolving problems. 19 We may not always have rational thoughts but they are real to us, and they affect the way we respond to one another. Many couples have routine and specific sexual roles within the relationship. For example the male partner may always initiate sex, and foreplay lasts for 10 minutes before intercourse occurs. When this ‘normal’ cycle alters because the erections are not hard enough for penetration, or when a partners concentration is affected by depression, couples often stop being intimate with one another. 20 It only needs to happen on a few occasions and then the woman thinks to herself. ‘I’m not going to bother anymore with giving him a kiss, after all | will be rejected’. He thinks to himself ‘I haven't the right to give my wife a kiss as | can’t get an erection’. With no touch or intimacy both start to feel lonely, anxious and depressed. We stop talking and we shut down our emotional needs.

Positive benefits of treatment 21 No-one wants to feel depressed and anxious — intimacy and sexual activity are very important for relationships. If you suffer from erection problems and you and your partner are trying to cope with the loss of intimacy and often minimal physical contact, you need to find a way to address your problems and get the help that you need to effectively manage your ED. 22 It is important that you understand why you have been experiencing erection problems. It may be due to high blood pressure, or you have been consuming too much alcohol or have been stressed at work. 23 A common misconception is that there is nothing that can be done about an erection problem. For example, a man may think that it is an inevitable part of the ageing process, but this is not the case. There is no reason that a man should accept ED, particularly if it is impairing his life in any way, as it is a condition that is medically treatable. There are many proven treatment options available for ED that your doctor can prescribe. Every man is different and their needs will vary, for example, for some men successful sex may be impacted by the hardness of their erection. It is therefore important that you not only work with your doctor in finding the right treatment but that you also persevere with the advice of your doctor, giving yourself the best

chance of success. Your treatment may not be effective immediately, but once you feel more comfortable with how to incorporate it within your love-making there is no reason why you cannot expect to enjoy a normal sex life. 24 It is very unlikely that your ED will improve on its own and the longer you ignore the problem the more likely it is that your quality of life and mental health will be affected and your relationship challenged. 25 Below is an overview of some of the treatment options available to you. The list is not exhaustive and your GP will be able to provide you with more details about those listed or alternative options which may be appropriate to your needs. 26 You must talk to your GP about the treatment that is right for you and they will conduct a thorough assessment to ensure that the treatment not only gives you the erection that you want, but it is safe for you to use. Discussion with your GP is essential in the management of your ED and treatments should never be purchased from other sources such as the internet without guidance from your GP. Although accessible on the internet and other routes, there is a high chance that the treatments may be counterfeit. It can be dangerous to take a medication which is not prescribed by a healthcare professional who has access to your medical history and can assess potential drug interactions and pre-existing conditions. Psychosexual therapy 27 One option for couples seeking help for an erectile problem is psychosexual therapy which frequently involves both partners and is non-invasive. Psychosexual therapy can range from sex education, partner communication and behavioural therapy and can help to resolve relationship problems that have developed because of the erection difficulties and the linked depression or illness. Consultations can provide a safe and supportive environment for a man to address any underlying concerns or issues such as guilt, anxiety or depression which may be impacting on his sexual relationships and can help couples address any barriers to intimacy which may exist. Such therapy can lead to a significant and sustained improvement in sexual functioning and satisfaction. It is very important that you ask your doctor for a referral to a counsellor who has training in sexual issues, or refer to Relate or The British

Association of Sex and Relationship Therapists to find your own therapist. Therapy is a longer-term treatment option; it is often used in conjunction with oral or other treatments, as men are usually anxious for a permanent and prompt fix to their problems. Vacuum pump 28 Pumps do work well, but you need to be shown how to use it properly. The pump draws blood into the penis and you place a constrictor ring at the base of the penis to keep the blood in. This must only stay on for a maximum of half an hour. So if you think you might fall asleep, tell your partner. Injection therapy 29 There are two treatment methods that are more invasive of the penis. The first involves putting a small needle into the shaft of your penis which will get an erection within 5-15 minutes. Another option is a pellet inserted into the male urethra. Men choosing either option need to be taught how to do this safely, and be told about all the risks. Oral treatment 30 Oral treatments offer a simple to use and non-invasive treatment option for men with ED. The introduction of

The oral tablets only work if your

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penis is being touched at the same time

Benefits of effective treatment

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phosphodiesterase type 5 (PDE5) inhibitors have been viewed as an important breakthrough in the effective and convenient

management of ED. Like most medications, PDE5s may have side effects for some men. They should be tried on several occasions for a period of at least 6 weeks to be fully effective, unless the side effects are intolerable. 31 The oral tablets work by increasing arterial blood flow helping to restore natural erectile function — but they only work if your penis is being touched at the same time. In other words you need genital stimulation. Now here’s the problem, some partners think that you shouldn’t need to touch your penis to get an erection they feel that something is wrong, so you will have to talk to them and explain. If you don’t tell them you are taking a drug to help your erection problems, they are likely to find you out, and then they will wonder what other secrets you may have. So this is a great time to start talking and listening to one another about your sexual needs. All treatments are effective, but they have different results and your choice will depend on personal preference, |.e., whether you want a hard and rigid erection. 32 Although not a PDE5, apomorphine (also taken orally) works on receptors in the brain which enhance the natural erectile signals that are sent out during sexual stimulation.

33 When your erections are back to how you want them to be, your mood will improve and your confidence will return as you hold your head up high. It puts back the intimacy and sex component — vital for so many to enjoy a successful relationship. 34 It is not just about getting your erection back, but for many men it is about getting the right erection, ensuring that it is back to a grade 4 or their personal best. Men may associate their enjoyment and that of their partner with the firmness or hardness of the erection. Men want to be the best that they can be in the bedroom to re-establish their confidence, satisfaction and self-esteem and to feel that they are giving a performance to be proud of.

Conclusion 35 The penis is a good barometer of your general health and your relationship and it is so important to deal with your ED. Although it is a hard topic to address with your partner or GP, if you talk about how you feel, you are one step further to resolving the sexual problem. The benefits of effective treatment, a performance to be proud of and the ability to satisfy your partner once again, will be worth the momentary embarrassment... So why suffer in silence?

Further information 36 There are a number of resources available if you would like to learn more about ED and how it can be effectively managed. A confidential website which offers support and advice concerned about ED and guidance to help address the It includes an interactive online role play with a GP to build your confidence and practice the conversation so talk to your GP about your ED. Website: www.erectionadvice.co.uk

to men problems. help you you can

The Sexual Dysfunction Association (SDA) has a range of leaflets and a help line which will give you information on all the treatments available. Website: www.sda.uk.net The British Association of Sex and Relationship Therapists will be able to provide you with a list of counsellors who specialise in sexual problems. Website: www. basrt.org.uk

References

H45451

The penis is a good barometer of your general health

1 NIH Consensus Development Panel on Impotence. NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993;270:83-90 2 Feldman HA et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts male ageing study. J Uro/ 1994; 151: 54-61 3. Boulton AJM et al. Diabetologia 2001; 44:1296-1301 4 Kirby M. Management of Erectile Dysfunction in Men with Cardiovascular Conditions, Br J Cardiol 2003; 10:305-07 Supported by an educational grant from Pfizer

» — Generalised Anxiety Disorder (GAD) Py

stigmatize

National Phobics Society The anxiety disorders charity

Contributed by the National Phobics Society 1 A certain amount of anxiety and stress is inevitable these days in most people’s lives. When this anxiety is persistent and excessive, lasting for six months or longer, and accompanied by physical symptoms — it is classified as Generalised Anxiety Disorder or GAD, for short. 2 The type of anxiety experienced by GAD sufferers is different to that of panic attack sufferers. The latter experience sudden attacks of intense and disabling anxiety while GAD sufferers wake up anxious and worried and go to bed feeling the same way. In other words GAD is anxiety which is present most if not all of the time; sufferers frequently describe their anxiety as ‘feeling on edge for no apparent reason’ or as if the anxiety is ‘lurking in the background’. 3 GAD causes people to worry excessively and unrealistically about nearly everything all of the time. For example, it is not uncommon for a GAD sufferer who has just been promoted to worry that he might lose his job. Despite feeling terribly anxious all the time, the GAD sufferer just can’t seem to ‘shake off’ their feelings of anxiety. Naturally, 24 hours excessive worrying over a period of time takes both a physical and mental toll on the body. It is not uncommon for GAD sufferers to also develop headaches, heart palpitations, sleeping difficulties, drink/drug problems. Despite the fact that these symptoms and the GAD itself create havoc in a person’s life, GAD sufferers usually do not seek professional help until their problems become very severe and/or have developed into another anxiety disorder.

@

Irritability and becoming startled by things like unexpected noises.

Muscle tension. Headaches. Difficulty in falling or staying asleep. Your anxiety is affecting your ability to cope with work, household chores, and social situations. 5 In order to be diagnosed with GAD by a clinician they must be satisfied that the symptoms you are experiencing are not as a result of fearing having a panic attack — as this would constitute panic disorder. GAD can itself be quite hard to diagnose as it lacks the dramatic and obvious symptoms of other anxiety disorders such as panic attacks, but can also mimic other

conditions such as panic disorder, OCD (see next Section), etc. 6 Likewise the physical symptoms of GAD are typical of other anxiety disorders. GAD sufferers often suffer with additional problems relating to substance/alcohol misuse, depression and panic disorder.

How many people suffer with GAD?

How can | tell if | have GAD?

7 It is estimated that approximately 3% of the general population experience GAD at any one time. When GAD sufferers seek help they tell their GP that they have ‘been a worrier all their life’ or that their anxiety began after a particular stressful event in their lives. 8 Children may also develop GAD. When this occurs they will often over-conform and try to have perfect performances in everything they do.

4 The following are the most common may help you to self-diagnose.

What causes GAD and who suffers with it?

symptoms of GAD and

@

Worrying excessively about a number of situations or activities in your life.

@

Spending most days worrying about how you will cope with events such as job responsibilities, financial responsibilities, health and welfare of family members and yourself, etc. Experiencing difficulty in controlling your worries. Feeling restless and on edge.

Feeling fatigued. Difficulty concentrating/mind goes blank.

9 Researchers have not yet identified the cause of GAD. To date the best evidence suggests biological factors, family background and life experiences are important contributors to this disorder. It seems that some individuals are genetically predisposed to develop GAD. There is also some evidence to suggest that people who grew up around anxious role models have been socially conditioned to view the world as a dangerous and uncontrollable place and this aids their development of GAD. 10 GAD tends to appear in the late teens, but as mentioned earlier, it can also appear in childhood. The most common trigger

(1)—

for GAD in all cases it seems is stress. Most GAD sufferers when asked to look back to the months or years before the development of their GAD report an increase in stressful events such as bereavement, divorce, illness, loss of job, etc. While these events are all negative, GAD can also be triggered by stressful ‘positive’ events, such as having a baby, getting married, moving house or changing job.

ge o-

C

Treatment of GAD 11 It is best, if possible, to try non-drug treatments for GAD before trying medication. Often GAD responds to such things as aerobic exercise, relaxation, etc.

Aerobic exercise 12 Many researchers believe that vigorous, regular, aerobic exercise stimulates chemical changes in the body that reduce anxiety and increase a person's ability to tolerate stress and anxiety. Aerobic exercise doesn’t necessarily mean going to the gym and working out; a 30 minute brisk walk every day is just as helpful, as is swimming, Relaxation therapies 13 Relaxation therapy is a powerful tool in controlling anxiety. Massage, progressive muscle relaxation, meditation, yoga and biofeedback are just a few of the many different types of relaxation techniques which have been shown to be helpful in treating anxiety/stress and GAD.

SSSA

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H45874 Regular, aerobic exercise stimulates chemical changes in the body that increase a person’s ability to tolerate stress and anxiety

Counselling/psychotherapy — ‘insight orientated therapy’ 14 This form of therapy aims to help the individual uncover and resolve emotional conflicts that may be at the root of their problems. It can be obtained through a GP on the NHS. Complementary therapy 15 There are numerous complementary therapies around, too, which many people have found helpful such as hypnotherapy, reflexology, aromatherapy, acupuncture and homeopathy. Drug therapy 16 If you find that the non-drug therapies are not working, it may be that you need to consider taking medication for your GAD. SSRIs (Selective Serotonin Re-uptake Inhibitors), TCAs (Tricyclic Antidepressants) and SNRIs (Selective Serotonin Norepinephrine Re-uptake Inhibitors) have all been used in the treatment of GAD, however, few have a license at present specifically for treating GAD. 17 Tranquillisers are not suitable for treating GAD because of the nature of GAD and the course of the condition. 18 Beta blockers are often given for the somatic (physical) symptoms of anxiety, however, there is no strong evidence of their benefit.

Further reading 19 We would very much recommend you obtain a copy of any of Dr Claire Weekes’ books as they are easy to read, and extremely informative.

Dr Kenneth Hambly Overcoming tension (Sheldon P, 1983)

There are numerous complementary therapies around, too, such as hypnotherapy,

reflexology, aromatherapy, acupuncture and homeopathy

Obsessive Compulsive Disorder (OCD) What are Compulsions?

stigmatize National Phobics Society The anxiety disorders charity

Contributed by the National Phobics Society. NPS would like to thank Dr Roz Shafran, psychologist, for allowing reproduction of this article 1 OCD is the presence of recurrent obsessions or compulsions severe enough to cause marked distress or to interfere with an individual’s optimal functioning in areas of work, social activities and/or relationships. 2 People with this problem recognise that these obsessional thoughts come from their own mind and are unreasonable, senseless or excessive. However, they are unable to control their

own thoughts or behaviour. 3 It is important to remember that while the symptoms of OCD may seem ‘crazy’, OCD sufferers are NOT crazy. The huge majority of OCD sufferers are sensitive, rational and productive individuals in other aspects of their lives. It is the disorder, characterised by compulsions and obsessions, which causes difficulties. If the symptoms of OCD can be alleviated, the sufferer’s life becomes happier and more fulfilling.

What are Obsessions? 4 An obsession is a recurrent idea, impulse or image which is experienced — initially at least — as intrusive, unacceptable or frightening. Examples include a parent having repeated impulses to kili a loved one, or a religious person having recurrent thoughts against God. 5 Persistent, unwanted thoughts such as ‘did | check the door was locked?’ which are followed by thoughts of burglary or other disasters are also considered to be obsessions. Sometimes the person attempts to ignore or to suppress such thoughts or

impulses or neutralises them with other thoughts or actions. 6 The most common obsessions are repetitive thoughts of violence (killing one’s child), contamination (eg, repeatedly wondering whether one has performed acts such as locking the doors, washing their hands ‘properly’, having hurt someone accidentally by knocking them over or poisoning them). The person recognises that their obsessions come from within their own mind, and not imposed from without. This is a major difference between psychotic illness and Obsessive Compulsive Disorder.

7 Acompulsion is a purposeful behaviour performed in response to an obsession. The behaviour is designed to neutralise or prevent discomfort of some dreaded event or situation. However, either the activity is not connected in a realistic way with what it is designed to neutralise or prevent, or it is clearly excessive. Often the behaviour is carried out according to certain rules or in a stereotyped fashion (rituals). The behaviour is performed with a strong pressure to carry out the act, along with the desire to resist the compulsion (at least at the beginning). The person usually recognises the behaviour is excessive or unreasonable. The individual does not derive pleasure from carrying out the activity although it provides a release of tension and anxiety. 8 Sometimes the compulsion may be an activity that other people cannot see, and is purely a mental ritual. These cognitive rituals may involve conjuring up a corrective image, or thinking a phrase which somehow neutralises the unacceptable thought. Counting and repeating a particular sequence of numbers are also common forms of mental compulsion. The most common compulsions involve hand washing, checking, counting and touching. A person may have several different compulsions. When a person attempts to resist a compulsion, there is a sense of increasing tension that can be immediately relieved by yielding to the compulsion. The person may give into them and no longer wish to resist them.

Other disturbances often accompanying OCD 9 Depression and anxiety are common features associated with OCD. Often there is a phobic avoidance of situations that involve the content of the obsession, such as dirt contamination. For example, a person with obsessions about dirt may avoid shaking hands with strangers. Depression can make it more difficult to resist the compulsion. Panic, agoraphobia and eating difficulties are other possible associated features.

Who suffers? 10 OCD affects both men and women equally, with more women thought to be suffering from obsessions and compulsions related to cleaning. In fact, obsessions and compulsions are not uncommon in the general population. There are many people who never go to a hospital or clinic seeking help who have obsessions and/or compulsions. Research has shown that 80% of people have obsessions. These obsessions have the same form and content as the obsessions of people who seek help, but are less frequent and their distress as a result of them is less severe. 11 Similarly, a large proportion of people have obsessions such as checking the gas taps are closed or that the house is locked before leaving it. However, when these obsessions and compulsions cause the individual distress or seriously interfere with normal functioning then professional help and advice may be needed.

()—

What else is known about OCD? Age of onset 12 This varies but it is most common in early adulthood — 21.2 years is the average for women, 17.5 is the average for men. The disorder can begin in childhood. Course 13 If untreated, the course is usually long standing with some periods better than others. It has been shown that the disorder gets gradually and progressively worse over time. Impairment 14 The impact of OCD is often moderate to severe. In some cases the obsessions and compulsions can be the dominating factor in an individual’s life.

Complications 15 Complications include major depression and the abuse of alcohol and drugs to reduce anxiety. Most common personality traits of OCD sufferers Chronic worrying. Extreme feelings of guilt. High sense of responsibility. Perfectionism. Hypersensitivity. Lack of confidence. Distressed by changes. @

Vivid imagination.

Causes of OCD 16 No one knows the reason why the symptoms of OCD develop. It is probably a combination of the following explanations: Biological Theory 17 A biological vulnerability may predispose certain people to OCD. This underlying biological predisposition may be influenced by learning and psychological factors.

Genetic Theory 18 Genetics may influence the development of OCD. Anatomical Theory 19 Areas of the brain that may be involved in OCD are the frontal lobe and the basal ganglia. Chemical Theory 20 Brain chemicals may be linked to OCD. Some of the effective drugs may correct possible abnormalities.

significance. For example, they may consider themselves a ‘bad person’ for having the thought ‘l could stab my son’. The more this thought is suppressed, the more it resurfaces. Ironically, it is those individuals who are distressed by having such unacceptable thoughts, that may be most likely to develop OCD.

Treatment of OCD 24 At this time there is no absolute cure for OCD. However, several highly effective treatments do exist and new ones are continuously being researched. Research to date has shown that 70% of people with OCD improve with a combination of available treatment — some of which are listed below. Behaviour Therapy 25 This is a new form of therapy centred around learning how to change the way we behave. The therapy helps individuals learn how to control compulsions and deal with the accompanying anxiety. The common principal in most behaviour therapies is exposure to stimuli that evoke discomfort until one becomes used to them. This process is often referred to as ‘habituation’. A combination of exposure and response prevention (i.e., no compulsive rituals) has proved effective. The therapy uses a series of ‘exercises’ — decided by the therapist and sufferer together to reduce the compulsions one by one, and to control obsessions before they can dominate the mind. This therapy also teaches you how to deal with the anxiety that may appear when you resist the obsessions and compulsions. Some behavioural techniques are modelling, flooding and reinforcement. Cognitive techniques are often used in conjunction with behavioural treatments. Cognitive techniques include thought-stopping, thought diversion, distraction and cognitive restructuring in which the basis for the thoughts are critically examined. Behaviour and cognitive therapy can be combined with drug treatments. Drugs 26 Drugs have been found to be helpful in reducing the intensity of obsessions and compulsions. People report that drugs can also take the edge off depression and anxiety associated with obsessional problems. Some people experience unpleasant side effects from these medications, although many do not.

Psychotherapy 27 On the basis of self-report, it does not appear that traditional insight-orientated psychotherapy provides symptom relief for people with OCD. A supportive therapy may be helpful for some people although an analytical approach seems to increase subjective discomfort.

Learning Theory 21 This theory suggests that obsessions and compulsions are conditioned responses to anxiety. The symptoms are reinforced when a person learns that anxiety seems to be temporarily relieved by performing a compulsion. Learning theories concentrate on the symptoms rather than the underlying psychodynamic explanations.

28 The first step is to go to your General Practitioner. You GP is able to refer you to a local centre for treatment. It is not normally possible to refer yourself for treatment. There is often a long waiting list for treatment.

Psychodynamic Theory 22 Freud defined obsessions as psychological defence responses to unconscious impulses.

P de Silva and S Rachman Obsessive Compulsive Disorder

Cognitive Theory of Responsibility 23 One theory concerning the causation of OCD is that the sufferers give commonplace obsessional thoughts special

How to get help

Further reading (Oxford medical Press, 2004) Frank Tallis Understanding Obsessions and Compulsions — a self help guide (Sheldon Press, 1992) Jeffrey Schwarz Brain Lock (HarperCollins, 1997)

Post Traumatic Stress

Disorder (PTSD) =~ (|)

stiomatize

others and an inability to trust. The future may feel foreshortened and hold nothing while at some time they may feel anger at those held responsible for the traumatic experience, ashamed of their own helplessness, or guilty about what they thought or did, or failed to do. They may quite easily become demoralised and isolated because of their anger, guilt, shame, avoidance and

National Phobics Society The anxiety disorders charity

Contributed by the National Phobics Society 1 PTSD is an anxiety disorder which may develop following exposure to any one of a variety of traumatic events that involve actual or threatened death, or serious Injury. The event may be witnessed rather than directly experienced and even learning about it may be sufficient if the persons involved are family members or close friends. 2 Typical traumatic events which may trigger PTSD are: Serious physical assault.

Sexual assault. Kidnapping. Motor accidents — the most common trigger of PTSD. Torture. Child abuse. Fire, flood, earthquake, plane crash.

Battle experiences. A diagnosis of PTSD is made primarily on the basis of a ®@ 8 W@e888 cluster of symptoms appearing following exposure to identifiable traumatic events such as those above. The post traumatic reaction often begins immediately but may emerge only after days, weeks, months or even years.

Symptoms of PTSD 4

There are three main symptoms present in all cases of PTSD. 1 Hyper arousal — extreme edginess — the sufferer is easily startled and is always on guard. For example, the rape victim who watches for rapists everywhere. 2 Intrusive recollections — victims involuntarily re-experience the traumatic events in the form of memories, nightmares and flashbacks during which they may feel or even act as though the event were recurring. Often they recall these episodes poorly or not at all. They also suffer when they are exposed to anything that resembles, recalls or symbolises some aspect of the trauma. 3 Emotional numbing — a loss of normal emotional responses, a feeling of being unreal or detached from one’s feelings and the everyday business of life. 5 Although these three types of symptoms must be present for a positive diagnosis, PTSD sufferers may also suffer from interpersonal problems due to feeling cut off from the concerns of

emotional numbing. More than a third of people with PTSD also suffer from major depression, phobias and substance abuse.

Age and the onset of PTSD 6 The condition can occur at any age including childhood and symptoms will typically begin within three months from the trauma, however, symptoms may take years to appear. Not everyone will develop PTSD and current research suggests that psychological, genetic and social factors may make some people more predisposed than others. Studies carried out on Vietnamese war veterans showed that those with strong support systems are less likely to develop the condition. The best prognosis is associated with symptoms that develop soon after the trauma and with early diagnosis and treatment. With adequate treatment about one third of the people with PTSD will recover within a few months and show no further problems. Many people take longer, sometimes a year or more to recover.

Treatment 7 Before any treatment for PTSD can begin it is important to address any substance misuse issues and treat any serious depression. Treatment for PTSD may take the form of trauma focused counselling in either a group setting or one to one. This kind of therapy often takes a long time since memories must be revived and contemplated repeatedly before they can be overcome. Through sympathetic questioning and reassurance unresolved feelings are expressed, memories are explored and the patient is hopefully able to move on. 8 Cognitive behavioural therapies are aimed at relieving symptoms without so much attention to uncovering the story of the trauma. In systematic desensitisation, the sufferer is trained to recreate the traumatic event by relaxing physically and imagining scenes that gradually approximate to it. Patients can also be directly exposed to cues reminiscent of the trauma. Eventually, since the danger is no longer present, the conditioned stimulus no longer evokes fear.

Medication 9 Drugs are prescribed for the rapid relief of severe traumatic symptoms, and in the longer term to help patients tolerate otherwise unbearable feelings so that psychotherapy can work. The most useful drugs are anti-depressants which not only relieve depression but improve sleep and suppress intrusive thoughts, jumpiness and explosive anger. Selective serotonin re-uptake inhibitors have been found the most promising drugs of choice in the treatment of PTSD.

PTSD counselling EXT:

early

morning

A normal house in a normal street in Belfast. The front door opens and is slammed shut by Robert. The sound of children crying and his wife calming the storm can be heard behind the door. He stands on the step and lifts his head to the sky and light drizzle of a winter morning. The

door

opens.

His

wife

leans

Phyliss:

(Worried)

Robert:

(Snaps) Yeah. Yes. I’m fine

Phyliss:

You

just

Robert:

I’m

fine.

out.

Robert?

Rob...

(takes love.

didn’t

a

say

are

you

deep

ok?

breath

and

tries

to

soothe)

goodbye.

INT: A small child’s bedroom at night Robert sits watching his youngest boy, Toby, asleep in bed. In his hand is an information brochure. We can read ‘Occupational Health and Welfare’ on the front. He looks at it and then at Toby. Robert:

(Whispers) Your Dad’s not a numpty, son. I’m just scared. I don’t mean to shout. I don’t want to shout. And I don’t know why I do. I’m going to get help... if I’m caught though. Son, I don’t know what to do. I think I can lose the job if they see me. And you and your mum will lose all this. I wish I could sleep like you. I’m scared and I should be strong. I’m scared of the doctors and shrinks. They read your mind and tell... och, I’m pathetic. I’m going to get myself sorted... for you.

Robert picks up a small bottle tells himself it’s medicinal.

of

Vodka

and

slugs

some.

INT: Car in a car park Robert pulls a cap with deer stalker ear flaps and a his pocket. He puts them on and pulls his collar up. the mirror. INT:

Dr

A

doctor’s

Kurall

is

He’s

not

drunk.

He

pair of glasses out of He checks himself in

room

enjoying

her

first

cup

of

tea

in

the

morning,

and

looking

out

of at

her window. She goes to take a bite from a chocolate biscuit. She looks the front cover of ‘Diet Monthly’ and puts it down. She looks out of her window and watches a suspicious looking man get out of a car. He looks around. Locks the car and steps backwards towards the kerb. The man stops. Looks down at his feet. Shakes his head. Lifts his foot

to

look The

at

his

Doctor

heel.

Shakes

watches

as

the

his

head

man

drags

again. one

foot

through

the

grass

verge.

INT: Outside Dr K’s Office, Occupational Health Robert stands outside Dr Kurall’s office. He slowly removes the disguise. He looks very embarrassed to have worn it. He goes to knock on the door. But he stops. He pulls away his hand and drops his head. He feels pathetic. The door opens like opens the door.

an

automatic

door.

Dr

Kurall,

who

is

far

smaller

than

him,

Dr

Kurall:

Well,

are

Robert:

How

Dr

Just come in. right shoe?

Kurall:

did

you

How

Dr

You've come you want to

Dr

I do And

Dr

Mr

Kurall:

And

Mr.

you

know,

eh?

you

please

remove

your

getting to my door. Now I know come in and close the door.

I bet

you

know

about

the

liquid

now. the

boozy

Peeler...

breakfasts.

please

come

in.

And you’1ll know that I’m That I don’t want you to get me carpeted. I don’t

Dr

(Softly)

I think

Dr

Please

sit

Police

Officers

I’m

losing down.

apparently.

with

scared, read my want to

and don’t want to be here. mind. I don’t want you to lose my job.

Robert.

Robert: Kurall:

could

just just

Robert:

Kurall:

in?

Peeler

a long way be here so

What else do lunches too?

Robert:

come

you...?

Robert:

Kurall:

to

you...?

Robert: Kurall:

do

going

my

marlies.

(Pause)

you

You’re

I’ve

know.

You

heard

all

guys

the

don’t

rumours

get

immune.

You’re

supposed

I’m

strong

enough.

about

stressed

to

just

get

on

it.

Robert:

I thought

Dr

But you’re here. And that’s a huge step to make. It’s hard to face a complete stranger. Especially a complete stranger from Occupational Health. But you’re here to get better. That’s a step in the right direction.

Kurall's

I could.

Robert:

Well,

Dr

I know. I saw your shoe.

you

Robert:

And

wonder

Dr

We will have to come to back to that. Would it help if I started by telling you what we’ll be doing here? We’11l explore the difficulties that you’ve been having, how these might have developed and what you think is keeping the issues going. I also want to ask you about you career as a Police Officer, about your life outside the job, your family, relationships...

Kurall:

Kurall:

I stepped

you

moonwalking

why

And explore anything else that affecting your everyday life.

Dr

OK, you is kept

Kurall:

all

good,

Inside

but

who

of

over

dog’s the

dickie

grass

to

stomach. get

it

off

I drink.

Dr

That’s

size.

aftermath

And

Robert:

shoe

the

Robert: Kurall:

my

might

in

not

leg...

else

may

will

be

see

on

or

have to understand that everything confidential in your medical file.

your

mind

and

hear

this?

we

discuss

here

Robert:

Aye,

right.

Dr

Your

authorities

Kurall:

They

do I have any think I won’t

could

use

don’t

have

arms,

Robert:

I think

my

mate

Dr

So,

are

you

comfortable

Robert:

Yes

and

no,

but

Dr

Well, let’s losing your

Kurall:

to

access

carpet to

this

me. information,

nor

contact with them. Despite what you might be getting you sized up for a jumper with

wraparound

Kurall:

this

buckles

Big

and

Steve

I want

begin. So, marlies?

locks.

would

with to

like

all

do

tell

that.

this?

this.

me

why

you

think

you’ve

been

Robert:

It’s hard putting this into words, but, erm. It feels like my brain’s been taken over by Michael Winner directing horror movies in my head using images and scenes that I’ve been involved in the past. It’s desperate. When it happens I feel like the bottom of my stomach’s going to drop out, my chest clenches, my head spins.

Dre

When

Kia:

was

the

last

time

egg shells with me which I apparently

INT: Bedroom in the morning Robert comes into the bedroom the end of the bed. Love’.

Phyliss:

I don’t

Robert:

T donee.

Phyliss:

We

Robert:

I just this.

want

to

Phyliss:

I want

you

back

Kurall’s

Robert:

Dr

Kurall:

Robert:

this

stm

as usual. She has gave her during a

with

Robert:

Dr

felt

bad?

Like this morning. I’m standing in the shower and my heart suddenly starts pounding. I start seeing these awful memories of stuff going through my head, my heart feels like its going to come out of my chest and my legs are about to go from under me. My wife comes into the bathroom walking on

Robert:

INT:

you

a towel

around

a bruise on her cheek nightmare last night.

his

waist.

Phyliss

sits

on

So...

understand.

can’t...

I can’t

go

be..

on

with

I hate

Robert.

this.

who

This

I am.

isn’t

I hate

feeling

like

you.

office I love I need

her. I love the kids, but they can wind me up. to get out before things get too much. Getting

on

the

motorbike

my my

head for head.

helps,

a while,

These images in your don’t worry too much of things go through

gets

the

anything

head. Can about the your mind

to

adrenaline

get

these

pumping,

images

out

And out clears

of

you tell me briefly? And details. Tell me what sort most often?

It doesn’t happen all the time, but something will trigger a memory of the last incident I was involved in where a guy tried to pull my gun from me, then I start to think of

other stuff. Like the time blast bombs were going off around me, especially the time one took my sergeant’s leg off; the house search where I was the first in, had to bang the door in, and found a child on the other side of it. I go back even further sometimes when I start going through all the worst bits of some of the worst times of the troubles, then I’1ll start to think about when I had to

pick up the bodies, I slipped on one once. Didn’t mean to, you know. My mate and a neighbour died in that one. Had to tell his family after that. Dr

Kurall:

When

do

you

Robert:

When I’m driving.

Dr

And are

Kurall:

notice

these

memories

staring at the white At the supermarket.

what do you triggered?

notice

within

getting

tiles

in

yourself

triggered?

the

shower.

when

these

When

I’m

memories

Robert:

My head is tight. My chest crushes in on me. My heart pounds. I’m sweating. Feel like I’m being pushed into a corner and need to get the hell out. Then I’m sitting and all of a sudden I’1ll just have a feeling come over me — no memories. Just feeling awful for no reason. Thinking my marriage isn’t working and I don’t know my kids. There’s no craic anymore with the mates in work and I haven’t slept for years. (Pause) And I think that people will just tell me wind my neck in get on with it.

Dr

Sounds like everyone in work has been told to just suck it in and get on with it. Help swallow the thoughts with a wash of whiskey. I bet they say that policemen don’t get

Kurall:

stressed.

They’re

control. Robert:

Cope

problem

with

solvers.

everything

Supposed

to

be

in

right.

S’'pose. Some scores while

fellas let their knees knock over the football others... it takes something more. But yes. I think you’re right. We turn to the beers to forget the worst of it. Chase them with shorts. And I’ve had my reasons too. The authorities have had me up. Me! After everything. After all I have been through. Been bombed. Shot at. Mates murdered. And threatened in my own home. And what for? To feel like this. It’s only since the incident

with

my

work

isn’t

gun

that what

things it

was.

have And

really home

is

turned.

The

just

bad.

as

craic

in

I’ve

kicked a hole in the back door before now. I’ve yelled the kids. And Phyliss. She can’t understand. Doesn’t understand. Phyliss just tells me to catch myself on. Dr

Kurall:

Robert:

How

do

you

She

doesn’t

know

she

get

it.

concentrate.

don’t Dr

Kurall:

like

You

need

Dr

I’m

not

like

Paul

McKenna.

do

Dr

I’m

not

some

You

don’t

Paul

not

understand?

thinking stuff.

straight.

Don’t

want

this.

Robert.

hypnotise

Well,

Robert:

I’m

remember

to

Robert: Kurall:

being

I understand

Robert: Kurall:

Can’t

doesn’t

magic Daniels

know

how

me

or

something.

then. either. relieved

at

I

am

to

know

that.

I can’t to

go

out.

I

De

Kuralie

What work

Robert:

Well,

Dr

Do

Kurall:

we do isn’t with me.

let

you

Robert:

Sorry.

Dr

Have

Kurall:

me

mind

you

if

ever

Robert:

I think

Dr

I could give it a little.

Kurall:

so.

Robert:

Yes.

Dr

Well, your If I could

Kurall:

be

It’s

an

illusion.

It

your

Debbie

McGee.

we

stop

this

Paul

of

Post

Traumatic

for

what

it

heard

But you You

slow.

works,

as

but

Daniels

you

to

thing?

Stress

Disorder?

is...

psycho-babble, but let have a computer right? Like

I need

me

try

and

simplify

me.

mind can crash in the same way use the computer as a metaphor

a computer can. to describe how the brain can crash when it experiences PTSD. The brain is like the central processing unit, the computer with a memory. A computer with PTSD has too much information that has been ‘keyed in’. Are you with me?

Robert:

Erm, like the whole

when the kids starts hammering thing starts to smoke.

Dr

You might right yes. scenes of control — it happens years. So

want to put smoke detectors in the room, but you’re (Pause) If this information is distressing — like horror, experiences of being terrified or out of then this is a lot for the CPU to process, even if in one single event, or accumulates over many it processes some of the experiences, and others

Kurald:

get

stored

away,

unprocessed

or

in

their

the

buttons

‘raw’

in

and

memory.

Robert:

So I’ve got lots of stored up memories that, as you say, are raw. Is that why, when I remember them I can still smell, hear and see some of this stuff as though it just happened yesterday?

Dr

That’s right. These memories can get activated when the computer registers input that matches what’s already stored in memory.

Kurall:

Robert:

Like the smell of meat when I walk past the butchers counter in Sainsbury’s makes me automatically think about the time I had to pick up bits of bodies. Then I start to feel awful again. Haven’t had a steak for years!

Dr

Exactly, and you might not always remember experience, but you may just suddenly feel

Kurall:

Robert: Dr

Kurall:

Policemen

You

do,

don’t

but

you

feel,

wear

do

the actual awful.

we?

a mask

to

pretend

that

you

don’t.

So,

when ‘bad’ memory files get activated this overwhelms the computer and it begins to shut down. You might feel very anxious and on anything

memories computer Robert:

Yeah,

the on

and find it difficult to sounds like you have lots

that are stored off in different as ‘unfinished business’.

loads.

most the

confused, else. It

Don’t

always

inconvenient

motorway!

know

times,

why

I think

especially

in

parts

of

the

concentrate of ‘bad’

of

this

the

stuff

shower,

or

at

Dr

Kurall:

When your mind is quiet, not distracted by other things needing your attention — what I mean is there is no other input for the computer to process — so it becomes active with the emotionally charged unfinished business it still needs to take care of. These memories get activated in an attempt

normal

to

get

processed,

and

eventually

filed

away

Robert:

But, this certainly

Dr

It’s your brain’s natural attempt to self heal, but memories are emotionally charged with feelings like

Kurall:

or

Robert:

Kuralis

need

You’re

and Dre

happens all not like it

helplessness,

and

as

memories.

it

outside

my

IT

can’t

do

it

on

its

own,

put

and

away,

if the guilt

it’ll

crash

help.

technician

re-process

Emotionally

the time and nothing gets feels normal, anyway!

then,

and

you’re

going

to

de-charge

me?

desensitise

and

cognitively

reprocess

to

be

accurate. Robert:

Sorry, I think you’ve just what you mean, but I can’t memories, and you don’t do I do?

Dr

Well

Kurall:

no,

I’m

not

here

to

lost me. (Pause) I think I know get rid of what happened or my hypnosis or magic — so what do

entertain

you,

and

I

can’t

turn

the clock back. (Pause) We’re either stronger or weaker, but never the same after traumas in our lives. Our work together, should you choose to come back, will be to help reduce your anguish, to heal the unseen scars, in essence to give you your life back. Robert:

Sounds

Dr

We'll go through a detailed assessment of your history and your experiences as a Police Officer. By doing this we’ll develop a comprehensive picture of the impact of any traumatic

Kurall:

like

magic

to

me.

How?

events. We’ll assess the meanings of these experiences negative feelings that may still be attached. Robert:

OK,

Dr

Then help

Kurall:

then

Robert:

OK,

Dr

Then

that’s

that

it’s

Kurall:

Robert:

Ok,

Dr

Enough

Kura:

then

of

some psychological interventions that will and feel differently about the traumas.

what? when the

you

start

traumatic

to

events

feel

like

that

you

have

are

been

normal,

what?

the

‘then

please.

Dr

If this was the Six Million Dollar Man then I would husky voice and say, ‘yes, we can rebuild him’. And put you together. Yes. Just

Dr

So,

Kurall:

if you’re you’ll be

whats’

I’m just... know that

Robert:

wanted

if

and

abnormal.

Robert:

Kurall:

any

what?

we’ll use you think then

and

to

you’re

know

with

going to take me apart I just want able to put me together again.

I

me,

was

in

then

safe

let’s

to

have a we can

hands.

make

another

appointment.

Social phobia/social anxiety disorder £

National Phobics Society The anxiety disorders charity

Contributed by the National Phobics Society 1 Social phobia is defined as a fear of negative evaluation from others — the fear of being judged and criticised. It is a fear of social situations that involve interaction with other people. 2 Social phobics experience overwhelming anxiety and excessive self-consciousness when in social situations accompanied by fear of humiliation and embarrassment. Whilst it is usual for most people to feel apprehensive about certain social events, such as public speaking, the anxiety experienced by social phobics is so intense that it can literally make sufferers of this condition avoid any social situation. In common with most anxiety disorders, social phobics are often well aware that their anxiety is irrational and misplaced, yet despite this, feel powerless and unable to overcome their fears

Specific and general social phobia 3 There are two types of social phobia ‘general’ social phobia, and ‘specific’ social phobia. Those with general social phobia worry excessively about being in any social situation. However, those with specific social phobia find their condition is limited to only one type of situation, eg, public speaking, eating/drinking in

eas

wd 4

public, writing in front of others, fear of using public toilets in front of others, etc. 4 People with specific social phobia often find they lead ‘normal’ lives and can get along fine in most social situations, however when asked, for example, to give a speech, they find they go to pieces, they dry up, can’t think of anything to say; feel stupid, embarrassed and humiliated. However the problem of specific social phobia is limited to specific social settings, and is therefore nowhere near as debilitating a problem as general social phobia. 5 People with general social phobia often have social skills deficits and report feeling shy most of their lives; often having limited social contact with others. Social phobics frequently find that as their peers develop further social skills they themselves become more marginalised from society; developing a sensitivity to rejection. They think that others think they are boring and unattractive. Such people cope with their problems by effectively minimising opportunities for negative evaluation by avoiding social contact wherever possible. As a result to others the social phobic may seem aloof, strange, anti-social, etc. However, deep down most social phobics crave social involvement, and acceptance from others. They long to have partners and an active social life — however the social phobia prevents any of this. Social phobics often experience significant distress in the following situations: Being teased or criticised. Being the centre of attention. Whilst being watched or observed while doing something. Having to say something in a formal, public situation. Meeting people in authority.

Going to parties. Using public urinals/toilets. Being introduced to other people. Eating out/drinking in public. Eye contact. Making telephone calls. Fear of examinations/interviews. @ Nn@O@eeeeeeeee Many social phobics find that their worries are associated with a particular physical symptom of their anxiety. For example they fear that others will notice their excessive blushing, sweating, shaking. The word excessive is in italics for it is very rare that those with social phobia are exhibiting noticeable physical symptoms of anxiety!

What does it feel like to have social phobia? 7 \f you suffer with general social phobia you will probably find that you spend a lot of your time worrying about being shown up in social situations, or making a fool of yourself. You probably have a

H45100

People with general social phobia report feeling shy most of their lives

very poor self-image and think that others find you boring, strange and anti-social. You experience excessive anxiety before entering into any social situation and spend hours going through all the eventual possibilities of the social situation that you are about to enter. You worry that others might notice you looking nervous and on edge; in fact you worry so much that you then start to look nervous — the very thing you hoped to avoid. At this time you start to experience the physical symptoms of anxiety — dry mouth, increased heartbeat, sweating, and feelings of needing to go to the toilet. You may also start to stammer, blush, sweat, shake and tremble. As your fear

increases you may even start to feel panicky and end up having a panic attack. Along with this come the feelings of wanting to escape. After attending a social situation you perform a self postmortem; examining everything in minute detail that you did, whilst looking for ways that you could have done things better. In fact you give yourself an incredibly hard time, often getting things totally out of context. Naturally living through these kinds of episodes on a frequent basis results in you feeling really demoralised and down. It is because of this that many social phobics also suffer with depression and other problems such as alcohol/drug dependencies (many social phobics use alcohol/drugs as a way of relaxing before going into a social situation). Indeed social phobia is not something that comes and goes, it is with you day in, day out.

How many people suffer with social phobia? 8 Social phobia is actually the third most prevalent psychiatric disorder, following only depression and alcohol dependence (Kessler et al. 1994). It is thought that social phobia affects approximately 2% of the population at any time. However, it is also believed that 90% of people with social phobia are misdiagnosed so the problem of social phobia is thought to be much larger than current statistics show.

What causes social phobia? 9 Noone knows for certain at present exactly what causes social phobia, but there are a number of theories around. A large proportion of people with general social phobia say that they have always felt uncomfortable in company and cannot say for certain when their difficulties began. Therefore it seem that the origins of social phobia usually lie in childhood. Parents of social phobics often report that their children were indeed shy. Studies have shown that the rate of social phobia in a social phobic’s family is about three times higher than average, and that identical twins are more likely to have the disorder than fraternal twins. These findings suggest thatesocial phobia has a genetic component. However, it is also likely that the behaviour of parents contributes to the likelihood of their children developing social phobia. Many social phobics describe their parents as both overprotective and insufficiently affectionate — constantly criticising them and worrying that they will do something wrong — the ‘what will the neighbours think’ scenario. Social phobics’ parents may over-emphasise manners and grooming, or exaggerate the dangerousness of approaching strangers. Some people believe that social phobics learn social phobia from parents who avoided social situations in a social conditioning style. 10 Other studies have shown that the amygdala, a central site in the brain that controls fear responses, is involved.

11 Another theory is that the disorder has a biochemical basis. Scientists are exploring the idea that heightened sensitivity to disapproval may be physiologically or hormonally based.

What can be done about social phobia? Cognitive Behavioural Therapy (CBT) 12 As with many anxiety disorders, the main component of social phobia is ‘negative thinking’. For this reason, CBT is effective in treating social phobia. This therapy involves gradual exposure of social phobics to social situations which would usually cause distress. The first stage involves introducing the social phobic to the feared situation. The second stage is about building up the risk of disapproval in that situation so that the social phobic can build confidence to enable them to handle rejection or criticism. The third stage involves teaching the social phobic techniques to allow them to cope with disapproval. To do this, they are taught to develop constructive response to their fears and perceived disapproval. CBT also includes anxiety management training — teaching people techniques such as relaxation and breathing exercises to help control their levels of anxiety. The other important component of CBT is helping people to identify negative thought processes and enabling them to develop more realistic, rational thoughts. In general it is thought that social phobics respond relatively well to short term therapy and do not benefit from years of therapy where they analyse and ruminate over their problems as this can often make the social phobia worse. Self help groups 13 Attending a self-help group is an excellent way to meet others experiencing social phobia and provides a form to share coping techniques, etc.

Assertiveness/confidence building courses 14 Many local Adult Education Centres now offer assertiveness courses. These can be very helpful for social phobics who want to learn basic assertiveness skills to help them cope with everyday social encounters. Contact your local education authority for information.

Social skills training 15 This is where people are taught simple social skills that most people take for granted — for example, how to make conversation with a stranger. These training courses provide people with lots of chances to practise social skills with others who experience similar difficulties. The courses also allow participants to give constructive feedback. Social skills courses are usually run by psychology departments, so you will need to speak in your GP. Drug therapy 16 SSRI — Selective Serotonin Re-uptake Inhibitors have recently been shown to be effective in treating general social phobia. Beta blockers can be useful for specific social phobia when used to help with performance anxiety or stage fright. This is because these drugs help with the actual physical symptoms of anxiety such as shaking sweating, etc. They are not usually found to be helpful for many with general social phobia. MAOIs — Monoamine Oxidase Inhibitors can also be useful for treating social phobia, however their use is often limited due to the

dietary restrictions imposed on people taking them. Medication in general for social phobia is often taken for more than 2 years.

Further reading Barbara Markway Dying of embarrassment: Help for social anxiety and phobia (New Harbinger Publications, 1992)

Men and stroke Words by Paula de Souza and Natika Halil Stroke Information Service, The Stroke Association

What is a stroke? Association

1 A stroke happens when there is an interruption to the blood supply to the brain. Most strokes happen when a blood clot blocks the flow of blood. Less commonly a stroke can happen because of bleeding in or around the brain. 2 A Transient Ischaemic Attack (TIA) is similar to a stroke and is sometimes called a mini stroke. The symptoms are the same as stroke but they do not last as long, and the person recovers completely within 24 hours. 3 The common symptoms of a stroke or TIA are: @ Sudden numbness, weakness or paralysis on one side of the body. Sudden problem with speaking or understanding speech. Sudden blurring or loss of vision, particularly in one eye. Sudden dizziness or unsteadiness. Sudden memory loss or confusion. There are no signs that a stroke is going to happen. When ®@ eee someone has the symptoms it is because the stroke or TIA is happening at that time.

m

Men and stroke

someone 12and BE" SoG ye you SUSPE

5 Stroke is a serious health issue for men. Each year in England and Wales, over 130,000

g stroke a a $00 medical hetp

people have a stroke, and 57% of strokes in those aged under 75 occur in men. Although stroke is more common

as we get older, it can

happen to anyone. Almost 25,000 people aged under 65 have a stroke each year, accounting for 18% of all strokes.

Psychological effects of stroke 6 Many people are aware of the physical effects of stroke such as one-sided weakness and loss of speech, but stroke can cause a range of psychological effects too. These effects can be because the stroke has directly affected the part of the brain controlling emotion or behaviour. Also, stroke happens very suddenly, and it can be hard coping with the emotional and physical after-effects. Depression 7 Depression is one of the most common problems after stroke, up to half of people who survive a stroke will experience some depression in the first year. Depression can affect anyone and it can develop immediately after the stroke happens, or weeks or months later. Being assessed and receiving the right help is crucial as managing depression can really make a difference. 8 Sometimes the stroke causes direct damage or chemical changes in the brain that can lead to depression. There can also be underlying physical causes for depression after stroke such as chronic pain. Depression often sets in once the initial period of recovery is over, and the person has become aware of how their lasting disability may affect their everyday life. With this, they

may have to come to terms with the loss of some hopes and plans for the future, as well as having to adapt to a changed role in the family, and possibly the loss of a career. All this can affect confidence and self-esteem. 9 The symptoms of depression after stroke are the same as for depression generally and include:

family to help them to make plans and overcome inactivity. As with many of the after effects of stroke feelings of apathy often begin to disappear through the recovery process, or if it is as a result of depression, as the depression begins to lift. If however after a period of time apathy linked to depression shows no sign of lifting, then anti-depressant medications and counselling may help.

@

Emotional lability 16 Emotional lability is the term used when someone is more emotional and/or has difficulty controlling their emotions. Some people describe feeling as though all their emotions are ‘much nearer the surface’ or more exaggerated after their stroke. For example they may become upset more easily, or cry at things they would not have cried at before their stroke. Their emotional response is in line with their feelings, but is much stronger than before the stroke. For other people the symptoms can be more exaggerated, and some stroke people find that they cry for little or no reason. Less commonly, people laugh rather than cry, but again the emotion is out of place and does not match how they are feeling at the time. 17 These emotions usually come and go very quickly, which is unlike when someone feels upset and is crying. Some people may even swing from crying to laughing. Although the stroke person realises that their crying or laughter doesn’t fit the situation, they cannot control it and this in itself can be very upsetting. 18 Emotional lability is generally worse soon after the stroke happens, but usually lessons or goes away with time as the person recovers from the stroke. If this doesn’t happen, the GP may be able to help. Some medications that are also used to treat depression can help with the control of emotions even if the person is not depressed.

Feeling sad, blue or down in the dumps. A loss of interest in everyday activities. Feelings of worthlessness, hopelessness or despair. Anxiety or worry. Changes in sleeping pattern or appetite. Suicidal feelings. @ Low self-esteem. 10 The most effective treatment for depression is psychological intervention or counselling combined, if appropriate, with antidepressant medication. Psychological and counselling services aim to encourage people to talk about their thoughts and feelings and help them to come to terms with what has happened. 11 Anti-depressant medication works by acting on the chemicals in the brain. Many anti-depressants are very effective and about two thirds of people who take them benefit. Anti-depressants take at least two weeks to work properly, and there are many alternatives to try if there is no improvement after this time.

Personality changes 12 Where parts of the brain controlling personality and behaviour have been affected by the stroke, this can result in personality changes. Some people become impatient and irritable or withdrawn and introspective. Sometimes previous character traits can be reversed, with a mild mannered person becoming aggressive, a difficult person becoming more passive or a once sociable and lively person may become less sociable and withdrawn. More commonly, however, existing traits are exaggerated. 13 These psychological changes can be very difficult for family and friends to cope with, especially if the behaviour is aimed at one person only. Some stroke people are unaware that their behaviour has changed or that it is upsetting for their families. Sometimes explaining this to the stroke person is helpful. It is also important for family members to have support for themselves. Apathy 14 Apathy is a lack of motivation or enthusiasm. Someone with apathy may appear indifferent to everyday occurrences and unmoved by emotional events that would arouse strong feelings in other people, or in themselves previously. Often there is a loss of interest in things going on around, such as socialising or previous hobbies. Apathy can be a symptom of depression after stroke, or can be a symptom on its own, a result of the changes

in the brain due to the stroke. 15 Many survivors with post-stroke apathy are happy to join in activities and are able to manage responsibilities, provided that they are assisted in getting started and setting goals. People with apathy depend upon kind encouragement from carers, friends and

Recovery and rehabilitation 19 As with all effects of stroke, these psychological effects can improve over time. As the brain heals and the stroke person comes to terms with what has happened and how life may have changed, effects such as depression can improve. Although most recovery from stroke happens in the first few months, there is no end to the recovery period and changes and improvements can still happen many months and even years later. 20 Unfortunately there is no way to predict how much recovery someone will make after stroke or how long that may take. For some people the damage done to the brain cannot be healed and they are left living with the effects of their stroke. Part of the rehabilitation process involves learning to adapt to how things have changed because of the stroke and there is help and Support available.

Help available 21 If you are concerned about any psychological changes after stroke, discuss these with the GP in the first instance. 22 The GP can advise on any medication that may be helpful, and make referrals to a clinical psychologist or counsellor if appropriate.

Mental men myths Stroke only causes physical effects While stroke does cause numerous physical effects, many people experience psychological effects too, such as depression, apathy and personality changes. Stroke cannot be prevented There are many lifestyle changes you can make to reduce your risk of stroke. These include: @ Eating a healthy diet: cutting down on salt, sugar and fat, and eating plenty of fruits and vegetables. @ Jaking regular exercise. @ Giving up smoking. @ Drinking alcohol in moderation. Doing any physical activity regularly,

@ Seeing your doctor regularly for check ups such as blood pressure, cholesterol and diabetes.

however gentle, can help

23 Relationship counselling, for example through an organisation such as Relate, can be helpful for the stroke person and their partner. 24 Support groups are a useful way of meeting people who have been through similar experiences. Contact The Stroke Association for details of groups near you.

Helping yourself 25 There are many things that can be done to ease the psychological effects of stroke. Not all of the suggestions will suit everyone, but most people find at least one or two helpful. Keep informed 26 Having information about stroke can be reassuring and if there is something you are not sure about, or you do not understand, don’t be afraid to ask your doctor or carer to explain.

Startling stats @ Stroke is a serious health issue. Each year in over 130,000 people have a stroke — that’s one person every five minutes. Stroke doesn’t just affect older people, it can happen to anyone. Almost 25,000 people aged under 65 have a stroke each year, accounting for 18% of all strokes. 57% of strokes in those aged under 75 occur in men. Stroke is the third largest cause of death in the UK, causing 9% of all deaths in men.

Stroke has a greater disability impact than other chronic diseases. Stroke causes a greater range of disabilities than any other condition.

The Stroke Association can also help with information about stroke and its effects.

Social contact 27 Meeting people regularly, everyday if possible, is important, especially against effects such as depression. Talking to others can also be a big help. Hobbies and 28 Returning rehabilitation to enable you look at trying

interests to hobbies and interests is an important part of the process after stroke. Many activities can be adapted to carry on enjoying them, and you could even new things.

Exercise 29 Recent research shows that exercise is very beneficial in treating and preventing depression. Doing any physical activity regularly, however gentle, can help.

Healthy diet 30 A poor diet can make you feel tired and run down. Try to eat regular meals with fresh fruit and vegetables every day.

Further information The Stroke Association is the only national charity solely concerned with combating stroke in people of all ages. Their vision is to have a world where there are fewer strokes and all those touched by stroke get the help they need. They can provide information and support on all aspects of stroke from prevention to rehabilitation. The website contains lots of information about stroke, and includes a discussion board, Talkstroke, where people affected by stroke can share their experiences. Tel: 0845 30 33 100 (Monday to Friday, 9am to 5pm) E-mail: [email protected] Website: www.stroke.org

Reference Grieving and coping with bereavement

Suicide Access your pharmacist! When things need fixing Complementary medicine

148 149 152 158 166

Meditation, happiness, personality and

the brain Use your brain when you use the net Further reading Contacts

Photo: Miroslaw ©iStockphoto.com, Pieprzyk

168 170 172 172

Grieving and coping with bereavement 1 Computers get lost in many ways. It is not always simple theft. You can lose a computer from viruses, worms and neglect. This is not a million miles away from the ways of losing someone you love. Losing someone means losing their presence, love and memories. Computers don’t supply much in the love and hugs department but interactivity and memory are a very real loss. 2 Death is inevitably upsetting and may occur at any age, even in childhood. As we grow older, our contact with personal loss increases, but it may never get any easier to deal with.

Death in old age 3 The loss of an elderly relative or friend is supposed to be less painful. People will attempt to console you with well-intended comments such as, ‘Well, she had a good innings’. Heads will nod, but a long innings often gives more reason to hope that death will never come.

Scale of misery 4 Psychologists often refer to a scale that rates life events in terms of the stress they can cause. The death of a spouse or child comes at the very top.

Predictable response 5 The scale is useful because it helps to demonstrate how you may feel when you have lost a loved one. The stages of the

‘grieving reaction’ are listed below. While the order of these stages remains the same for almost everyone, the severity and duration of each will vary from person to person. Denial ‘It can’t be true. There’s been some mistake.’

Anger ‘It must be the doctor’s fault. Why did they leave me?’

Guilt The next emotion, self-guilt, can be the most destructive. ‘How could | be so idiotic? It’s all my fault.’ People will find the most unlikely things with which to whip themselves unmercifully. This stage can last a long time even when people rationalise the cause of their misery. Acceptance After a variable amount of time there comes a period of acceptance. There is no fixed time for this period, which can even depend upon the community. People generally will profess to have come to terms with their loss before they have actually done so. Coming to Terms Well-meaning folk will tell you that you'll get over it. The truth is that you never ‘get over’ a major life event. What happens is that you come to terms with it; the pain diminishes gradually with time. It is not a smooth progression, however, and anniversaries,

returning to places, or even casual mention of the person or some object or event will release waves of heartache.

Just to help me sleep 6 People close to the recently bereaved can be so shocked by the effect on their loved one that they may ask for, or even demand, sedatives from the doctor. 7 \|ndeed, this used to be the norm, and there can be no doubt that drugs will numb the pain of grief. Unfortunately, grief will not be denied; and if it is not allowed to take its course with the support of friends and relatives, it will resurface after the drugs and the support have gone. 8 People in grief then find themselves alone but with the heartache they should have had when help was at hand. People often talk of such an experience as ‘floating above the events’ only to come down with a thump later on.

Effects underestimated 9 Most people underestimate the effects of bereavement on a person, until it happens to themselves. Some effects can be so bad that the bereaved person often will not realise that loss of interest in job or family, constant pacing of the floor, spontaneous weeping or complete loss of appetite are all normal and common manifestations of grieving. 10 People close to the bereaved person may also become impatient as time wears on, again underestimating the extent of the effects of grief and the length of time they can be felt. It is at this point that true friends are worth their weight in gold. To know when to leave the person alone and when to sit and listen, often to the same story over and over again without interruption, is a gift that few people have nowadays. 11 Bereavement can even affect the memory, and people will say they experienced a ‘complete blank’ for a period following the death. Almost every facet of life can be and is affected — only the scale and duration varies between people. 12 Thankfully, there are professional agencies that specialise in bereavement counselling and can be contacted through your GP. Nobody pretends that strangers are as good as friends or relatives, but they can often help people who have difficulty coming to terms with their loss. 13 Points to remember: @ People have different ways of expressing grief; there is no ‘normal way’. @ Talk about it, even if it hurts. @ Don't be afraid to seek support from friends, relatives or your doctor. @ Aggression is natural, even towards close relatives and wellmeaning neighbours. Doctors are a common focus of anger. @ Allow yourself time to grieve, avoiding dependence on alcohol or drugs. @ Support for those left behind, and love for those about to die, can help make life better for us all.

Suicide southwark allianc LOCAL STRATEGIC PARTNERSHIP YOUR

LI!

R MacQueen, Southwark Men’s Health Programme, Southwark PCT.

With credit to CALM, Menstuff®, The National Youth Agency, and PAPYRUS for relevant source material.

1 This Section is about suicide. It talks about what a suicidal person might be going through, the warning signs, and how they might get help. It also contains information headed Network support which is aimed particularly at people who might know someone that feels suicidal. Ever wanted to ‘log out’ of life ? 2 It's not as uncommon as you might think. Suicide is the biggest killer of young men in England and Wales. And overall, attempted suicides account for a staggering 140,000 A&E admissions every year in England and Wales. Despite the awful Statistics it doesn’t mean that suicide is the answer for you. There are other ‘ways out’ of feeling depressed, worthless or hopeless about the future.

If you have reached crisis point and the desire to kill yourself is overwhelming, you must tell someone immediately. Ask them to keep you company on the phone until the feelings pass. There are help lines at end of this Section. Advisors are there to listen, not to judge, and they can link you up to

Error: Keyboard not found. Press F1 to continue If there is no way to get help how do you make people aware that you have problems? Answer, go around the daft messages and call the Samaritans.

Error log 5 To use another computer analogy; when things go wrong and you can't figure out why, you might look to the ‘error log’ for explanation. It won’t necessarily give you the root cause of the problem but it might help to know what happened along the way. Caution is needed here because in life there is rarely an ultimate cause to ‘pin all the blame on’ and as Alexander Pope reminds us: ‘To err is human’ after all. You can feel suicidal for all sorts of reasons:

Something might have happened that has upset you a great deal.

organisations that offer the support you need to stop feeling

sad and suicidal.

Temporary

malfunction

3 The tragedy of suicide is that it is a permanent solution to what are often temporary problems. Most suicidal people don’t actually want to die, but do feel they are in more pain than they can cope with. While suicide can seem like the only option at the time there’s ALWAYS another way but finding it can be difficult when you're feeling this way. That’s why having someone to talk it through with is so important, as they can offer another perspective. 4 Most people experience situations at ; some point in life that cause them to panic. When you are feeling really low, out of CMe, oe Soicse By opine tn jie you sisi aay pyle about suicide. It’s normal and usually a passing feeling, but try

not to let your mind run wild with the idea. If these feelings last

@ @

Someone close may have attempted or actually killed themselves. You have been using drugs or drinking heavily.

@

You may be upset for no reason at all.

@

Chemicals in the brain which control how happy and sad we feel can also get messed up, and if they’re not in balance you

can feel depressed, confused, manic or out of control. @ A combination of any of these things. 6 Error logs can also highlight processes that frequently occur when things are heading toward a breakdown. Human ‘processes’, i.e., thoughts and feelings that often feature in people feeling suicidal include: @ Finding it hard to tell others how you are feeling. @ Feeling like you have no friends. @

Setting yourself targets which are difficult to achieve. ae : ate,

© Being sensitive to failure or criticism.

for longer or intrude into your normal thoughts, talk to someone

@ Finding it hard to cope with disappointment.

about it. To have felt suicidal does not mean that you are bad or

@

weak person.

Finding it difficult to admit to having problems you don't know how to solve.

Warning messages 7 Killing yourself is rarely a decision acted on in the spur of the moment. In the days and hours before people kill themselves there are often warning signs including behavioural or physical changes, or clues to their thoughts and feelings: Behavioural changes @ Showing a marked or extreme change in behaviour. @ Crying or withdrawing from other people. @ Impulsive or reckless behaviour such as fighting or breaking the law. Abusing drugs or alcohol. Self-harm or previous suicidal behaviour. Daydreaming or writing about death and suicide. Getting affairs in order and giving away valued possessions. Physical changes Showing a marked or extreme change in appearance. Lack of energy.

you don’t Know and in confidence. If the person you are talking to doesn’t seem to understand, talk to someone else. If you find it difficult to talk to Someone in person, write it down and send a letter, an e-mail or a text. More caution is advised regarding website support as not all sites are helpful, and some have been known to cause more distress. Reputable websites that give positive help and hope for the future are likely to be the safest. Recognising and dealing with suicidal thoughts or feelings 11 The more often you have ‘bad’ thoughts about yourself or about suicide the worse you will feel, so it’s crucial to prepare for these times. You can do this by finding something that will help you think about them less often. So even though you won't feel like it, things you could try include: @ Doing something you enjoy to distract your thoughts. @ @ @

Doing something that is relatively easy but takes concentration. Doing something active (as this stimulates the brain to release endorphins, i.e., ‘happy’ chemicals). Give yourself a break — tell yourself what you did well today.

Disturbed sleep patterns — sleeping too much or too little.

Depression

Change in appetite or sudden weight gain/loss.

12 Suicidal feelings may be linked to being depressed. Depression is a serious illness but can be successfully treated by anti-depressant medication and/or ‘talking and listening treatments’. Contact your GP to find out what they can offer to help. Further information about depression and its treatment can be obtained from Depression Alliance (see Further information for contact details).

Looking depressed, tired or showing lack of self care. Increase in minor illnesses. Change of sexual interest. Thoughts and feelings Showing a marked or extreme change in attitude or mood. Thoughts about suicide. Unable to see beyond a narrow focus. Feeling lonely, rejected, marginalised or helpless. Feeling deep sadness or guilt. Feeling very depressed, anxious or stressed.

@ A sense of loss of self-worth.

Recovery process 8 For computers ‘recovery’ of a program or data is a process which few us understand — it happens behind the scenes as if by magic. For people ‘recovery’ is about finding a way to deal with the pain you are feeling and finding solutions to your problems in the longer term. Neither of these happen as if by magic. This is a guide for the short term:

Talk about it 9 Talking about your thoughts and feelings out loud for the first time can be scary, but it does start to make them feel less frightening. People you might trust and consider talking to could include someone in your family, your doctor, a teacher, a counsellor, or someone from your faith group. It can be helpful to make a list, with phone numbers, of people and/or organisations you can turn to for help in a crisis. Get help 10 Don't be afraid of going to see a counsellor, psychiatrist or other specialist. ‘Talking treatments’ like counselling and CBT (cognitive behavioural therapy) can work really well, especially if you go in the early days of feeling depressed or unwell. Help lines are also a useful option if you prefer to talk with someone

Medication 13 Tablets may be prescribed by your doctor to help with depression or suicidal feelings. It can take a while before they start having an effect, so ask the doctor to explain what you can expect to feel. Then, if they don’t seem to be working, tell your doctor so they can prescribe a different kind. Finding the type of medication to suit you might mean trying different types. If you start to feel better or have side effects, see your doctor, don’t just stop taking the medication, they will advise you on what to do. Your pharmacist can also talk with you about your medication.

Alcohol and drugs 14 Although having a few drinks, hits or tokes might appear to give you a lift at first; in the long run they are known to make people feel even worse, especially if you are depressed. Under the influence of alcohol or drugs you may do things or make decisions you would not normally make. They can even make some people feel suicidal. For these reasons it is safer to avoid alcohol and drugs altogether if you are feeling depressed or suicidal.

Risk taking and impulsive behaviour 15 Be aware that you could be attracted to behaving in ways that put you at an increased risk of dying by doing them. You can reduce this risk by avoiding those activities, or people who might pressure you into doing such things, or places where you might feel compelled to do impulsive things.

One day at a time 16 It will help to give some structure to your day. Try to get out into the daylight for a while every day and increase your activity. Light and activity are both natural mood enhancers. Regular meals using fresh food can also improve how you feel and help to reduce mood swings. What you listen to or read can also make a difference to how you feel, find something that helps your mood to lift. If some music or writing make you feel more depressed, turn it off or stop reading it. Getting enough sleep can really help your concentration, mood and energy levels. There are some easy relaxation techniques to help you sleep well and most libraries can help you find helpful books and audio materials. However, try to only sleep at night time rather than during the day — it will help to give your day structure and to sleep better.

OK computer 17 It won't be OK all of a sudden. Life will get better, but gradually. Just knowing that it will means that there is light at the end of the tunnel.

@

A&E department may make a referral, or a GP can be asked to. If you feel that the situation is getting worse rather than better, and you are worried about another suicide attempt, trust your instinct and share your concerns straight away. Contact the GP, or any professional who has been involved already and they can follow it up. Give practical support, and help them to cope with any extra pressures. It could be as simple as agreeing what you will do if a suicidal crisis happens again, helping with child care arrangements or prioritising bills. If the person you are helping doesn’t act on your advice try not to nag or intrude too much, nobody wants to be pestered all the time, although it may be well meant. Try to balance being watchful with a respect for privacy and making sure they don’t feel abandoned or rejected. Your help, Support and attention are vital if they are to begin to feel that life is worth living again. As life gets back to normal for them, and they seem to be getting better it is important to still pay attention to their situation and feelings as they may continue to be at risk for quite a while.

Network support

Further information

18 Any suicide attempt should be taken seriously, and it should never be ignored. People sometimes think that someone who talks about or threatens to kill themselves won’t actually attempt it. Statistics show however, that this is not the case. Attempted suicide may not always succeed, but people who survive can remain at high risk of taking their own life for quite some time afterwards. If you know someone who is feeling suicidal, take their feelings seriously. Helping someone who feels suicidal can be very stressful, so be aware of your own limitations. Get help by asking family members and friends for their assistance and to share the responsibility. Here is a brief guide to what you can do: @ Ask them how they were feeling before it happened and how they are feeling now. Talking about suicide does not make it more likely to happen. Try to be patient if they are angry or refuse to talk. It may be that writing things down is an easier way for them to communicate with you. @ Listen. This is the most important thing you can do. Treat them with respect, and try not to be judgmental or critical. It might be that you don’t feel you are able to listen to the person at times or even at all. It is better to be honest than being unrealistic with the person about what you can offer. Do not agree to keep the person’s suicidal thoughts or plans a secret.

CALM (Campaign against Living Miserably) Service for guys to chill out a little, sort stuff out, and go places.

@

@

@

Empathise by showing that you really are trying to understand things from their point of view. Words don’t always matter. A hug or a hand on a shoulder can go a long way to show that you care. Don’t criticise their actions, whatever your own feelings are about their situation. Try to remember that they were ,and may still be, going through much pain and distress. Reassure them that it is common for people to have times when they feel desperate and hopeless, and there are ways to overcome those feelings and their situation. Things can and do change, help can be found and there is hope for the future. People do get better! Find out what professional help is available and encourage the person to take it up. There are many ways in which health workers, social services staff and others can help someone who has attempted suicide. The staff in the hospital

Tel: O800 58 58 58 (any time from 5pm to 3am) Minicom number: O800 027 2982 Website: www.thecalmzone.net Depression Alliance Can give more information about depression and its treatment. They also have many support groups they can link you into. lelnOSAaelZsyZ2an20 Website: www.depressionalliance.org

NHS Direct A 24-hour helpline offering advice on all areas of health and well-being. Tel: 0845 46 47 Website: www.nhsdirect.nhs.uk Samaritans A 24 hour service providing confidential emotional support. You can contact Samaritans by phone, e-mail, letter or visit.

Tel: 08457 90 90 90 Website: www.samaritans.org Saneline Offers emotional support and reassurance during periods of crisis, give information on local and national services and can discuss symptoms of illnesses and treatments available. Tel: 0845 767 8000 (Lines are open from 12 noon to 2 am) Website: www.sane.org.uk Papyrus Prevention of young suicide. Its helpline, HOPElineUK, offers support, practical advice and information to anyone concerned that a young person they know may be at risk of suicide. The helpline is open 7-1O0pm Monday to Friday and 2-5pm on weekends. Calls are confidential and cannot be traced. A call back service is in place for people leaving a message on the answer machine.

Tel: HOPElineUK 0870 170 4000

Access your pharmacist! If you think that your local pharmacist is only there to

Graham Phillips and Sandra Gidley

download (label) prescriptions and upload (sell) aftershave — think again! Pharmacists undergo five years of development. When it comes to medicines their help pages are more detailed than your system administrator (family doctor) and there is a whole load of back up material in many other aspects of health care. Men seem reluctant to visit their GP but visit a pharmacy quite regularly to pick up life’s peripherals such as aftershave,

condoms and vitamins. So why not take advantage of your pharmacist? He or she will be happy to discuss your technical problems whether it’s occasional sleep malfunction, the odd screen freeze (panic attack) or you feel like you’ve been attacked by some sort of virus.

How do | initialise a search for a pharmacy?

Find the green cross icon. Click and enter.

Find the green cross to access your pharmacist

How do | know which one is

Just ask! They'll be more than happy to talk to you.

the pharmacist?

But | don’t want the whole world to know my problems!

—(2)

Most modern pharmacies have a private interface (consultation) area where you can talk to someone with technical expertise and who understands the need for confidentiality. There’s a good chance there’s one less than a mile from you (both at home and at work) and it sure beats calling a premium rate number and having to deal with an anonymous help line. (Best of all there’s no press * for this, press 1 for that and definitely no

answerphone!)

But I’ve got all the peripherals | need so there’s nothing | want to buy — surely the pharmacist will just want to sell me a load of unnecessary add-ons?

In fact extensive ‘googling’ (research) shows that, on a third of all occasions, pharmacists’ output is to simply offer advice on routine maintenance without making any sale at all. Of course there will be occasions when some output from your wallet is required but this is not a mandatory component of this experience. Go on — Log Onto Your Pharmacist — It’s a fully interactive programme!

Why do pharmacists ask me so many questions every time | just want to buy some routine maintenance software (eg, vitamins?)

It's simply a safety protocol to ensure nothing goes wrong. Just as the latest software may only work with Windows XP, so it is with drugs and the body’s operating system. All computers are not the same, dependent upon memory, operating system, additional loaded programmes, etc. So pharmacists are preprogrammed to ensure that you receive the most appropriate

version of the maintenance software (medicine) risk of a system crash (side effect). They do this working through an interactive help programme questions such as: a) Who is the medicine for? b) What are the symptoms? c) How long have you (or your computer)

with the least by systematically which includes

had the

symptoms?

d) e)

What action (if any) have you taken so far? Are you taking or have you tried any software (medicine) for this?

All this is done to protect your system integrity not unnecessarily to prolong the access time!

So what technical knowledge does my pharmacist have to deal with my system errors?

(health concerns)

What about the other staff on the pharmacy help desk: are they qualified too?

It would fill quite a hefty manual. Pharmacists must undertake a four-year degree course and complete a practical year before qualifying and being allowed to staff the help desk unsupervised. They come fully loaded with a comprehensive database about medicines but also have supplementary software at their disposal. They are also loaded with interactive help programmes on health and well-being. Interestingly they run different software to the system administrator (GP) and will always refer you to one if that’s what they think you need.

All pharmacy operatives come loaded with lite versions of the pharmacists’ software which is useful but is not a comprehensive version or the full diagnostic programme. The ‘lite’ database is often sufficient to help you solve more minor system glitches but a more complex problem will automatically boot up the pharmacist when that is required.

I’m thinking of getting a ‘lifestyle’. Can the pharmacist help?

Yes. Pharmacists are now much more commonly loaded with lifestyle information. Six million people log into (visit) a UK pharmacy every day. In other words we all ‘go to the chemist’ pretty often. Many people find the interface more user friendly and less intimidating than the system administrator’s surgery. Whatever the subject there is plenty to access and pharmacists are happy to provide help on diet, sex, mental health, exercise, etc. The output is often simple advice but there are some helpful add-on products, such as vitamins, that the pharmacist can recommend as well.

Pharmacists are happy to provide help on diet, sex, mental health, exercise, etc. There are add-on products, such as vitamins, that

the pharmacist can recommend as well

It’s just a bit of stress — my pharmacist can’t help with that, surely?

Oh yes! We could go back to that improved lifestyle function we were thinking of acquiring... Don’t wanna upload that programme? In that case your friendly pharmacist will make some general recommendations about stress triggers and simple solutions such as ‘Rescue Remedy’. If it’s a real problem though then it’s off to the System Administrator (GP) with you!

Your pharmacist can even help with a bit of stress

445830

My system is run down and I’m feeling a bit low — what about inputting some St John’s Wort?

Sorry to keep harping on about this ‘lifestyle’ thingy... but often making small adjustments to your lifestyle sorts lots of other things as well. It always helps to make sure that you haven't got the equivalent of bugs or adware programmes slowing up your system. There's good medical evidence that optimising your snooze function on a regular basis, and getting puffed at least three times a week is as good for your brain (software) as it is for your body (hardware). Booze, fags and eating habits are all part of the ‘big picture’. It’s a classic case of ‘garbage in — garbage out’. So you can see, pharmacy programmes are not just about drugs: they deal with the whole system. And as for St John’s Wort... yes it certainly does have some anti-depressant and anti-anxiety action. It’s important to choose the optimum version as it can conflict with existing software (medicines) so ‘Ask Your Pharmacist’

I’m having trouble getting my hard drive to enter sleep mode - can the pharmacist help?

This will depend on the nature and cause of the malfunction. If your ‘lifestyle’ is at fault then the pharmacist may want to advise on routine system maintenance. For example, changes to the input of coffee, booze and food. With some malfunctions an increase in exercise may restore a frozen programme. As with so much else size and timing are critical. Some prescription drugs and even vitamins can affect sleep. It may be necessary to make adjustments to all of these factors in order to bring your ‘snooze’ function back into sync but the pharmacist will often suggest practical ways that you can make small changes at a time. It's simpler and often more successful than a complete system overhaul.

I’ve been suffering a lot with screen freezes and headaches recently — can the pharmacist help?

Almost definitely yes. Headaches have very many causes which can vary from eye-strain (get a screen shield) to lack of sleep or from excess alcohol to high blood-pressure. We’re back with the lifestyle thing again (yawn) and the first thing is to exclude any serious underlying system errors (So sorry guys, we're also back to lotsa questions). But assuming the issue is not severe (and doesn’t require reformatting the hard drive) pharmacists have many solutions to common headaches and even migraine. So bring your little pains to the pharmacist!

Assuming the issue is not severe,

pharmacists have many solutions to common headaches and even migraine

Me

H45831

Isn’t it better to input medicines only? After aren’t they natural so corrupt my system or

herbal all, won’t do

harm?

| think I’m having some problems with the maintenance software

(medicine) my system administrator (doctor) prescribes. Can my pharmacist help?

Negative. While it’s true that herbal medicines, administered properly can be just as effective as man made ones by the same token they have just as much potential to introduce system errors. Generally speaking man made drugs are subject to far greater bench testing and quality control than natural remedies. The government imposes very high standards of manufacturing and beta testing (clinical trials) to ensure that a drug is ‘safe’ and that it ‘works’. If it doesn't reach those standards it won't get near a doctor's prescription pad or a patient. The same cannot be said for all natural remedies. Take opium for example... a natural product made from those lovely poppies. Safe? Free of all sideeffects? We suggest not! Affirmative! Pharmacists are loaded with a particularly advanced programme on the use of medication. Their database helps identify what is effective and how to troubleshoot any problems. They know about side effects and which drugs can introduce bugs, or even a complete system failure, when used with another. Most illnesses are treated, at least to some extent, with drugs. That’s true for blood pressure, diabetes and many mental health problems. But the sad truth is that most people don’t take their medicines in the way that will benefit them most. For example blood pressure medicines must be uploaded every day to be effective. The same is true for anti-depressants, yet most people use them intermittently, not at all, or stop too soon, so they simply don’t work. So if you have any worries just ask. It doesn’t matter if it’s a frequently asked question. The government has become so concerned about the way people take their medicines they are now paying pharmacists to provide a new (free) NHS service called ‘medicines use review’. The pharmacist will spend 10 minutes or so talking to you about your medicines, how to get maximum performance, any problems you may have, etc. As part of the service they will complete a report for your system administrator and may recommend some system and software changes to help you.

Pharmacists can provide an NHS service called ‘medicines use review’ which takes about

10 minutes

British Hea

Foundatio

My doctor has prescribed some anti-depressants but | don’t want to take them in case they are addictive or contain a Trojan!

This is a common misconception. Anti-depressants are not addictive. All bugs have been removed prior to marketing. They help restore the natural system balance and in so-doing help you feel better. A few configuration problems (side-effects) are very common but are generally only troublesome for the first couple of weeks. The most important point to note is that it also takes a couple of weeks before the medicine optimises system performance. Many people stop taking the medication after about 10 days, just when the benefits are about to start — and the operating system is returning to normal. There is no justification for any stigma. It’s no different really from taking a medicine for blood pressure or diabetes — they’re not addictive either — but they also help restore your natural balance/system performance.

Won’t they think I’m being a bit of an anorak because I’ve only got a few niggling little concerns?

Why? One man’s niggle is another man’s panic attack. It’s a little known but terribly sad fact that the major cause of preventable system failure in young men under 20 is neither drugs nor AIDS but suicide. Perhaps if some of these young men would open up a bit (and the pharmacy is as good a place as any) we could do something to fix the problem. ‘Niggles’ are pharmacist’s stock-intrade — it’s what they do every day. If it is just a ‘niggle’ your pharmacist can almost definitely help... and if it’s more serious then your pharmacist will send you to your system administrator

(doc)!

Convinced?

So by now we hope you're convinced that the help-desk at your local pharmacy is a user-friendly, easy-to-access source of advice and reassurance. They can deal with a multitude of system-

related issues. Pharmacy help is open long hours and conveniently located wherever you happen to be.

So do yourself a favour... make the most of your pharmacist.

When things need fixing .

British Association to

CounsellinganuPsychotherapy

1 When systems malfunction or crash they are telling you something is wrong. All of the different types of problems described in this manual are signposts that the system needs sorting. Finding the best way of putting things right isn’t easy, and the more complex the malfunction the more difficult things can be. However, there are lots of different types of support and many organisations and experts able to help.

Isn’t asking for support a sign of weakness? 2 One of the biggest myths around is that asking for technical support is a sign of weakness. Men are particularly guilty of this, often preferring to try and sort things out by themselves rather than call in the experts when necessary (the official term for this is ‘head in the sand’ syndrome). For example, a BBC report! showed that men’s macho attitudes stopped them from going to their GP when they need to. This would be understandable if men never ever had any emotional problems. But unfortunately this isn’t true. The organisation MIND? (which is the National Association for Mental Health) tells us, for example, that:

@

Depression occurs as often in men as in women.

@

Many men with physical illnesses also suffer from low mood and mental distress.

@

One in seven men who become unemployed develop depression within six months.

@

Alcohol and substance abuse is five times more common in men than in women 3 Pretty grim reading, isn’t it? But it still seems as if some men prefer to ignore their problems, hoping things will just get better over time?. Luckily increasing numbers of men know better, realising that technical support is not a sign of weakness, but of the courage to sort things out when necessary. 4 Remember, human beings are infinitely more complicated than any machine yet invented, so the likelihood of a system malfunction is extremely high. Indeed, 1 in 44 people at any one time have some kind of mental health system problem, be it alcoholism, depression or something else. Real men know this, seek technical support, and then just get on with their life. For example, a recent survey® showed that 83% of adults have had, or would consider, having counselling or psychotherapy when they need to. Many of these are men. This is just one example but again goes to show that real men either do use, or would consider using, technical support to make things better. 5 Now for some more good news: you are likely to be one of those men. The fact that you’re reading this right now means that you are probably interested in your own well-being and you're not scared to ask questions or get help if you need it. Indeed, you've already started finding out about the role of technical support in making things better. So now we will turn to the different types of support available, finding out what they involve and how to use them if you want to.

What kind of technical support can you get? 6 There are loads of different types of technical support available. Indeed, it can sometimes be difficult to work out the right sort for you. A good first step is always to speak to your GP. for he or she will be able to point you in the right direction. Another is to find out as much as you can about the problems you are having. This might even help you sort them out, for a lot of information will contain hints and tips on making things better. Learning ways to help yourself can be a hugely valuable process in getting things back on track and keeping them there.

Self-help 7 Doing things to help yourself (self-help as it is often called) might seem like a new phenomenon, but did you know that even back in 1859, a doctor called Samuel Smiles wrote a manualé to make people help themselves in all sorts of ways, such as to work in a better way or to feel happier about their achievements? This manual, snappily titled Se/f-Help; with Illustrations of Character, Conduct and Perseverance, was So

widely read in Victorian times that it was second only in popularity to the Bible! 8 Self-help is popular nowadays too, with many books, websites and information resources available for those who wish to understand a particular type of problem and to find ways of dealing with it. Learning to help yourself may also, save you time and money. The best types of self-help materials are as follows: Books, leaflets and information packs 9 There are a vast range of books, leaflets and information packs dealing with all kinds of issues or problems. Reading

things to help you get better is called bibliotherapy. Remember this word to dazzle your friends or colleagues when you need to!

10 Your GP is likely to be able to recommend some good books, leaflets and materials, and you will find others in bookshops, libraries, dentists, health-centres, community centres and, of

course, online. There are literally thousands of organisations that can help give you information you need. Some of them include: the Samaritans, NHS Direct, Alcoholics Anonymous, National Association for Mental Health (MIND), Alzheimer’s Society, Depression Alliance, Eat Well (Food Standards Agency), etc. You can often find out how to contact these organisations in the phone book or Yellow Pages. The sections in the Yellow Pages on Counselling/Advice, Charitable/Voluntary and Health are particularly useful, containing contact details of very many organisations able to help you. Indeed, many of these organisations offer confidential telephone helplines as well. 11 If you don’t manage to find what you are looking for, another way of getting hold of information is to call the NHS Direct phonelines. These will put you through to people who know a lot about different problems, and can advise you best to find relevant materials. See Further information at the end of the Section.

The internet and websites 12 Many people have access to the internet through home or work. This is an excellent source of information for people looking for selfhelp resources. However, it is important to be careful about where you read information. Just because someone writes something down and puts it on a website doesn’t mean it’s good advice.

15 Every support group is different. Some are quite educational and will invite guest speakers to come in who are experts in that field. Other groups might have one-to-one support from a trained professional, and the rest of the time be social. Whatever the type of group, most people who enjoy support groups do so for the following reasons: @

Warning: Don’t believe everything you read on the internet! Always get your information from a trusted source. If in doubt, check out the advice with a qualified professional first. 13 There are thousands of websites designed to help people deal with particular problems or difficulties. From these you can often access leaflets, information, advice. Some also have access to experts that can help you. A good way to start looking is to go to a reputable website, such as the NHS, which will provide you with some basic information, as well as give you links to other useful sites. Other well-known organisations, such as the BBC will help you find out more. Also use search engines such as Google or Yahoo to search for sites that may be relevant. Type in a few words, such as ‘anger’ and ‘help’, and you are likely to come across some useful websites in the list provided. Surf around the internet, and see what you find. Finally, you might want to look at the Men’s Talk website. This site is designed to help men find information and help on a range of problems and issues. Like the others, it has a range of links to other organisations and resources. See Further information at the end of the Section for addresses. Support groups and organisations 14 Another really good way of helping yourself is to make contact with other people with similar problems. These people may have formed a local support group, and meet regularly to help one another deal with things. Many men have found that going to a support group is one of the best things they’ve ever done.

John’s story Since | was 15, | have used alcohol to make me feel good

about things. | always had a drink in my hand and, to be honest, loved the feeling of being drunk. However, it became a problem when | realised | was out of control, and that drink was not just something | enjoyed but something | had to have. | used to get really angry when | was drunk, and finally one night | lost it, smashing a coffee table in our front room. Then | knew | had to do something. | found a local Alcoholics Anonymous group in the phone book and agreed to go along. It was terrifying at first, and | hated having to admit to everyone there that | was an alcoholic. But they were all so supportive and friendly, helping me to realise that | was not unusual or ‘mad’. In many ways, that group turned my life around. If it wasn’t for them, | daren’t imagine where | would be today.

@ @ @ @

They thought they were the only ones in their situation, but found other people with the same problems. They feel totally accepted by people who understand what they're going through. They are able to help out other people with their own experience. They can sit quietly and just listen, with no pressure to talk if they don’t want to. Support groups are often a good place to get access to other

information, books and leaflets. 16 If you are not sure if a group is for you, many will offer taster sessions. You can go along for a meeting or two and see if it’s for you. You never know, you might make good friends there too. 17 You can find out about support groups and organisations from libraries, health-centres, the internet, telephone directories and, of course, your GP. Local newspapers may also have adverts for upcoming meetings.

Your GP is a technical wizard! 18 Your GP is a pretty important person to know in helping you find the right sort of help. See, the reason for this is that your GP is paid to know about systems like yours, and how best to deal with malfunctions or crashes. Often this just involves helping identify what the problem is, and then helping you find the right kind of self-help information or support organisation. However, sometimes the system might need more expert help, having a more complex problem or long-running malfunction. In such cases your GP knows loads of professional technicians able to help, and will even contact them for you. One common type of technician is a counsellor or psychotherapist. In the next section we will look at what this kind of technician does, and how they may be able to help when a system malfunctions or crashes. You can choose! 19 Did you know that you can ask to see a specific doctor at your surgery? If you like a particular doctor or want to see a male doctor, you can ask the receptionist when you phone to make your appointment. Sometimes you might have to wait a day or so longer, but if this is what has stopped you going before, it might just be worth it.

Counselling and psychotherapy 20 Counselling and psychotherapy are often called ‘talking therapies’ because they involve talking about what is going wrong and finding ways of making things better. Talking about things often helps because it enables the cause of a problem to be identified, which helps you to consider different ways of dealing with it. Although, in the past, some people viewed talking about

things as a sign of weakness, Surveys now show that things are changing. Indeed a recent survey” found that 72% of people think everyone would be happier if they talked more about their feelings. Of course, certain types of feelings or problems are easier to deal with than others. But in most cases, there is strong evidence’ to show that simply talking about things with a trained counsellor or psychotherapist is a great way of helping things to change. 21 So what is the difference between counselling and psychotherapy? Well, often not a great deal. Counselling is generally considered to take less time (often between 6 and 20 sessions) and focuses mainly difficulties you are experiencing in your life at present. 22 Psychotherapy takes longer, sometimes years, and looks in depth at your past as well as present. However, generally speaking, counselling and psychotherapy involve the same thing — talking through things with a trained practitioner who is there to help you find ways of making things better.

The different types of counselling and psychotherapy 23 Like computer programmers or mechanics, every counsellor or psychotherapist has a preferred way of doing things. However, there are some particular methods of counselling and psychotherapy that are very popular. Some of the most popular are:

a) b) c)

Some common myths about counselling

and psychotherapy There are loads and loads of myths about counselling and psychotherapy. Three of the most common are as follows: Myth 1 — Counselling and psychotherapy is for women Loads of men see a counsellor or psychotherapist. Indeed up to around a third of all people seeing a counsellor or psychotherapist at any one time are male9. And some are very well known — think of Will Smith, Jonn Cleese, Paul Merton, Stan Collymore, Woody Allen, Paul Gascoigne ... and many, many more. Myth 2 — My mates will laugh at me Maybe, but most people like to be around men who take responsibility for themselves and sort things out when they need to. More important though, is the question ‘how would your mates know?’ Your counsellor or psychotherapist won't say anything. They are bound by strict rules of confidentiality!°.

Myth 3 - I’ll have to talk about things | don’t want to Again, utter nonsense. A counsellor or psychotherapist might ask you questions, but will not make you talk about anything you feel extremely uncomfortable about. Indeed, it would be the last thing they would want.

Person-centred. Psychodynamic. Cognitive-behavioural.

d) — Solution-focused. 24 These technical terms might seem quite daunting but what they mean is not really something to worry about. Do you always want to know exactly how a technician does his job if it works? No, didn’t think so. 25 The main thing to think about is if you and your counsellor or psychotherapist get on, and if what they are doing is helping you to eventually feel better about things. Indeed, most scientific evidence shows that the most important thing in counselling and psychotherapy is a good, trusting relationship!!. However, if you do want to find out more on all the different approaches that are be used, a good book to read is called Who Can | Talk to? The Users Guide to Therapy by Judy Cooper and Jenny Lewis?!2. You should be able to get hold of it through your local library or bookshop. Alternatively, a free information booklet called Ja/king Therapies is available from The Department of Health (see Further information for contact details). 26 As well as working in a particular way, lots of counsellors and psychotherapists specialise in particular problems or issues. For example, some are experts in working with depression or anxiety, others help people with difficulties linked to bereavement, abuse, sexuality or alcohol. It is always worth trying to find someone who knows a bit about the type of problems you are having. Indeed, it might be worth seeing a counsellor or psychotherapist with your wife or partner, if the problems you are having are

related to how you get on with one another. Couples often see a counsellor or psychotherapist together for reasons such as sexual difficulties, arguing all the time or simply not getting on well enough. The are many people who specialise in this kind of work, often called relationship counselling. A good place to find out more is to contact the organisation, Relate (see their advert in Yellow Pages for your local branch). 27 So, what actually happens when you see a counsellor or psychotherapist? 28 You are right to ask that question. Before seeing a counsellor or psychotherapist a lot of men feel really worried that they feel really uncomfortable, embarrassed or simply stuck for words. They also worry about what the counsellor or psychotherapist will think about them, whether they well see them as ‘mad’ or wasting their time. However, you can put your mind at rest. Counselling and psychotherapy is a very user-friendly process, and you will be put at ease as much as possible. Counsellors and psychotherapists are familiar with working with all types of people and therefore are very unlikely to be judgemental about you and your problems. Sometimes, of course, you might not like the counsellor or psychotherapist you are working with. If so, it might be best to find someone else instead. However, don’t be too hasty in deciding to do this. It might be that you need to get to know them a bit better. They may have hidden depths! 29 Remember, you are always in control of counselling and psychotherapy. If you feel unhappy or want to see a certain type

of person, such as another male, make this clear as soon as you can. Tell this to your GP as well. And remember, it sometimes can take a while to find someone you feel happy to work with. Don’t ever feel uncomfortable about asking to see someone else or stopping counselling or psychotherapy for a while. Face-to-face 30 The most common way of seeing a counsellor or psychotherapist is to meet face-to face. They will have their own room which will probably have some comfy chairs for you to relax into while you talk. It’s generally quite an informal process, and you will be there for between 50 minutes to an hour (this is often called a ‘session’ or ‘meeting’). If you want to, you will be able to finish early. However, most men find that once they start talking about things with someone trained to help them, the time just flies by. In groups 31 Sometimes it is possible to join a counselling or psychotherapy group, often called group therapy. This is like a support group and involves people talking about their problems with the other members of the group, who may offer advice or speak about their own experiences. However, these groups are run by at least one, and possibly two, trained counsellors or psychotherapists. By telephone 32 An increasing amount of counselling and psychotherapy is now taking place by telephone. One reason for this is that it is so much easier for you and your counsellor or psychotherapist to get together. Neither of you will have to travel far and you can talk in the comfort of your own home, at a time you know will be OK. Lots of organisations offer telephone counselling or psychotherapy services. You can find out about these from your GP, or in many of the ways we looked at earlier. Alternatively, the Samaritans provide free 24-hour confidential emotional support over the telephone which is open to everyone. Even online 33 Using e-mail and the internet is also a popular way of having a counsellor or psychotherapy. How this works is that you and the counsellor or psychotherapist agree to send e-mail messages backwards and forwards over a period of time. Alternatively, you can agree to send instant messages or talk in a confidential chat room where what you type immediately pops up on the other person’s screen. Some people even meet their counsellor or psychotherapist by web cam. 34 One of the nice things about online counselling is that you can go at your own pace and feel comfortable in revealing what you want to about yourself and your problems. Unless you want them to, your counsellor or psychotherapist won't be able to see you or even know your name.

So how do you contact a counsellor or psychotherapist? 35 There are lots of different ways of finding a counsellor or psychotherapist when you need to. The easiest ways of doing so are as follows. Speak to your GP 36 As you now know, your GP is a technical wizard who knows

an awful lot of expert technicians who can help. Many GP practices have their very own counsellor or psychotherapist, who they can arrange for you to see. You might have to ask though, as GPs often assume that men won't be interested in counselling and psychotherapy. Those GPs with no in-house counsellor or psychotherapist will probably have a list of local agencies or organisations that offer free or low-cost counselling. They will be happy to copy this for you. Use your workplace counselling service 37 Loads of employers now provide a confidential counselling service for their staff, recognising that things can be difficult at work and that, sometimes, people need technical support to get things back on track. Indeed, a recent survey on behalf of the British Association for Counselling and Psychotherapy showed that more than 7 out of 10 people found work itself stressful. And of course stress is one of the most common system malfunctions. So if you work for a big company or organisation, it is highly likely that they have some kind of programme designed to support their employees. This might be called ‘employee assistance’, or something similar, and it is likely to offer free counselling either online, telephone or face-to-face. Don’t worry though, most workplace counselling is completely confidential, so nobody will know. If you are worried about this, do check first. Agencies, organisations and charities

38 There are literally thousands of agencies, charities and organisations offering counselling and psychotherapy to men. These might be community-based, or specialise in a particular mental health problem, such as depression or drugs. Those local to you will often be found in the Yellow Pages (often under Counselling and Advice), online, or advertising in your local health centre or community centre. Your local library may also have lists of counselling services for you to look at.

Going private 39 Lots of men who decide to see a counsellor or psychotherapist prefer to find one who works privately. This is sometimes necessary if waiting lists are long, or if it is proving difficult to find someone you get along with. The best way finding a counsellor or psychotherapist who works privately is to look on the lists of accredited or registered practitioners maintained by the British Association for Counselling and Psychotherapy (see Further information for contact details). This organisation will also be able to give you some information on the different types of counselling and psychotherapy and advise you on what to look for in a good practitioner. Private counselling or psychotherapy is not free, and can cost quite a lot of money (between £25 to £100 per session). However, most practitioners offer concessions for those on low incomes.

Psychologists 40 Psychologists do a very similar job to counsellors and psychotherapists, in that they use talking therapy to find out what is causing a particular problem and help make it better. Most psychologists work in the NHS and are often more specialised than counsellors or psychotherapists, so sometimes deal with more complicated problems or difficulties. Psychologists also tend to focus upon short-term treatments and mostly use an approach called Cognitive Behaviour Therapy. This approach looks at problems in terms of the links between thoughts, emotions and

behaviours, which might sound like a very strange idea but it is really very simple. For example, if, say, your mate John thinks his workmate is trying to get one over on him all the time, he starts feeling very stressed and angry; a feeling that makes him feel physically tense. As the weeks pass, his body starts to suffer as a result of all this tension and eventually John stops being able to go to work because he feels so tired all the time. However, not going to work makes him feel even worse, because now also he thinks he has let himself down. This thought makes him even more stressed and frustrated, which increases the level of physical tension in his body. The effect of this is that he feels even more tired, and thus can’t return to work for an even longer period. And so on and so on... 41 What has just been described is a vicious circle, a very common system malfunction which psychologists are very skilled in helping people deal with. As you have seen, it involves what we think, feel and do affecting one another and making each one worse. 42 Psychologists help to change things by looking at a vicious circle such as John’s, and by finding ways to break it. If you think seeing a psychologist might help you it is important to speak to your GP. Again, he is able to refer you to see one. Indeed, he might even suggest this is something you do, if you have a problem that might be helped in this way.

Complementary (or alternative) therapies 43 Complementary (or alternative) therapies have been around for a long time. These are non-medical treatments such as acupuncture, chiropractic treatment, hypnotherapy, homeopathy, massage and meditation which can really help you feel better about things. They are called ‘complementary’ therapies because they are generally based on the principles of nature, and are often seen as an ‘alternative’ to the way doctors make things better through manufactured medicines and drugs. 44 Lots of men now use complementary therapies to help them deal with system malfunctions. For example, meditation (calming the mind) or other relaxation techniques (eg, deep breathing) can help manage worries or low mood, as well as invigorating the

body (through resting the muscles). Things like reflexology and massage can also help, although do make sure you see someone who is properly trained, experienced and registered with a professional body or organisation. Make sure they have lots of training and experience as well, by asking about this before booking an appointment. You can find out more about complementary or alternative therapies in various ways. There are lots of books in your local library on different types of therapy, and loads of practitioners advertise in the Yellow Pages (under Complementary Therapies). Meditate and learn to fly! 45 Did you know that there is a type of mediation called Yogic Flying'?, where you start to bounce up and down on crossed legs, eventually learning to fly around the room! Maybe it’s something to learn to impress your friends, although a hard hat is recommended for experienced practitioners. Ceilings can hurt when approached at speed... Exercise 46 Guess what one of the cheapest and most effective forms of complementary therapy is called? Yes, it’s EXERCISE! Simply

Simply doing some more exercise can make many problems so much better

doing some more exercise can make many problems so much

better. In 2002, the organisation MIND!4 looked at the benefits of exercise. They looked at people who did regular exercise and asked them what benefits they found: @ 75% of respondents said they felt better about their physical appearance, as it had improved. @ 66% said they were eating more healthily. 59% said exercise had helped them maintain their mental health. 57% said their relationship with their partner had improved. 32% said their performance at work had improved. 28% said their sex life/sex drive had improved. 13% said their relationships with their children had improved. 47 So just getting out and doing more physical activity can be hugely beneficial in loads of different ways. However, be very careful to check with your GP if you have ongoing health problems before starting any new exercise regime.

Psychiatrist 48 Sometimes a system malfunction or crash requires very significant technical expertise to sort it out. A specialist is needed who can both understand what is happening as well as use a whole range of methods for making it better. A psychiatrist is a medically trained doctor who specialises in the diagnosis and treatment of serious mental health problems. As medical professionals, psychiatrists are able to prescribe medications for particular difficulties, so have a wide range of tools to help you get better. Psychiatrists are not experts in talking therapies, and in the NHS often work with alongside a psychologist or a Community Psychiatric Nurse (CPN) in helping you make progress. Alternatively, they may invite you to see a counsellor or

psychotherapist, take part in a support group or visit a hospital (either to stay for a short while or as an ‘out-patient’) to help you get back to normal. 49 In some rare cases, a psychiatrist does have the power to make you take the medicines they prescribe or undergo the treatment they think will help. This only happens in extreme cases, for example if you are having such significant problems that you present a risk to your own health or that of other people. In such circumstances it is likely that you will be initially admitted to a hospital ward (often called an in-patient psychiatric unit), designed to allow staff to take better care of you than if you were at home. Sometimes this will only be a short stay until they have worked out the best way to treat you. 50 However, it’s important to remember that you shouldn't be scared of speaking to a psychiatrist. If your doctor feels this is the best approach for you then you may as well take advantage of the significant expertise on offer. Psychiatrists will, in general, want to find the quickest and most effective method of making things better, while minimising any disruption to your everyday life.

See a shrink! 51 Did you know that the word ‘shrink’ is a shortened form of ‘headshrinker,’ and was originally meant as an insult to psychiatrists? ‘Head shrinking’ refers to the practice of certain primitive tribes of decapitating enemies and preserving their heads as trophies. So, if you see a display cabinet in your psychiatrist's office with rows and rows of shrunken heads it might be a good idea to start looking for someone else to speak to...

Using medicines 52 Medicines are a very common way of helping people deal with problems, and you might have heard people make jokes

about ‘keep taking the tablets’ when prescribed drugs for mental health difficulties. However, there are many medicines that can have a really effective role in dealing with such system malfunctions or crashes. These can include medicines to help you feel less depressed (often known as anti-depressants), those to help you deal with worries and lack of sleep, as well as those designed to stop things like hallucinations or overwhelming thoughts. 53 Often you will find that your GP or psychiatrist will want you to use medicines to help you deal with system malfunctions when they occur. This is always something you should consider very seriously, for medicines have been shown to have a positive effect on many people. However, if it is at all possible, the best way of making things better when using medicines is to see a counsellor, psychotherapist or psychologist at the same time. This way, you are not only helping take away the symptoms of the problem (using the medicine), you are talking about what caused it and finding ways of making things better in the future. 54 All medicines are carefully designed but have to be used with caution, particularly if you are taking more than one at the same time. Some also have side effects, such as making you sweat or feel restless. If you start to take a medicine and you don't like the effect it is having you must speak to your GP or psychiatrist as soon as possible. They may wish to alter the dose or try something different. 55 Linked to this is a common myth that taking any medication can make you feel like a zombie. In really extreme conditions, a psychiatrist might give someone a powerful medicine to stop them hurting themselves, until a proper treatment is given. However, in most cases, this doesn’t happen and the medicines used often just make things seem more manageable. Furthermore, they generally seem to work, which is always a good thing.

References 1 2 3

4 5

6

8 9

BBC News, Monday, 24 May, 1999 www.mind.org.uk See Millar, A. (2003). Men’s Experiences of Considering Counselling: entering the unknown. Counselling and Psychotherapy Research: 3 (1). Statistics on Mental Health. www.mentalhealth.org.uk The Age of Therapy. Exploring attitudes towards acceptance of counselling and psychotherapy in Britain. Project by the Future Foundation on behalf of the British Association for Counselling and Psychotherapy Smiles, S (reprinted 1996). Self-Help; with illustrations of Character, Conduct and Perseverance. Civitas: London. The Age of Therapy, Op Cit. Treatment Choice in Psychological Therapies. www.doh.gov.uk/treatmentguideline For example, a 2004 survey showed that around 35% of all college and university students seeing a counsellor or psychotherapist were male. www.aucc.uk.com

10

All counsellors and psychotherapists agree to a set of ethical guidelines regarding how they practise. You can find an example of this at www.bacp.co.uk/ethical guidelines

11 See Choosing Talking Therapies. Available at 12 13

www.doh.gov.uk/mentalhealth or by post on 01623 724524. Published by Headway Books in 1995. See PermanentPeace.org/technology/yogic_flying.htm|

14 www.mind.org.uk

Further information Some useful websites: www.alcoholconcern.org.uk www.alcoholics-anonymous.org.uk www.alzheimers.org.uk

www.bbc.co.uk www.cancerbacup.org.uk www.cancerhelp.org.uk www.depressionalliance.org www.diabetes.org.uk www.fpa.org.uk www.google.com www.mens-talk.co.uk www.mentalhealth.org www.mindovermood.com www.nhsdirect.nhs.uk www.samaritans.org www.yahoo.com British Association for Counselling and Psychotherapy A list of practitioners in counselling and psychotherapy in your area and details of useful contacts can be found at: Tel: 0870 443 5252 E-mail: [email protected] Website: www.bacp.co.uk If you don’t manage to find what you are looking for, another way of getting hold of information is to call the NHS Direct. These will put you through to people who know a lot about different problems, and can advise you best to find relevant materials. Tel: 0845 46 47 in England and Wales Tel: 08454 24 24 24 in Scotland Both these numbers are available 24 hours a day

The free information booklet called Ta/king Therapies is available from The Department of Health. You can get hold of this by writing to: DH Publications, PO Box 777, London SE1 6XH E-mail: [email protected]

Samaritans Tel: 08457 90 90 90 (24 hour telephone counselling service)

Complementary medicine Making complementary medicine work for you 1 This Section will help you to make sure that you know what questions to ask and what information you need to give, to get the best out of your treatment. It will explain the following: @ How complementary and conventional medicine work together. How to decide what treatment you need. Questions to ask about your treatment.

What complementary therapies are regulated. How to decide which therapy to use.

What is complementary medicine? 2 Complementary medicine includes health-related therapies and treatments that are available in addition to conventional medical treatment (from a health professional such as a GP, nurse, pharmacist, etc). Complementary medicine can be used alongside conventional medicine. There are many different kinds of complementary therapies and treatments available including acupuncture, chiropractic, herbal medicine and osteopathy. Complementary and conventional medicine working together 3 Complementary medicine is becoming increasingly popular and there is now good evidence that some complementary treatments can be effective. Complementary medicine is not an alternative to seeing your GP, nurse, hospital doctor, pharmacist or other health professional for conventional diagnosis and treatment. Using both complementary and conventional medicine and treatment can offer you a wide range of choice to help you manage your health. This is why some GP practices now offer access to some form of complementary therapy. 4 |n order to get the best out of any treatment or medicine it is important to make sure that the health professional or complementary practitioner treating or advising you is fully informed about any other treatments or medicines you may be taking (including any supplements like vitamins and minerals).

Mixing medicines 5 Some medicines, whether they are prescription, over-thecounter or complementary can interact with other medicines to produce unpleasant side-effects. They can also block the effects of other medicines and stop them from working. For example,

women using the contraceptive pill should not take St John’s Wort (a herbal medicine commonly used to help reduce depression and anxiety) as it may stop their Pill from working. 6 Always check with your pharmacist, GP or complementary practitioner if you are taking or planning to take more than one treatment. Taking more than one medicine may also mean that you get too much of a particular ingredient. Medicines you buy from a pharmacy, including complementary medicines, can be just as strong as prescription medicine. This is why mixing medicines and treatments can be dangerous. Make sure a health professional (such as your GP or pharmacist) or a complementary

practitioner knows if you are taking (or planning to take) anything else or receiving any other treatment so that they can give you the best advice.

Deciding what treatment you need Treating your ailment yourself 7 Decide if you can treat your health problem yourself with selfcare or advice from your pharmacist, NHS Direct, or complementary practitioner.

Diagnosis and treatment 8 If you need more advice or treatment you should call NHS Direct or your GP surgery to make an appointment. It is important that you are properly diagnosed by your GP or practice nurse to make sure that any illness is identified. 9 If you wish to use complementary medicine for your condition you can get advice from a health professional: @ Some GP practices provide access to complementary practitioners so may be able to refer you. @ Some pharmacies sell complementary medicines and pharmacists can give you the appropriate advice. Make sure you tell your pharmacist, GP or complementary practitioner about any prescription or over-the-counter medicines you are taking. See Deciding which therapy to use.

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Ask about your treatment 10 Make sure you get the best from your complementary medicine. Here are some questions to ask your complementary practitioner or health professional if you are thinking about using complementary medicine:

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What will this treatment do? How long will | need to be treated for? How much will it cost? Can | take this treatment alongside other treatment/medicines | am taking? @ What are the chances of side-effects or after-effects? 11 All medicines come with instructions on how to take them and details of what they contain. Always read the label and the instruction leaflet before you take any medicine. If you are unclear or worried about your medicine ask your pharmacist or complementary practitioner.

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Regulation means that there is a system governing how a health professional works. It determines what happens if you are unhappy with your treatment or something goes wrong, and should also ensure high standards of practice.

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There is no single regulatory system that oversees the work of all complementary healthcare practitioners in the UK. Some complementary medicine practitioners are regulated by law. Like doctors and nurses, they have a body that all practitioners have to be registered with to legally practice. The two complementary professions in the UK regulated by law are osteopaths (by the General Osteopathic Council) and chiropractors (by the General Chiropractic Council). There are complementary healthcare professions which use a voluntary system of regulation (such as acupuncture and herbal medicine at present) but without a legal requirement to register practitioners’ standards of training, and practice may vary.

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Other complementary healthcare professions are not regulated by law. Some are at different stages of developing voluntary systems of regulation and are working together to develop common standards of training and practice. Standards of training can vary so it is important that you have reliable up-todate information. Check the Prince of Wales’s Foundation for Integrated Health website to find out more about regulation.

Deciding which therapy to use 12 |t can sometimes be difficult to find out if a complementary therapy is recognised by experts to be effective. In some cases there is clear and reliable evidence. In other cases there may be evidence but it may not be reliable for a number of reasons — for example if it is based on too few people to be able to draw a reliable conclusion. In still more cases there is no evidence at all. However, this does not necessarily mean the therapy does not work. 13 A complementary practitioner or health professional such as a GP or pharmacist may be able to advise you on which complementary therapy can best meet your needs.

Further information 14 To find out more about individual therapies you can contact The Prince of Wales’s Foundation for Integrated Health. The Prince of Wales’s Foundation for Integrated Health 12 Chillingworth Road London N7 8QJ Tel: 020 7619 6140 E-mail: [email protected] Website: www.fihealth.org.uk

Meditation, happiness,

personality and the brain David Peters

What is meditation anyway? 1 Meditation is a state of mind, not a religion — though it features in most major religions, especially Eastern ones. When science first took an interest in Transcendental Meditation in the 1970s it soon became clear that TM boosts slow ‘alpha waves’ and harmonizes the two hemispheres to produce a ‘relaxation response’ (the opposite of what the body and mind do when you feel stressed). More recently, neuroscientists have been putting Buddhist monks — experts in a practice called Mindfulness — into brain scanners, to discover why it trains their attention to become broader and more flexible. Mindfulness is the mirror image of Attention Deficit Disorder: it makes you more aware of what's going on around you, more chilled in emotionally charged situations, more ‘able to live in the present moment’. Not only can it boost creativity, but your immunity, too. And it appears to be the best treatment for severe chronic pain, as well as panic disorder. If Mindfulness were a drug, patients would be clamouring for prescriptions.

Why should meditation matter to me? 2 Perhaps you need any of these proven benefits; perhaps you simply want to feel better and calmer, have more energy, and need less sleep. Then again, you might be fascinated by what neuroscience has discovered about the way meditation can alter brain size and circuitry. 3 The amygdala may be the key, because it gate-keeps the

balance between the right and left brain. Having evolved as part brain the amygdala is a much simpler and

of the mammalian Unnecessary conflict is more likely where previous experiences,

shocks and trauma bias the amygdala to switch into networks that light up the right frontal cortex

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faster processor than the newly evolved frontal cortex whose vast networks of deep and wide processing give us reason and intelligence. The amygdala’s job is more basic: it scans all sensory and emotional inputs and triggers the response needed. For this survival circuitry to be life-saving, it must do this even before data can reach the neocortex — because we need to spot the bear and leg it without stopping to think first. This makes the amygdala lightning fast, but error-prone: in a risk-free, though high-emotion situation it may flip the flight and fight switch before we know what’s happening. The stressful consequences — unnecessary conflict, anger, or irrational anxiety — are more likely where previous experiences, shocks and trauma (and genetic

tendencies) bias the amygdala to switch into networks that light up the right frontal cortex. Psychologists call this ‘instability’.

Brain studies and personality types 4 lf your brain processing networks prod you more toward incentives and stimulation, you will be more extravert; more introverted if you avoid them. Neuroscientists call the brain networks that push this mental/emotional accelerator pedal, the Behavioural Approach System or BAS. People with high BAS activity tend to be outer-directed, stimulus-loving, sociable, affectionate, talkative and fun (more aggressive and dominant too). People with these extravert characteristics are more prone to be happy, but only if they are ’stable’: ‘unstable’ extraverts are typically the heart attack prone ‘hostile type As’. Neuroscientists see the left frontal cortex and the neurotransmitter dopamine as heavily implicated in the BAS networks. 5 The Behavioural Inhibition System or BIS is the complementary network. Someone with a more active BIS will be prone to negative emotions, because the BIS processing promotes avoidance and aversion. It’s a mental/emotional brake pedal and when it's on we pause and withdraw from stimulation to scan the environment for threats. High-BIS people are more introverted: inner-directed, stimulus-avoiding and tend to be more anxious, depressed, moody, pessimistic, and self-conscious extraverts; and especially if ‘unstable’, more unhappy too. The right frontal cortex and the neurotransmitter serotonin are much involved in the BIS

networks (most antidepressant drugs boost brain serotonin). 6 The trigger-happy amygdala may be the key to ‘instability’; it lights the short fuse that causes these negative over-reaction. And it's how our reactions to life events that in the long-term causes unhappiness, rather than the events themselves. Our reaction style will be strongly affected by personality factors, ingrained (possibly genetic) and enduring tendency that make a person more, or less introvert or extravert. But the good news is that ‘instability’ can be shifted. This is where meditation comes in: recent neuroscience shows that even a new-comers to meditation can boost left frontal cortex activity a little. What's more amazing is that long-term meditators can supercharge it. 7 Mindfulness-based stress reduction or MBSR is now widely researched. The University of Massachusetts Medical School’s Mindfulness-Based Stress Reduction Programme deals with

chronic pain and illness, anxiety and panic, digestive distress, sleep disturbances, fatigue, high blood pressure and headaches. People who complete the eight weekly classes and the one day course experience a lasting decrease in physical and psychological symptoms, more ability to relax, reduced pain levels and an enhanced ability to cope with pain, greater energy and enthusiasm for life, improved self-esteem, and an ability to cope more effectively with both short and long-term stressful situations.

Complementary therapies and the brain 8 Biochemical therapies work on cells and tissues to stimulate under-active chemical pathways or damp down over-active ones. Drugs work this way; can herbs, unconventional diets and nutritional supplements? The herb St Johns Wort can be as effective as prescribed antidepressants for moderate depression, probably because it increases levels of serotonin in the brain. Fish oil supplements are said to be effective for depression too, and may help prevent Alzheimer’s Disease. 9 Structural therapies work on the body, using touch, massage, stretching and manipulation to release tension, improve circulation and encourage relaxation. They can mobilise stiff stuck joints and reduce pain. The relaxation response produces a particular brain state with denser alpha rhythms. Some gentle forms of bodywork (cranial osteopathy, cranio-sacral therapy) claim to produce beneficial rhythmic micro-movements in the skull bones, and a widespread normalisation of tension and organ function. Simple forms of acupuncture needling can stimulate the body to produce pain-killing endorphins in the brain, but brain scans show they stimulate particular brain networks too. 10 Psychosocial therapies ranging from meditation and hypnotherapy, to counselling and a great variety of new psychotherapies which offer new options to people with mental health problems. New approaches to post-traumatic stress disorder use eye movements or tapping on the body to ‘reprogramme’ the way the amygdala and the right/left cortex process memory and shock. 11 Energetic therapies like homeopathy, healing, and traditional acupuncture are harder for science to grasp. They explain their effects in terms of the movement of a ‘life-energy’ that science has yet to detect. The nearest thing to it may be the flow of information that coordinates the intricate processes of mind and body. Only lately has science begun to appreciate that this information is carried not only by electrical impulses in the nervous system, and in hormones, but also in ‘molecules of

emotion’ that allow a two way stream of messages between brain and body. The latest news is that nano-molecular circuitry

connect each cell nucleus to its cell membrane, run out into the connective tissue and through to other cells; this whole-body biophysical matrix makes it possible for pulsations, pressure, rhythm and touch to communicate information deep into the tissues of brain and body.

Use your brain when you use the net Jim Pollard

On the internet there's a lot you can't see: is this independent site really trying to sell you something?

The human brain is a wonder but even the very best would struggle to keep up with the speed at which the world wide web is growing. Google, the most-used search engine, includes about eight billion pages but that’s the tip of a very big iceberg. Some experts reckon the true number of pages is nearer 3,000 billion — 3,000,000,000,000 — and that the web is growing by maybe 25,000 pages an hour. Mindboggling. There’s a lot of information out there but, of course, what you'll want to know depends on who you are. The information needs of someone with a diagnosis of depression will be different from those of someone who wants to ease their stress at work, the needs of someone with a phobia differ from those of someone with epilepsy, the needs of a someone worried about their memory are different from those of his or her doctor. Looking for information related to mental health and wellbeing reveals both the best and the worst of the internet. It’s good news that you can look up anything you want, post to sites, read bulletin boards and blogs and all sort of other things and do it all anonymously. You can even get help in a crisis online by emailing [email protected]. The problem arises when you want to go beyond this. On the internet you can’t see the cowboys’ black hats. To find a therapist, counsellor or someone to talk to, it’s vital that you go only through the sites of recognised professional bodies such as the British Association for Counselling and Psychotherapy (www.bacp.co.uk) or the United Kingdom Council for Psychotherapy (www.psychotherapy.org.uk).

As for talking itself, there’s only so far you can go online in a chat room or bulletin board. They’re no substitute for real conversations with real people. It’s only through real conversations with real people — and here | mean everyone including professionals, family, friends, the lot — that any of us can find contentment and well-being. The internet itself can be addictive. So can some of things available through it such as gambling, pornography and non-stop shopping. In other words, using the internet in an unhealthy way can become part of the problem rather than the solution. To use the internet to find out what you want to know takes time and a little knowledge about how internet search engines work. The first thing to note is that despite their name, internet search engines do not actually search the internet. They search their own databases which in turn link to real websites. Search engines use programs called spiders to check these links from time to time but they are not always up to date. That’s why you sometimes click on a link on a search engine to a page that is no longer there. Spiders find new pages to add to their database by going to the pages they already know about and following the links from those pages. In other words, if a page is not linked to any other, a spider cannot find it. An unlinked site will only appear on a search engine if it has been submitted to it directly. (Google and all search engines offer this facility.) Search engine statistics are staggering. The website searchenginewatch reports that in December 2005, there were nearly 5.1 billion search engine searches — a 55% increase on December 2004. Many of these searches turn up millions of pages. Do a Google search on ‘mental health’ and you'll get 245,000,000 results. Refine that to ‘counselling’ and you'll still get 43,300,000. Where do you start? The top of the list? Not necessarily. Spiders rely on links to find new sites. Search engines use a similar system to govern where on a search a particular site appears. Generally speaking, the more links, the higher the ranking. The theory is that the number of links reflects the popularity and-so the usefulness of that site. This sounds fine in theory but may simply mean that the website has included as many links as possible — never mind the quality or relevance. Many commercial sites have long lists of so-called ‘links’. Good sites choose their links more carefully and so might appear further down the search list as a result. The Men’s Health Forum website, malehealth.co.uk, for example, is inundated with proposed link ‘exchanges’, many from wholly unsuitable sites. The Forum rarely says yes. But the reality is that if they did malehealth would feature far higher on web searches. Search engines also tend to prioritise sites which are selling something rather than those offering merely information. Is the organisation running the site you're looking at reliable? Many sites have an About Us section which you can check out. If you don’t know who they are, be wary. Is the site simply a shop window or part of the marketing of a product or does it aim to provide information for its own sake?

Refine your search To get the best out of a search engine, try to be specific. Use the ‘advanced search’ option if available. This may allow you to select only UK sites or only those updated in, say, the last three months. This is not because you are only interested in new information but because you may want to avoid dormant sites which are no longer being updated. You aren't restricted to searching for individual words. You can use speech marks to search for specific phrases. For example, to search for “post traumatic stress disorder”. Also use + (plus) and - (hyphen/minus) to narrow down your results. For example: psychotherapy +’Sigmund Freud” will retrieve items that mention both psychotherapy and its founder. The minus command might help if, for example, you’d forgotten Mr Freud’s first name but wanted to avoid references to his famous descendents whose names you did know. A search for Freud -Clement -Emma would not display pages about the former MP or the TV presenter. A combination of the above can be very powerful indeed, enabling pinpoint searches. For example, “post-traumatic stress” +”Dr Smith” +”Belchester Bugle” could help you to track down an article even when the writer has the commonest of names. This assumes, of course, that your search engine is aware of the Belchester Bugle website which, as we've already seen, is far from guaranteed. Although most search engines recognise short-cuts like pluses and minuses, not all engines work in the same way so a bit of trial and error is needed to get the best out of them. (Search engines within a particular site — rather than a global search engine like Google — can be particularly frustrating as they are frequently built on far simpler technology.)

Get a second opinion Not only do search engines all work differently, they also all include different content. Many, many pages appear only on one search engine and no other so it’s always worth getting a second or third opinion. Google (www.google.com) may be the most popular search engine but there is also Yahoo (www.yahoo.com),

MSN (search.msn.com), AOL (search.aol.com), Ask (www.ask.com or www.myway.com) and more. So should you use the web to find advice on mental health and well-being? Yes, but be careful. As you will have learned from this book, we’re all different and we each have our own needs when it comes to being — and feeling — well. That’s where the health professional comes in. The internet is a resource that can help you get the most from a conversation or a consultation. But it is not a substitute for a health professional and it is never a substitute for real talking. Don’t underestimate the value of the net. Simply remember that you use it at your own risk. The best place to start is malehealth.co.uk. Run by the Men’s Health Forum, it’s fast, free and independent with up to date sections on mental health and well-being and links that you can trust.

Further reading Peter Baker Real Health for Men (Vega, 2002) Edmund J Bourne The Anxiety & Phobia Workbook (New Harbinger Publications, 2005) Richard L Gregory Eye and brain: The Psychology of Seeing (Oxford University Press, 1997) Dr Kenneth Hambly Overcoming tension (Sheldon Press, 1983) P de Silva and S Rachman Obsessive Compulsive Disorder (Oxford Medical Press, 2004) Jim Pollard A/! Right, Mate? - an easy intro to men's health

(Vista, 1999) Jeffrey Schwarz Brain Lock (HarperCollins, 1997) Frank Tallis Understanding Obsessions and Compulsions — a self help guide (Sheldon Press, 1992) Claire Weekes Simple, effective treatment of agoraphobia (Angus & Robertson, 1984)

Contacts We don't have room to include contact details here, but you'll find them on the malehealth website: www.malehealth.co.uk

BODYWORK. Understanding and looking after yours and those you care about In general, men are likely to look after their cars better than their own bodies and, while vehicle MoTs are required by law, there is no such equivalent for the driver. The fact that generations of men have come to trust and rely on the advice contained in Haynes manuals to look after their motor vehicles is fundamental to the development of this unique series of books. Each of these manuals presents factual, no-nonsense health advice in a well tried accessible manner. There are numerous illustrations and diagrams to support the Jargon free text along with fault finding charts more familiar to mechanics than medics. If anything is going to persuade men to take an interest in their own health and the health of their nearest and dearest, it is the Haynes Family Manual Series. All written from hands-on experience by healthcare professionals and in conjunction with the Men’s Health Forum, these manuals represent a truly dramatic breakthrough in the communication of health information to men.

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