Nicotine Paradox and Gender Differences in Schizophrenia

Nesbitt's Paradox: Why Smokers Report Feeling Relaxed

One of the paradoxes about nicotine addiction is that smokers report feeling relaxed after using, in spite of the fact that nicotine is a biological stimulant. The phenomenon is known in the literature as Nesbitt's Paradox, or simply the nicotine paradox. Early research into Nesbitt's Paradox revealed that a number of potential variables influence the perception of a relaxed emotional response. Behavioral activity levels, the level of central nervous system arousal, the type of emotion being reported, time elapsed since the last nicotine fix, and both the rate and dose of administration are linked to perceived emotional responses to smoking cigarettes containing nicotine (Gilbert, 1979). Of these variables, the degree of nicotine deprivation has been most closely linked to the paradoxical sensation that a stimulant creates a relaxation response.

The solution to the paradox, then, is that addiction to nicotine creates sensations of anxiety, irritability, and distress, and these symptoms are alleviated by a "fix." As Parrott (2002) puts it, there is no paradox at all. Addiction creates withdrawal symptoms, which include heightened states of arousal. Smoking alleviates the withdrawal symptoms and therefore makes the smoker feel more relaxed.

Mood Normalization and the Role of Nicotine Withdrawal

One of the functions of smoking is "mood normalization," according to Parrott (2002, p. 27). In other words, smokers begin to need nicotine in order to "feel" or "function" normally (Parrott, 2002, p. 27). This would account for the fact that smokers report feeling more relaxed after smoking. The central nervous system is measurably aroused, and yet psychologically the person feels relieved after satisfying the craving that feeds the addiction.

It should also be noted that not all smokers report feeling reduced anxiety; many report feeling increased anxiety, agitation, and restlessness (Gilani, n.d.). How a person feels after smoking is related to how long the person has been addicted to cigarettes, how long the withdrawal period has lasted, and how anxiety-prone that person was regardless of smoking.

Anxiety Sensitivity and Individual Differences in Smokers

The nicotine paradox is therefore slightly more complex than being related only to nicotine withdrawal. Evatt and Kassel (2010) found that there are differences between smokers who are sensitive or prone to anxiety and those who are not as easily aroused. High-anxiety smokers tend to report feeling more relaxed after smoking when in a stressful condition, but do not report reduced anxiety after a low-stress condition. In other words, persons prone to feeling a baseline level of anxiety react differently to nicotine than their lower-anxiety counterparts. Persons not as prone to experiencing anxiety actually report that smoking calms them at all times (Evatt & Kassel, 2010). These findings nonetheless substantiate the basic notion that Nesbitt's Paradox is related more to nicotine withdrawal than to actual reductions in biological features of anxiety in smokers.

There are additional variables that must be taken into consideration when evaluating the nicotine paradox. For example, persons who have pre-existing anxiety tendencies might be more prone to becoming addicted to cigarettes. This would mean that smokers set themselves up for a feedback loop in which their addiction creates an illusory means of self-medicating for an anxiety disorder.

Gender Differences in Schizophrenia Onset and Outcomes

Gender differences in schizophrenia etiology, onset, prevalence, and outcome are well documented, but the biological reasons for these differences are not completely understood. Usall, Ochoa, Araya, and Marquez (2003) conducted a study suggesting that women have better outcomes than men, but the research contains internal flaws. For example, the study included 126 men and only 74 women — hardly an even sample. This appears to substantiate findings by Longenecker et al. (2010), whose meta-analysis found that women are significantly under-represented in non-epidemiological research on schizophrenia. Furthermore, the Usall et al. (2003) study fails to account for social and other variables that might cause the increased rate of male hospitalizations and increased length of male hospital stays. For example, it is possible that males exhibit more socially undesirable symptoms and thus find themselves hospitalized against their will more often. It is also possible that their behaviors in hospitals present more concerns than those exhibited by female patients. Likewise, parents might be alert to symptoms in boys earlier than in girls because of gender differences in self-expression or socialization. Males with schizophrenia might also exhibit "socially adverse illness behaviors," which would cause a perceived poorer outcome score in research (Hafner, 2003).

The robustness of research results would also be improved if "outcomes" were operationalized in terms of specific features of positive outcomes. Some research suggests that there are no gender differences between female and male schizophrenia patients in terms of social functioning (Mueser et al., 2010). Other studies do show that males with schizophrenia exhibit poorer social functioning compared with females (Hafner, 2003). The difference could be linked to poorer social development at illness onset (Hafner, 2003). Hafner (2003) also reports no gender differences in symptomology, lifetime risk, or symptom-related course of the illness, even when age is a controlled variable. Because symptomology is generally measured in qualitative rather than quantitative terms, it may be difficult to determine with certainty whether outcomes are actually better for females than for males. Social functioning remains a core dependent variable in outcome-based research.

Ochoa et al. (2012) offer a unique hypothesis related to gender differences in schizophrenia outcomes. Males with schizophrenia are more likely to develop substance abuse problems, which may account for their longer periods of hospitalization and worse exhibition of symptoms that can be considered social, cognitive, or affective. Still, women do appear to have lower rates of symptom relapse and better remission outcomes compared with their male counterparts (Ochoa et al., 2012).