Morning anxiety can be a shock to your system that lays the foundation for a long, anxiety-filled day. If you’ve ever been jolted awake by an obnoxious alarm clock and immediately started worrying about the day ahead and/or the mistakes you think you made yesterday, you’ve begun your day frantically and with anxiety. You don’t have to continue to live this way. Read on to learn how to get rid of morning anxiety.

Anxiety in the Morning

Experiencing anxiety in the morning is common. When we first wake up, we are predisposed to anxiety and stress. Morning anxiety, even extreme morning anxiety, has nothing to do with our flaws or weaknesses. It has much to do with our physiology.

It is in the morning that our bodies produce the greatest amount of cortisol (Manfred, n.d.). The surge of cortisol happens in order to wake us up. That’s not a problem. The issue is that cortisol also happens to be a stress hormone involved in our fight-or-flight response to danger. The increased production of cortisol contributes to morning anxiety in many people.

Our physiology’s involvement in morning anxiety doesn’t stop with cortisol. In the morning, we naturally have low blood sugar due to hours without food (Manfred, n.d.). Low blood sugar (hypoglycemia) can increase anxiety, and the physical symptoms of hypoglycemia mimic symptoms of a panic attack. If severe morning anxiety has you experiencing anxiety attacks before you even get out of bed, you may actually be experiencing hypoglycemia. Keeping healthy food by your bedside, such as whole grain crackers, unsalted nuts, or granola bars (not overly processed, full-of-refined-sugar granola bars) to eat first thing when you awaken can help head off that panicky feeling.

In addition to keeping healthy, energy-inducing snacks handy, there are other ways to get rid of morning anxiety.

Tips for Managing Morning Anxiety

Cortisol and low blood sugar are indeed contributing factors to morning anxiety. Anxiety in the morning is also typically one part of the bigger picture of your anxiety as a whole. Certain lifestyle changes can help get rid of anxiety in the morning.

• Practice deep breathing during the day and upon waking up in the morning.
• Exercise during the day, which reduces anxiety and keeps it at a consistently lower level.
• Eliminate caffeine.
• Decrease your exposure to news, as doing so reduces anxiety during the day and makes you less likely to wake up and instantly worrying,
• Use an alarm that has a pleasant tone; being shocked awake by beeping and buzzing starts the heart racing, setting anxiety into motion even before your mind catches up.
• Practice good sleep hygiene, such as going to bed early enough to allow for seven- to eight hours of sleep, making your room comfortable, and avoiding using anything with a screen an hour or two before bed can help you get enough sleep so you don’t wake up tired and ill-equipped to deal with anxiety.
• Notice your negative thoughts and replace them with positive, realistic thoughts. Positive affirmations for anxiety work well for this. Have statements by your bed ready to go in the morning. Choosing a few statements to read and re-read is a great way to change anxious thoughts.
• Create a relaxing morning ritual to give yourself a pleasant start to the morning.

Keep Morning Anxiety from Ruining Your Day

Sometimes, it’s hard to get rid of morning anxiety no matter what you do. This is actually okay. Experiencing even severe anxiety in the morning doesn’t have to set the tone for your whole day.

Anxiety demands attention, but the more you focus on it, the stronger it grows because that is where your thoughts and emotions lie. Rather than fighting with your morning anxiety, try these methods for distancing yourself so you can make a good day despite starting off with morning anxiety (Peterson, 2016).

• Just observe your thoughts rather than getting tangled with them. It’s not the anxious thoughts that cause the most trouble; it’s how you react to them that can make your morning miserable.
• Separate yourself from the content of the anxiety. If anxiety is telling you you’re worthless, for example, use a positive affirmation that replaces this thought with something accurate.
• Remember your “why.” Why do you want to get up? What do you value in your day?
• Action speaks louder than anxiety. You don’t need this anxiety to go away before you get up and act.

Morning is important because it sets your day. To get rid of morning anxiety, use the above tips, and create the right mindset to keep morning anxiety from ruining your day. Anxiety is loud, but it’s not in charge. You can deal with even severe morning anxiety and create a positive day.

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Whether or not marijuana helps anxiety is largely unknown (Chopra et al, 2010). The evidence is mixed regarding the effectiveness of cannabis (Are Herbs and Supplements for Anxiety Safe?). This is largely because there isn’t a great amount of research into the use of medical marijuana for anxiety; marijuana’s federally illegal status inhibits research.

One thing is known: “Marijuana affects the brain” (Casarett, 2015, p. 12). According to Casarett, the brain has numerous cannabinoid receptors throughout multiple areas. These bind to components of cannabis and affect conditions like anxiety. It seems that cannabis for anxiety can act on the brain’s circuitry in quite a focused manner rather than providing general relaxation.

The Term Marijuana Refers to Different Substances

A reason there is mixed opinion regarding the effectiveness of medical marijuana for anxiety is that the terms for the substance can be misleading. Marijuana and cannabis aren’t what act on the brain. “Cannabis” is the scientific name for the entire plant, but it can also represent the drug and other products made from the flowers of the plant. “Marijuana” is a synonym for cannabis when it applies to the drug. What people typically refer to when they use the terms “marijuana” and “cannabis” are the psychoactive substances of the plant known as THC and CBD.

It is THC and CBD that affect the brain and anxiety (Casarett, 2015). They’re different, they have different effects, and their differences contribute to the mixed evidence of the ability of medical cannabis to help anxiety. In Stoned: A Doctor’s Case for Medical Marijuana, Casarett (2015) explains the difference between THC and CBD.

THC is the abbreviation for tetrahydrocannabinol. Researchers have learned that THC

• may not be safe to use,
• causes the euphoria associated with cannabis use,
• can be calming in low doses, and
• can cause or aggravate anxiety in higher doses.

CBD, short for cannabidiol, has received more favorable attention than THC.

• It isn’t as psychoactive as THC (it doesn’t make people high).
• CBD is a sedative that lowers anxiety.
• CBD doesn’t increase or cause anxiety the way THC does.

Positive Aspects of Cannabis and Anxiety

Using cannabis, specifically CBD, for anxiety does have some potential benefits.

• CBD is calming, as is THC in low doses; therefore, marijuana can help panic attacks and anxiety in general.
• Some people who experience anxiety report that medical marijuana makes them more relaxed so they can function better.
• Some experts believe that marijuana is safe to use because it’s neither toxic nor deadly, nor does it cause other medical problems (Weil & Rosen, 2004).
• Marijuana isn’t associated with problematic withdrawal symptoms.

These findings in support of medical marijuana for anxiety are encouraging. They don’t, however, paint the whole picture.

Risks to Cannabis Use for Anxiety

Again, there haven’t been enough studies to provide definitive evidence for or against anxiety and cannabis use. Some facts and information are being discovered. As mentioned above, marijuana does have positive attributes. It also has known risks. Separately, Weil & Rosen (2004) and Chopra et al (2010) report risks of cannabis use for anxiety.

• It is fat-soluble (particularly THC), so it remains in the body for a long time.
• The abuse factor is higher than that of psychedelic drugs.
• Marijuana makes concentration difficult.
• It decreases coordination.
• Smoking cannabis can damage the lungs.
• When eaten, cannabis is absorbed unevenly, making its effects on the body and brain irregular.
• Cannabis makes the mind feel fuzzy.
• It interferes with memory.
• The feeling of sedation it creates can become too strong, impairing functioning.
• People can develop a tolerance (as with alcohol for anxiety), creating dependency and need for more.
• Reactions to marijuana include panic attacks, which increase anxiety in general.
• Cannabis use can increase the heart rate, which can spark an anxiety attack.

Medical Marijuana for Anxiety: For Better or Worse

When considering using medical marijuana for anxiety, keep in mind that while it can induce feelings of calm and relaxation, it doesn’t address anxiety itself. Cannabis and anxiety can have a dysfunctional relationship. Cannabis may just mask the symptoms of anxiety rather than fixing underlying problems. Consequently, people remain in a state of anxiety when not using the substance, which increases the desire to use more.

Because the evidence about its risks and benefits is mixed, whether or not to use medical marijuana to help your anxiety isn’t a simple decision. If you decide to use it, consult with a doctor to know if it is right for you and your unique anxiety. Remember, too, that with marijuana, less is more. The less frequently you use it, the more likely it is to work (Weil & Rosen, 2004).

Medical marijuana can help anxiety. Medical marijuana can make it worse. Know exactly what you’re putting into your body. CBD seems to be safer and more effective than THC. Informing yourself is the best thing you can do for your anxiety.

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Although it might seem like a chore or even homework, worksheets to guide you through dealing with post-traumatic stress disorder (PTSD) symptoms are useful tools, especially if you’re the kind of person who likes to write things down or if you aren’t sure where to start. PTSD self-help worksheets can come in many different forms and be used for different purposes, but overall they aim to help you through your process of PTSD recovery and act as another self-help strategy.

What Can I Expect from PTSD Self-Help Worksheets?

Some PTSD self-help worksheets might be simple exercises you can do or checklists that get you started with knowing the basics before you move to the next steps. Others are more involved and require you to really pay attention to your PTSD signs, symptoms, and feelings and then document, analyze, and even challenge them, usually with a chart. These kinds of worksheets get you more familiar with the intricacies of your PTSD in order to confront and address them more effectively.

Although this might seem daunting, understanding the particulars of your disorder itself can be a strategy for combatting PTSD. When you use these worksheets, keep them to look back on; doing so will not only show you patterns in your own behaviors and reactions but may alert you to PTSD triggers you weren’t aware of or didn’t think were so serious. Comparing them over time will also help you track the progress you’ve made and show you what you’ve learned.

If you’re also seeing a counselor or therapist as a part of your recovery, bring the PTSD worksheets to your session. Together, you should be able to form an even stronger treatment plan.

Self-Help Strategies for PTSD Used in Worksheets

Here are a few of the most popular PTSD self-help strategies and exercises you will come across using PTSD worksheets.

1. Breathing techniques. Understanding how our breathing changes in moments of anxiety and how that affects everything from the pace of our thoughts to the way our body responds to situations is an important part of the self-help process. Learning or following along with breathing exercises can be the first step to making a difference in coping with PTSD anxiety and stress. 
2. Identify and challenge what you’re thinking or feeling. Depending on the severity of your symptoms, this one may be difficult. However, challenging the negative thoughts and feelings of helplessness or high anxiety can serve to break you out of that state and force you to focus on the facts and realities. Some worksheets help you accomplish this by asking you to identify the thought, emotion, or sensation, and then have you answer why you’re feeling that or what triggered it, how it’s impacting you, and what you can do to change it. Some will even ask you to fill in an alternate thought on the sheet.
3. Form a plan to move forward. Many worksheets outline different ways to move forward, whether it’s working through facing things you’ve been avoiding, changing negative self-talk, or having plans on what to do if you encounter situations that unexpectedly trigger your PTSD.

There are a number of free PTSD self-help worksheets available to download and try across the Internet. Here are a few you can start with right now, courtesy of psychologytools.com and get.gg.

See also:

How Can Depression Worksheets Benefit Your Mental Health?

Many teenage girls and young women wonder if what happened to them is "really" rape or sexual assault. In plain English, here are the legal definitions of sexual assault and rape.

According to New York State statutes, sexual assault is defined in various degrees. However, the basic summary is as follows:

Rape is the perpetuation of an act of sexual intercourse with a person against his or her will and consent, whether his/her will is overcome by force or fear resulting from the threat of force, or by drugs administered without consent or when, because of mental deficiency s/he is incapable of giving consent or when s/he is below the arbitrary age of consent.

In other words, the term "rape" is used when penetration is involved, even slight penetration, and even if no ejaculation occurs. Also note that the threat of force is sufficient - many people report fearing for their lives even when their attacker is not carrying a weapon.

New York State law does recognize that a married woman can be raped by her husband. Marriage does not necessarily imply consent.

Rape in the first degree is defined as above, and the age of consent is seventeen (17).

Rape in the second degree is not defined by consent. Rather, when one person is over 18 and the other is less than 14 years of age, the State defined any sexual intercourse between them as rape.

Rape in the third degree is similarly defined. Here, one person is over 21 and the other is less than 17 years of age.

Sexual Abuse is also defined in three degrees, according to the same system as rape. However, the difference is that penetration is not required. Rather, all that is required is "sexual contact" - touching of intimate or sexual parts, either directly or through clothing.

Therefore, sexual abuse in the first degree is roughly defined as sexual contact by force or threat of force, or when the individual is incapable of consenting due to mental deficiency, or when the individual is below age 17.

Criminal sexual acts is the third major term, and is also defined in three degrees. This term is used when the assault involves penetration to areas other than the vagina (e.g. rectum).

Sexual assault of any kind is a felony.

The belief that alcohol helps anxiety is common. People often use alcohol as a way to cope with anxiety, stress, and tension, believing that alcohol induces relaxation. Turning to a substance such as alcohol to reduce anxiety is known as self-medication. People don’t use alcohol to treat anxiety because they are weak or “bad” but because they are attempting to deal with the awful experience of anxiety by treating themselves.

Once people begin to use alcohol for their anxiety, they often continue to do so. Alcohol, after all, is a sedative, a depressant for the nervous system. It does help people relax and lower their feelings of anxiety, which can take the mind off problems.

Occasional mild- to moderate alcohol use can actually be safe and reasonable. Unfortunately, when people are self-medicating for anxiety, alcohol use can easily escalate to a level at which it does not help anxiety and actually increases it.

When Alcohol Use for Anxiety Becomes Dangerous

Alcohol quickly shifts from helping to harming because, despite its temporary ability to lower anxiety, it isn’t truly an anxiety treatment. Genuine anxiety treatments work with your mind and body to systematically lower anxiety as well as help you cope with it.

Alcohol, on the other hand, temporarily masks symptoms of anxiety. Then the alcohol leaves your system and the effects wear off. When your blood alcohol content (BAC) drops, you crash. Anxiety returns in full force or even worse than it was before alcohol entered your system.

Anxiety and Alcohol Abuse

Alcohol use for anxiety becomes dangerous when drinking goes beyond moderate. Moderate alcohol use is frequently defined as two drinks per day for adult men and one drink per day for adult women (Cherney & Jewell, 2016). This is a very general guideline, as people are unique. Alcohol affects everyone differently.

When people use alcohol for anxiety and stress management, the initial experience of relaxation stops occurring because the body becomes tolerant of the level of alcohol consumed. A greater amount of alcohol is needed for anxiety reduction. Not only are higher and higher quantities of alcohol needed to feel better, when the alcohol exits the bloodstream, it becomes increasingly difficult to manage anxiety. People become reliant on alcohol to help with anxiety, but their anxiety grows because of it. The cycle continues and can easily spiral out of control.

Alcohol also becomes dangerous when prescription anxiety medication is involved. Serious side effects, some of which may be life-threatening, can occur when alcohol mixes with the chemicals in pharmaceuticals. It’s extremely important to be honest with your doctor if you are using both anxiety medication and alcohol.

Does Alcohol Cause Anxiety?

Alcohol’s help for anxiety is small and temporary. It doesn’t help anxiety in a satisfactory way, but does alcohol cause anxiety? Yes, it can. It can also exacerbate existing anxiety and make it much more difficult to manage.

The relationship between anxiety and alcohol has become increasingly clear thanks to research (Clark, 2006). We know with certainty that alcohol affects anxiety negatively.

• Alcohol increases existing symptoms of anxiety.
• Alcohol increases or causes anxiety during the period of time when it is used as well as during times of withdrawal.
• When alcohol takes over once tolerance develops, it creates more anxiety, and that increased anxiety is stronger and harder to manage.
• As BAC drops, anxiety returns with a vengeance and can be long-lasting.
• Alcohol changes the levels of neurotransmitters such as serotonin in the brain.

Moderate alcohol use has been proven to worsen existing anxiety. When moderate use becomes heavy drinking, it can cause new anxiety. Either way, anxiety is a side effect of alcohol (Cherney & Jewell, 2016).

How Heavy Alcohol Use Causes Anxiety

Describing an extensive study he and colleagues engaged in, Dr. Thomas Kash (2012) explains that heavy alcohol use causes anxiety because it disrupts functioning at the molecular level. Alcohol can cause anxiety because it damages the brain. Says Kash, heavy alcohol use can

• change the shape of nerve cells in the prefrontal cortex,
• suppress nerve receptors,
• disrupt specific brain circuits such as those implicated in anxiety, and
• interfere in the way “our cognitive brain centers control our emotional brain centers,” making emotions and experiences like anxiety dominate over rational thought processes.

Alcohol and anxiety are a harmful, even dangerous, combination. Alcohol affects anxiety by increasing it as well as causing it. Heavy alcohol use damages and disrupts the functioning of the brain and directly causes and increases anxiety.

While it can be genuinely tempting to use alcohol to help anxiety, alcohol isn’t a safe or effective anxiety treatment. Occasional moderate use can start out innocently, but beware the tolerance that develops and the increasing need for alcohol. Other treatments such as anxiety self-help, therapy, and medication will be much more successful in the long run.

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Numerous herbs and nutritional supplements have been shown through scientific research to reduce and prevent anxiety. Many people like them not only because they can be effective, but also because they tend to have fewer side effects than prescription anxiety medication. To find and use supplements and natural remedies that improve anxiety safely, without major, lasting side effects would be a great way to get rid of anxiety and thrive.

Herbs and supplements do offer great potential in anxiety treatment; however an important question must be explored: are herbs and supplements for anxiety safe? Do they do more harm than good when used to lower anxiety?

Many herbs are benign and don’t impair bodily functioning (Russo, 2001). Generally, most herbs and supplements are considered safe, but like anything you put in your body, they have the potential to be dangerous. The following considerations can help you decide if herbs or supplements are right for you.

Caution: Herbs and Supplements Aren’t Regulated by the FDA

The U.S. Food and Drug Administration (FDA) oversees the food and pharmaceutical industries to make sure the foods we eat and the substances we take are safe. The FDA does not regulate the herb and supplement industries, however.

Without FDA regulation, it can be difficult to know what, exactly, you are getting when you purchase herbs or supplements for anxiety. Things like strength, effectiveness, and safety can be a mystery.

Further, without FDA oversight, there is a lack of standardization in the supplement and herbal industries. This means that the exact ingredients, quality, strength, and quantities of products vary across brands. One brand’s products might be stronger than another’s, for example, which makes it difficult to know how much to safely and effectively take for anxiety.

While researchers have learned many of the herbs and supplements that work for anxiety, researchers typically aren’t the people who are manufacturing them and selling them to individuals for anxiety management. So an herb, vitamin, or mineral might itself be safe, but the way it’s manufactured and sold may be ineffective at best and harmful at worst.

Many companies that produce supplements and herbs hold themselves to high standards and produce quality products. The safety and consistency of the products simply aren’t tested by the FDA and thus can’t be guaranteed.

Important Considerations in Using Supplements and Herbs for Anxiety

In addition to the precaution about non-regulation by the FDA, some other factors bear mentioning to help you decide if herbs and supplements for anxiety are right for you.

• Herbs and supplements shouldn’t be taken alongside prescription medication, as dangerous, and possibly life-threatening, interactions can occur.
• Even when taken on their own, without prescription medication involved, herbs and supplements for anxiety can sometimes cause dangerous side effects.
• For a great many herbs and supplements, short-term use is considered safe; however, long-term use can lead to unpleasant side effects. For some supplements and herbs, long-term effects are still unknown.
• Some supplements are water-soluble, which means that they aren’t stored in the body and are therefore considered safe. It’s impossible to overdose on water-soluble substances because they are flushed out of the body.
• Other supplements are fat-soluble. These are stored in the body and can build up to toxic levels. Overdose is possible with fat-soluble supplements.
• Some herbs are considered safe for the general population but not for special populations such as children, the elderly, pregnant women, and people with compromised immune systems.

Everybody is different. Our anxiety is unique, and our bodies are unique. It’s possible for an herb or supplement for anxiety to be safe for one person but dangerous for another. Make sure you treat your anxiety in a way that is effective for you.

For Herb- and Supplement Safety, Consult Your Doctor or Professional

Herbs and supplements for anxiety can be effective ways to enhance wellbeing and live anxiety-free. There are indeed safety considerations, but the best way to determine if herbs and supplements are safe for you is to consult with your doctor, an herbalist, or a naturopath.

If you are taking any prescription medication, whether or not it’s for anxiety, it’s imperative to talk to your medical doctor before proceeding with herbal or supplemental remedies because of the risk of dangerous, even life-threatening interactions.

Inform yourself about herbs and supplements. Working with a professional can be helpful so you can receive recommendations tailored for your unique body, anxiety, and lifestyle. Consulting books on herbs and supplements for anxiety can also help you choose a program that is safe.

Consulting with a professional to make sure you follow a nutrition and supplement plan that works for you personally is the best way to benefit from herbs and supplements for anxiety. This can help you feel confident that the herbs and supplements you are using for anxiety are safe.

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Supplements are specific nutritional elements that are added to your daily diet. Supplements include vitamins, minerals, herbs, amino acids, and other dietary enhancements, and together, they help increase our health and wellbeing. They can improve specific conditions, including anxiety. Taking vitamins, herbs, and supplements can prevent anxiety as well as reduce your anxiety symptoms.

How Supplements, Vitamins and Herbs for Anxiety Work

During times of anxiety, the human body rapidly depletes stores of important nutrients. Deficiencies in such things as B-vitamins can cause anxiety, fatigue, restlessness, and irritability. Further, we become more easily excitable and jittery. Lack of nutrients can cause symptoms that mimic anxiety and anxiety attacks. Also, we are zapped of the energy we need to function well and reduce anxiety (List of Foods That Help and Hurt Anxiety).

Anti-anxiety supplements work to replace lost vitamins and minerals. Doing so can increase calm and feelings of relaxation, soothe the nervous system, and aid in the making of neurotransmitters, key brain chemicals that play an important role in anxiety and other mental health conditions. When we have proper nutrients, we are better equipped to handle stress. Vitamins, minerals, herbs, and other supplements help restore balance within our body’s system, including the brain, and they center our thoughts and emotions.

Below is a list of vitamins, minerals, herbs, and other supplements that research has linked to anxiety improvement. These anti-anxiety supplements can help you strengthen yourself from within and equip your body to stave off anxiety.

One caveat before diving into the list: it’s important to talk to your doctor before starting any supplement program. Supplements aren’t for everyone. Certain groups such as pregnant women, children, the elderly, and people with compromised immune systems shouldn’t take supplements unless instructed by a doctor. Supplements can also cause dangerous symptoms or interactions in anyone, not just people in high-risk categories. Given that the goal is to be healthy and reduce anxiety, it’s wise to have the guidance of a healthcare professional (see Are Herbs and Supplements for Anxiety Safe?).

Anti-Anxiety Vitamins

Vitamin C and the B vitamins play an important role in decreasing anxiety and reducing stress. They calm the nervous system, adrenal glands, and brain chemistry. The following vitamins are B vitamins:

• thiamin (B1),
• riboflavin (B2),
• niacin or niacinamide (B3),
• pantothenic acid (B4),
• pyridoxine (B6),
• biotin
• folic acid or folate
• choline
• inositol
• cyanocobalamin (B12)
• para-aminobenzoic acid (PABA)

Minerals for Anxiety

Some minerals work together, so it’s best to take them in combinations as delineated here.

• Calcium and magnesium tranquilize and relieve tension.
• Potassium, phosphorus, and zinc help the nervous system and can keep anxiety at bay (deficiencies in phosphorus, for example, can contribute to anxiety).
• Iron supplements prevent deficiencies that can increase panic attacks.

Anti-Anxiety Herbs

Like vitamins and minerals, herbs work in multiple ways to reduce anxiety (Do Herbal Remedies for Anxiety Really Work?). They can be tranquilizing and calming, they can revitalize the nervous system, improve concentration, and induce sleep. Some herbs known to help anxiety are

• chamomile,
• verbena
• lavender,
• skull cap,
• lemon balm,
• passionflower,
• ginko biloba,
• ginseng,
• St. John’s Wort,
• ginger,
• kava-kava (or simply kava),
• valerian,
• rose petals,
• ashwaghanda,
• lemongrass,
• dried red clover.

Other Anti-Anxiety Supplements

Many essential nutrients exist to reduce anxiety and calm your body systems. In addition to vitamins, minerals, and herbs, these supplements also help anxiety:

• bioflavonoids,
• amino acids,
• glutamine,
• glycogenic amino acids,
• gamma-aminobutyric acid (GABA),
• tryptophan,
• flaxseed,
• melatonin (a hormone supplement).

Supplementing your diet with essential nutrients is an effective way to treat and prevent anxiety. Vitamins, minerals, herbs, and other supplements for anxiety provide your body with the substances it needs to be well and anxiety-free.

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Contents:

• Impotence
• Physical Causes of Impotence
• Treatment of Physical Impotence
• Psychological Causes of Impotence
• Premature Ejaculation
• Retarded Ejaculation

Impotence

The word impotence is derived from the Latin impotentia, meaning lack of power. It was first used to describe loss of sexual power in 1655 in, of all places, a treatise entitled 'Church History of Britain' by Thomas Fuller.

Impotence is the inability to obtain or maintain an erection for the satisfactory completion of heterosexual vaginal intercourse. Satisfactory is usually taken to mean an adequate erection, of sufficient hardness, maintained for a sufficient length of time, that ends in a controlled ejaculation and provides sexual satisfaction for both partners.

Impotence is a common and distressing condition affecting 10 to 30 percent of men on a regular basis. All age groups are involved, but due to embarrassment or a mistaken belief that nothing can be done, victims often suffer in silence and despair. Whatever the cause of impotence, 99 percent of men can get their erections back by one of the many treatment options now available.

It is often assumed that impotence is a purely psychological problem, but in 40 percent of cases, a physical cause is involved. If a man awakes with a morning erection or can masturbate to orgasm when alone, the problem is more likely to be psychological rather than physical.

If a male never manages an erection, even on waking, a physical problem is likely and this must be carefully looked into by a doctor specializing in urology.

During a night's sleep, between four and eight erections occur naturally unless there is a physical blockage preventing them. A special device can be attached to the penis before going to sleep that regularly measures penile diameter and rigidity throughout the night. This is useful for differentiating between physical and psychological causes of impotence.

Often, however, both physical and psychological factors play a role as a vicious circle builds up that causes anxiety and negative feelings to set in.

Physical Causes of Impotence

The most common physical cause of impotence is tiredness, overwork and stress. It is perfectly normal to perform under par in these circumstances. Other physical causes include drug side-effects, hardening of the arteries (atherosclerosis), leaking valves that stop blood pooling within spongy tissues, fibrosis, hormonal imbalances and nerve damage.

Drug Side-effects

Drug side-effects are a common and reversible cause of impotence. Among the prescription drugs, the worst offenders are beta-blockers which work by damping down the activity of certain types of nerve. Beta-blockers are excellent drugs which are frequently prescribed to treat high blood pressure, angina, heart attacks, anxiety, palpitations, migraine, glaucoma and an over-active thyroid, but if this side-effect becomes troublesome it is important to tell your doctor so you can be switched to a different type of drug.

Thiazide diuretics (water tablets) prescribed to lower high blood pressure or reduce fluid accumulation in the body can also trigger erectile failure. Patients taking diuretics are twice as likely to be impotent as those on no drugs. Again, tell your doctor; alternative treatments are available.

Anti-depressant tablets affect nerve endings in the nervous system and can also be at fault.

If you are taking any drugs at all it is worth asking your doctor or a pharmacist whether these are likely to affect your sex drive.

It is easy to forget that cigarette smoke contains a powerful drug, nicotine. Cigarette smoking is closely linked with erectile failure, and there is a clear dose-related effect: the more cigarettes smoked per day, the less rigid the erection. Cigarette smoking damages blood vessels and hastens 'furring up' of the arteries.

Atherosclerosis

Hardening and furring of the arteries is common in late middle age. Sometimes, the arteries leading to the penis become blocked and furred up with cholesterol deposits. This poor circulation means blood cannot flow into the penis in the volume required for a normal erection, and impotence results.

Tests that outline blood flow into the penis (using dyes that show up on X-ray) will show any narrowing of the arteries that may be the cause. Ultrasound is also sometimes used to measure changes to the blood flow after injection with an erection-inducing drug.

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Slow Leaks

In some males, erection starts off rigidly and then slowly sags due to a slow leak of blood out of the corpora cavernosa and corpus spongiosum (see Chapter 1). This is due to a weakness in the mechanisms that constrict outlet veins and prevent pooling blood from draining away during erection. This problem can be detected by special tests using dyes that show up on X-ray (cavernosometry). Venous leaks are a common cause of impotence in older men. Some men suffer from both poor blood supply and a venous leak.

Fibrosiss

If the blood supply is normal, fibrosis or a build-up of scar tissue (e.g. Peyronie's Disease) can make the penis rigid on one side, rather than expansile. This stops the penis inflating fully, or makes it curve dramatically and painfully to one side. This can cause partial or total impotence. Surgical treatment to remove the scar tissue, or to take a tuck in the opposite side so erections become straight again, can help solve this problem.

Hormonal Imbalances

Occasionally, a hormonal imbalance may be the cause of impotence, especially if testosterone hormone levels are too low or prolactin hormone levels too high. If you suffer from impotence you will have blood tests to screen for hormonal problems. If an imbalance is found, this is usually easily treated once its cause is sorted out.

Diabetes

Diabetes causes impotence for two main reasons: it encourages furring up of the arteries (atherosclerosis) and, if not well controlled, can lead to permanent nerve damage from the high levels of circulating sugar.

Nerve Damage

Diseases or injuries that affect the nerves can cause impotence. This includes men who suffer from severe multiple sclerosis, or who have sustained a spinal cord injury as a result, for example, of breaking their back. Sometimes reflex erections occur but ejaculation is not normally possible without electrical stimulation.

The Treatment of Physical Impotence

The treatment of physical impotence is now sophisticated. Several options are available after full investigations have suggested the likely cause.

Oral Drugs

International trials of an oral drug treatment for impotence are currently underway. The drug, a derivative of yohimbine hydrochloride, is derived from the African Pausinystalis Yohimbe tree. Results of the trials are expected soon but it will be a few years before it becomes widely available on the market.

Topical GTN

Glyceryl trinitrate (GTN) is a drug normally used to treat heart angina pains. GTN dilates blood vessels and increases blood flow. Research has found that GTN patches applied to the penis for one to two hours before intercourse can help to overcome impotence. Of 10 males aged 4571 who had suffered impotence for an average of five years, four achieved an erection with intercourse and ejaculation a success rate of 40 per cent.

The use of GTN patches has an advantage over GTN creams, as the latter are absorbed by vaginal tissues and cause the side-effect of headaches in any female partners.

Vacuum Erections

For a vacuum erection the penis is placed in a plastic cylinder from which air is extracted via a pump. The resultant partial vacuum makes the penis fill with blood and triggers an erection. A tight ring is then placed around the base of the penile shaft to trap the blood and maintain rigidity. The penis then remains erect once the vacuum cylinder is removed. Obviously, as it acts rather like a tourniquet, the penis looks a little blue, and the ring can only be left in place for a short while (otherwise the blood supply of the penis may be compromised). Another problem is that the elastic band prevents semen coming out of the tip of the penis during ejaculation. Semen may seep out later, or may wash into the bladder to be urinated away. This is not harmful but does affect fertility.

P.I.P.E.

Some patients are taught to give themselves an injection into the shaft of the penis. This is known as P.I.P.E. Pharmacologically Induced Penile Erection. The injections are given via a very fine needle inserted into the corpora cavernosa. The shaft of the penis is not very pain-sensitive and the injections are described as no more painful than a mosquito bite. After withdrawing the needle, the injection site is pressed firmly for 30 seconds so that no bleeding occurs. After 510 minutes, an erection starts to form as the arteries supplying blood to the penis dilate and draining veins constrict.

The commonly used drug, papaverine, can induce prolonged erections and priapism, however. Priapism is a surgical emergency the penis needs to be drained of trapped blood to restore the circulation. Papaverine can also cause internal scarring and curvature (Peyronie's disease) in a few males. In the majority of cases, nevertheless, P.I.P.E. is very successful and has transformed the lives of many impotent males.

Another drug, prostaglandin E1, is prescribed instead of papaverine by some doctors as it has a lower risk of side-effects.

A new development is a self-injection system known as Caverject (alprostadil). This works in a similar manner to prostaglandin E1 and can be prescribed by doctors. Some men find it more painful than other drug treatments, however.

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Vascular Surgery

If there is a physical blockage to penile blood inflow, it is possible to have an arterial by-pass graft operation in which the blockage is by-passed using a length of vein, or synthetic tubing. In some cases, a single stricture can be dilated with a special balloon inserted into the artery under X-ray control.

Another successful approach is to hook up another artery, which normally delivers blood to the lower abdominal muscles, to the penis. This is joined to one of the penile arteries using microsurgical techniques; the procedure instantly increases the blood flow to the penis. The lower abdominal muscles do not suffer either, as several other arteries also supply them with blood. Some of the penile-draining veins are usually tied off at the same time to increase the effect: this combines a better blood flow coming in with a weaker blood flow draining out. Success rates are as high as 70 per cent.

Arterial by-pass surgery involves a fairly large incision extending up the lower abdomen, and requires a stay of several days in hospital.

If impotence is due solely to a slow venous leak, this is simply corrected by tying off the major veins draining the penis. This procedure is known as venous ligation, and is successful in 50 per cent of cases. Occasionally, new veins open up after the operation and venous leaking may recur after a few years.

Surgical Implants

Prostheses are devices that can be surgically implanted into the penis to produce erection. There are two main types:

1. semi-rigid rods giving the patient half an erection all of the time

2. complicated, inflatable devices with small pumps implanted in the scrotum and a fluid reservoir bag implanted in the abdomen or pelvis. These devices are activated by squeezing the pump or activating a trigger button in the scrotum. Deflation is brought about by pressing another button.

Some semi-rigid implants have an embedded silver wire to make them bendable. The penis can then be bent and 'parked' when not in use. Newer designs consist of implanted, interlocking discs made of plastic. These can be rotated in one direction to lock and become rigid, then, after intercourse, rotated the other way to become flaccid when not required.

Insertion of an implant takes from one to three hours, depending on the type selected. The procedure is done under a local anesthetic, or under a spinal epidural (the body is numbed from the waist down).

It takes around two weeks for the discomfort and swelling of the operation to settle down, especially under the scrotum where the base of the penis is situated. Intercourse can be resumed from four to six weeks after the operation, depending on the procedure used. The main risk with penile implantation is a post-operative infection, but this seems to be relatively rare. Ninety percent of men with an implant are entirely happy with its performance. Most implants are invisible, although the semi-rigid rods can make the penis stick out a little bit at all times. This does not look abnormal, however.

Psychological Causes of Impotence

Psychological problems account for 60 percent of cases of impotence. Counseling and psychotherapy are helpful and often result in dramatic improvement.

Psychological problems are usually based on fear, guilt or feelings of inadequacy. The more a man worries about not getting an erection, the more the erection is likely to fail. It becomes a self-fulfilling prophecy. Relaxation training and professional psychosexual counseling are vital.

Psychosexual counseling often involves a temporary ban on penetrative sex. Sufferers are taught to relax with their partner while exploring each other's bodies afresh. Usually, it is agreed in advance that even if an erection is achieved, sexual penetration will not be attempted.

After several weeks of abstinence, couples are then allowed to try having sex with the partner on top. This is known as the Mistress position. The so-called 'Missionary position' (man on top) is not good for men with semi-rigid erections.

A caring and sympathetic partner is important. He or she is an invaluable support during the investigation and treatment of the partner's impotence. A partner who mocks or ridicules (or even feels overly sorry for) a man's performance is making the problem worse and may even have contributed to it in the first place.

Premature Ejaculation

Premature ejaculation is the most common male sexual dysfunction. There are three different ways of defining it:

1. if the man comes before he wants to or before his partner wants him to

2. if ejaculation occurs before the penis penetrates the vagina

3. if the man cannot stop himself ejaculating for at least one minute after penetrating his partner.

Most men experience premature ejaculation several times during their lives most commonly when losing their virginity. It also occurs in over 50 percent of males when making love to a new partner for the first time. Premature ejaculation is particularly common among teenagers and tends to become less of a problem for men in their twenties and thirties and beyond.

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If a man can stop ejaculating for anything over one minute after penetration, this is normal. It may not sound very long, but our primitive male ancestors were originally designed to thrust only five or six times before reaching orgasm. Humans are unique among the animal kingdom in using sex for pleasure. The male chimpanzee, for example, ejaculates within 30 seconds of intercourse and the female satisfies herself by mating with many males in quick succession.

Premature ejaculation is usually due to anxiety especially if a new partner is involved. This often results in eagerness and over-excitement. The other main cause is anxiety about performance whether you will be 'good enough' for your partner or will fail to satisfy. No man wants to feel his performance is not up to scratch.

Other causes of premature ejaculation are the man feeling that his partner is not really interested in sex, or if either partner has difficulty in showing or responding to affection.

Sometimes the opposite problem of retarded ejaculation occurs especially if the male is trying to postpone his orgasm to make sure his partner is satisfied (see below).

The easiest way to make premature ejaculation less of a problem is to bring your partner to the point of orgasm during foreplay. Then, when your partner is about to come, penetration can occur or you can wait until after your partner's orgasm before entering. There are eight other techniques that help to overcome premature ejaculation. As some of these seem to take the pleasure out of sex, they will not suit every man:

1. Wear a condom. This damps down sensory stimulation and usually helps to prolong intercourse.

2. Use a local anaesthetic cream to numb the tip of the penis. These creams can be bought over the counter. Make sure you buy a pure anaesthetic cream rather than a preparation intended for piles, as the latter sometimes contains other agents that might cause irritation to both yourself and your partner.

3. Tense the buttock muscles while thrusting. This helps to mask signals from nerve endings in the penis and gives you something else to concentrate on.

4. Think about something other than sex while making love, such as problems at work, or your plans for the following day. By taking your mind off sex (just for a moment!) you may find you can penetrate your partner for longer.

5. Just before ejaculation, the testicles naturally rise in the scrotum to sit close to the base of the penis. If you gently pull the testicles back down into the scrotum, you may find this helps delay ejaculation. Be careful not to twist them, however.

6. If you are able to penetrate your partner, pre-arrange a signal, such as saying 'stop'. Then, when you feel you are about to come, both you and your partner can become still and stop thrusting. This may help to prolong intercourse and can be repeated as often as necessary.

7. The most famous way of preventing premature ejaculation is the 'squeeze' technique. The man's partner gently masturbates him until he says he is about to come. The partner then gently squeezes the penis between the thumb and two fingers just below the helmet, where the glans joins the shaft. The squeeze should be firmly sustained for about five seconds and then the pressure relaxed for a minute. This can be repeated to postpone ejaculation as often as you wish and is often highly successful. By retraining your sexual habits, you will eventually be able to achieve normal intercourse. During intercourse, a man can also squeeze his penis himself, providing he has enough prior warning of impending ejaculation to reach down in time.

8. After experiencing premature ejaculation, wait for an hour and then try again. The second erection often lasts longer and orgasm can be delayed.

If none of these tips work, seek help from your doctor. You can be referred for professional psychosexual counseling in which you and your partner will be given help and exercises to try. Often, intercourse and orgasm are banned altogether, which takes away the pressure to perform.

Retarded Ejaculation

Retarded ejaculation is the inability of a man to ejaculate, despite having prolonged intercourse, adequate stimulation, and an intense desire to do so. This is an occasional occurrence in most men, especially when tired, but some males have never achieved ejaculation during sexual intercourse. Most affected men are able to ejaculate during masturbation.

Medical conditions such as diabetes, an enlarged prostate gland, previous prostate operation or certain drugs (e.g. water tablets, tricyclic antidepressants, treatment for high blood pressure) are sometimes at fault.

The commonest cause of ejaculatory failure, however, are psychological inhibitions such as in the case of:

• newlyweds sleeping next door to their parents

• discovering a spouse is unfaithful

• a recent condom break when pregnancy would have been disastrous

• having recently been interrupted during sex, such as by your children.

These episodes can trigger retarded ejaculation through a subconscious inhibition of the ejaculatory reflex. Make sure your surroundings are compatible with unstressful sex that is, quiet, with no risk of interruption or being overheard, warm and comfortable. If problems persist you can be referred for psychotherapy, which will involve a structured program of sexual exercises as 'homework'.

Diagnosing Male Sexual Dysfunction

If you think you are experiencing male sexual dysfunction, see your doctor.

• Your doctor will ask you to describe the problem and will ask questions to help determine whether the cause is physical, psychological, or a combination of both.

• A general physical examination, including examination of the penis and testicles, will be performed, and other tests may be done to evaluate your health.

• Blood tests may be done to determine if there is a hormonal problem contributing to sexual dysfunction.

Treating Male Sexual Dysfunction

• For psychological causes of sexual dysfunction, such as relationship problems, counseling, either individually or as a couple, may be beneficial. Sexual therapy with a therapist who specializes in sexual dysfunction may also help.

• Depression or anxiety disorders may need treatment.

• Any physical problems that may be affecting sexual function should be addressed.

• If a medication is interfering with sexual function, it may be possible to change or discontinue the medication.

• Prescription medications that treat erectile dysfunction may help a man achieve and maintain erections.

• Hormonal treatment, such as testosterone replacement therapy, may help with hormone imbalances that are contributing to sexual dysfunction.

Talking with your doctor about your sexual problems can cause you anxiety, but in order to get the best care, you must be able to communicate your needs. These tips can help you when bringing up sexual problems with your doctor.

• Remember that a doctor is human, too. He or she may have anxieties about discussing sexuality with patients. Don't take it personally or as a judgment on you if your doctor becomes uncomfortable.
• Medical school courses on female sexual anatomy and human sexuality are relatively recent and not addressed in all medical schools.
• Don't take no for an answer. Some doctors may minimize your problem or dismiss it, but that's usually because they don't know how to help, they think it may be psychological, or they are not aware of potential treatment.
• Educate yourself. Arm yourself with information found on this web site as well as our book For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life. Information you take to your doctor will be extremely helpful to him or her as well as to you.
• Most doctors will be open and receptive to your comments and will be happy to learn of any new information, particularly if it is based on science and research.
• If your doctor avoids addressing your sexual problems, acknowledge that the subject is embarrassing for both of you, but make it clear that your sexuality is a basic part of you.
• Start the conversation on a positive note: "I was hoping that you might be able to help me with this problem I have."
• Many women find it helps to bring an article (or our book!) with them, starting the conversation with "I was reading this and wondered what you thought."
• Be persistent. If you don't get the response you want, don't feel bad about finding another physician.
• Look in your local yellow pages or check with your local hospital or women's health center for referrals to physicians. Even if they don't treat sexual function complaints themselves, they usually have a network or physicians who are sympathetic to women's issues.