Psychotherapy for Depression

Psychotherapy -- or "talk therapy" -- is an effective treatment for clinical depression. On its own, psychotherapy may not be enough to resolve severe depression. But it can play an important role when used with other treatments, including medications. What can psychotherapy do to help with clinical depression? The role of psychotherapy in treating clinical depression is to help the person develop good coping strategies for dealing with everyday stressors. In addition, it can encourage you to use your medications properly. Many studies support the idea that therapy can be a powerful treatment for depression. Some, although not all, have also found that combining depression medicine with therapy can be particularly effective. A review published in the Archives of General Psychiatry, for example, concluded that therapy combined with antidepressants worked better than depression medicine alone. It also supported the idea that therapy can help people stay compliant with their drug treatment in the long term. Although there are fewer studies of therapy for treatment-resistant depression specifically, many experts still recommend it. One 2007 study found that for people who didn't respond to a specific drug treatment, cognitive behavioral therapy worked as well in reducing symptoms as switching to a different medication. On its own, therapy might work more slowly than medication, but it also causes fewer adverse reactions. How Does Psychotherapy Help Depression? Psychotherapy helps people with depression: y y Understand the behaviors, emotions, and ideas that contribute to his or her depression. Understand and identify the life problems or events -- like a major illness, a death in the family, a loss of a job or a divorce -- that contribute to their depression and help them understand which aspects of those problems they may be able to solve or improve. Regain a sense of control and pleasure in life. Learn coping techniques and problem-solving skills. What are the benefits of psychotherapy with depression? There are a number of benefits to be gained from using psychotherapy in treating clinical depression: y y y y y y It can help reduce stress in your life. It can give you a new perspective on problems with family, friends, or co-workers. It can make it easier to stick to your treatment. You can use it to learn how to cope with side effects from depression medication. You learn ways to talk to other people about your condition. It helps catch early signs that your depression is getting worse. What are the different types of psychotherapy? Therapy can be given in a variety of formats, including: Individual counseling is a one-on-one session with a professional therapist with experience in treating depression and other mood disorders. Your therapist can teach you more about depression and help you understand the diagnosis. You can discuss new strategies to manage stress and to prevent your depression from worsening or coming back. One-on-one sessions can help you identify the specific stresses and triggers that worsen your depression. A therapist can help you work through issues at home

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or at work, and encourage you to maintain healthy connections with family and friends. Your therapist can also help you adopt good habits, like making sure you take your medicines, seeing your doctor regularly, and getting enough sleep. Family counseling treats the entire family -- because it's not only the person with the diagnosis who is affected by depression. If you're depressed, your family feels it too. And unfortunately, although family members might have the best of intentions, without professional guidance, they sometimes make things worse. Family therapy is a great way for family members to learn about depression and the early warning signs of trouble. Studies suggest that family sessions might really help with treatment, too, improving a person's lifestyle, compliance with medication, and sleep habits. . Family meetings also offer an opportunity for everyone -- you and your family members -- to talk about the stresses of life with depression. You may all feel more comfortable talking openly with a therapist there to guide the conversation. Group counseling sessions give you a chance to meet other people who are struggling with depression just like you are. You can share your experiences and coping strategies. The give-and-take at group sessions is often a productive way of learning new ways to think about your illness. Marital/couples -- This type of therapy helps spouses and partners understand why their loved one has depression, what changes in communication and behaviors can help, and what they can do to cope. Approaches to Therapy for Depression After talking with the patient about their depression, the therapist will decide which approach to use based on the suspected underlying factors contributing to the depression. Cognitive therapy, behavioral therapy, and cognitive behavioral therapy all focus on how your own thoughts and behaviors contribute to your depression. Your therapist will help you learn new ways to react to situations and challenge your preconceptions. You and your therapist might come up with concrete goals. You might also get 'homework' assignments, like keeping a journal or applying problemsolving techniques in particular situations. Extension: Cognitive Behavioral Therapy for Depression Cognitive behavioral therapy (CBT) includes several different approaches to therapy, all of which focus on how thinking affects the way a person feels and acts. The idea of cognitive behavioral therapy is that you can change your way of thinking about a situation, and when you do, you also change the way you feel and act. As a result, you can feel better, or at least remain calm, even when the situation stays the same. While other approaches to therapy rely heavily on analyzing and exploring people's relationship with the world around them, the focus of CBT is on learning. The therapist functions as a teacher. He or she guides the client through the process of learning how to change his or her way of thinking and then how to act on that learning. Because there is a specific goal and a process for arriving at it, CBT is often more narrowly focused. It also is typically completed in less time than other therapies. Two examples of different types of CBT are: y Rational emotive behavior therapy or REBT. REBT focuses on the way emotions affect thinking and actions. It helps the client recognize that the intensity of negative emotions can change the quality of his or her thinking. The result is often overreaction and loss of perspective. The emphasis of therapy then is on learning how to restore emotional balance by thinking more realistically about situations. Dialectical behavior therapy or DBT. DBT emphasizes the validity of a person's behavior and feelings and reassures the individual that those feelings and behaviors are understandable. At the same time, it

encourages the individual to understand that the responsibility for changing unhealthy or disruptive behavior is his or her own. Interpersonal therapy focuses on how your relationships with other people play a role in your depression. It focuses on practical issues. You will learn how to recognize unhealthy behaviors and change them. Interpersonal therapy focuses on the behaviors and interactions a depressed patient has with family and friends. The primary goal of this therapy is to improve communication skills and increase self-esteem during a short period of time. It usually lasts three to four months and works well for depression caused by loss and grief, relationship conflicts, major life events, social isolation, or role transitions (such as becoming a mother or a caregiver). Psychodynamic therapy is a more traditional form of therapy. You and your therapist will explore the roots of your depression. You might focus especially on any traumas of your childhood. Psychodynamic therapy is based on the assumption that a person is depressed because of unresolved, generally unconscious conflicts, often stemming from childhood. The goal of this type of therapy is for the patient to understand and cope better with these feelings by talking about the experiences. Psychodynamic therapy is administered over a period of weeks to months to years. How do I find a therapist? You will want to find a qualified therapist -- usually a psychiatrist, psychologist, social worker, psychiatric nurse, or counselor. If possible, find someone who has expertise in helping people with treatmentresistant depression. Ask your health care provider for recommendations. What is maintenance therapy for depression? While some people only need therapy for short periods of time, people with treatment-resistant depression might need it for longer. This is called maintenance therapy. Studies show that maintenance therapy lowers your risk of relapse. You and your therapist can watch for signs that your depression might be worsening. Over time, you will also learn about the patterns in your life that lead to depression. If you have treatment-resistant depression, you may have already tried therapy. Maybe you didnt feel like it worked. But it may be time to give it a second chance. Here are some things to consider before you try again. y y y Think about the reasons you didn't like therapy before. Why didn't it work? What did you need from therapy that you weren't getting? Decide what you want out of therapy now. Do you want to tackle specific problems? Do you want to work through upsetting events from your past? Come up with goals. Consider going back to your old therapist. Even if therapy didn't work last time, that doesn't mean that the therapist was at fault. The experience may be different if you approach therapy with specific goals this time. Going back to a previous therapist may be easier, since he or she will already know your history and situation. Consider trying someone new. It's very important that you like and respect your therapist. If you and your therapist didn't "click," therapy is unlikely to work. So you could try someone new. You might even want to meet with a few different therapists before choosing one. Ask about their approaches. Talk about your goals. Give it time. Once you have settled on a therapist, you need to give therapy a chance to work. Don't give up after a few sessions. Like with depression medicine, therapy can require a little time before you feel the benefits

Therapy Tips Therapy works best when you attend all of your scheduled appointments. The effectiveness of therapy depends on your active participation. It requires time, effort, and regularity. As you begin therapy, establish some goals with your therapist. Then spend time periodically reviewing your progress with your therapist. If you don't like your therapist's approach or if you don't think the therapist is helping you, talk to him or her about it and/or seek a second opinion, but don't discontinue therapy abruptly. Tips to Help You Get Started With Therapy y y y y y Identify sources of stress: Try keeping a journal and note stressful as well as positive events. Restructure priorities: Emphasize positive, effective behavior. Make time for recreational and pleasurable activities. Communicate: Explain and assert your needs to someone you trust; write in a journal to express your feelings. Try to focus on positive outcomes and finding methods for reducing andmanaging stress. Remember, therapy involves evaluating your thoughts and behaviors, identifying stresses that contribute to depression, and working to modify both. People who actively participate in therapy recover more quickly and have fewer relapses. Therapy is treatment that addresses specific causes of depression; it is not a "quick fix." It takes longer to begin to work than antidepressants, but there is evidence to suggest that its effects last longer. Antidepressants may be needed immediately in cases of severe depression, but the combination of therapy and medicine is very effective.

Cognitive Behavioral Therapy for Depression

Cognitive behavioral therapy (CBT) is an effective treatment for depression. At the heart of CBT is an assumption that a person's mood is directly related to his or her patterns of thought. Negative, dysfunctional thinking affects a person's mood, sense of self, behavior, and even physical state. The goal of cognitive behavioral therapy is to help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking. At the same time, therapists who practice CBT aim to help their patients change patterns of behavior that come from dysfunctional thinking. Negative thoughts and behavior predispose an individual to depression and make it nearly impossible to escape its downward spiral. When patterns of thought and behavior are changed, according to CBT practitioners, so is mood. How Does Cognitive Behavioral Therapy Differ From Other Depression Treatments? The focus and method of cognitive behavioral therapy sets it apart from other, more traditional therapies: y CBT is based on two specific tasks: cognitive restructuring, in which the therapist and patient work together to change thinking patterns, and behavioral activation -- in which patients learn to overcome obstacles to participating in enjoyable activities. CBT focuses on the immediate present: what and how a person thinks more than why a person thinks that way. CBT focuses on specific problems. In individual or group sessions, problem behaviors and problem thinking are identified, prioritized, and specifically addressed. CBT is goal oriented. Patients working with their therapists are asked to define goals for each session as well as longer-term goals. Longer-term goals may take several weeks to achieve or even a couple months. Some goals may even be targeted for completion after the sessions come to an end. The approach of CBT is educational. The therapist uses structured learning experiences that teach patients to monitor and write down their negative thoughts and mental images. The goal is to recognize how those ideas affect their mood, behavior, and physical condition. Therapists also teach important coping skills, such as problem solving and scheduling pleasurable experiences. CBT patients are expected to take an active role in their learning, in the session and between sessions. They are given homework assignments at each session -- some of them graded in the beginning -- and the assignment tasks are reviewed at the start of the next session. CBT employs multiple strategies, including Socratic questioning, role playing, imagery, guided discovery, and behavioral experiments. CBT is time limited. Typically, treatment with CBT lasts 14 to 16 weeks. Who Can Benefit From CBT? Anyone with mild or moderate depression can potentially benefit from cognitive behavioral therapy, even without taking medication. A number of studies have shown CBT to be at least as effective as antidepressants in treating mild and moderate depression. Studies also show that a combination of antidepressants and CBT can be effective in treating major depression. CBT can be an effective treatment for mild and moderate depression in adolescents. It's also been shown to be effective at reducing relapses in patients who experience frequent relapses after having gone through other treatments. Nearly two out of every three patients who are treated successfully for depression are treated with medications alone. Other patients, though, have lingering symptoms even when medication is partially working. CBT can be effectively used to treat many of these patients. Although a wide range of people respond well to cognitive behavioral therapy, experts point out that the type of person likely to get the most benefit is someone who:

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is motivated has an internal locus of control has the capacity for introspection What Is Cognitive Restructuring? Cognitive restructuring refers to the process in CBT of identifying and changing inaccurate negative thoughts that contribute to the development of depression. This is done collaboratively between the patient and therapist, often in the form of a dialogue. For instance, a college student may have failed a math quiz and responded by saying, "That just proves I'm stupid." The therapist might ask if that's really what the test means. In order to help the student recognize the inaccuracy of the response, the therapist could ask what the student's overall grade is in math. If the student answers, "It's a B," the therapist can then point out that his answer shows he's not stupid because he couldn't be stupid and get a B. Then together they can explore ways to reframe what the performance on the quiz actually says. The "I'm stupid" response is an example of an automatic thought. Patients with depression may have automatic thoughts in response to certain situations. They're automatic in that they're spontaneous, negatively evaluative, and don't come out of deliberate thinking or logic. These are often underpinned by a negative or dysfunctional assumption that is guiding the way patients view themselves, the situation, or the world around them. Other examples of automatic thinking include:

Always thinking the worst is going to happen. For instance, a person may convince himself he is about to lose his job because the boss didn't talk to him that morning or he heard an unsubstantiated rumor that his department was going to cut back. Always putting the blame on oneself even when there is no involvement in something bad that happened. For example, if someone did not return your call, you might blame it on the fact that you are somehow a very unlikeable person. Exaggerating the negative aspects of something rather than the positive. Think of someone who exercises a stock option from a bonus a week before the stock rises another 10%. Instead of enjoying the bonus money he just got, he tells himself he never gets the breaks or that he's too afraid to take risks that he should take. If he weren't, he would have known to wait. The idea in CBT is to learn to recognize those negative thoughts and find a healthier way to view the situation. The ultimate goal is to discover the underlying assumptions out of which those thoughts arise and evaluate them. Once the inaccuracy of the assumption becomes evident, the patient can replace that perspective with a more accurate one. Between sessions, the patient may be asked to monitor and write down the negative thoughts in a journal and to evaluate the situation that called them up. The real goal is for the patient to learn how to do this on his or her own. What Is Behavioral Activation? Behavioral activation is another goal of CBT that aims to help patients engage more often in enjoyable activities and develop or enhance problem-solving skills. Inertia is a major problem for people with depression. One major symptom of depression is loss of interest in things that were once found enjoyable. A person with depression stops doing things because he or she thinks it's not worth the effort. But this only deepens the depression.

In CBT, the therapist helps the patient schedule enjoyable experiences, often with other people who can reinforce the enjoyment. Part of the process is looking at obstacles to taking part in that experience and deciding how to get past those obstacles by breaking the process down into smaller steps. Patients are encouraged to keep a record of the experience, noting how he or she felt and what the specific circumstances were. If it didn't go as planned, the patient is encouraged to explore why and what might be done to change it. By taking action that moves toward a positive solution and goal, the patient moves farther from the paralyzing inaction that locks him or her inside the depression. Is There a Standard Procedure for Therapy Sessions? Mental health professionals who practice CBT receive special training and follow a manual in their own practice. Although actual sessions may vary, they typically follow this outline: y y y y y y y The session begins with a check on the patient's mood and symptoms. Together, the patient and therapist set an agenda for the meeting. Once the agenda is set, they revisit the previous session so they can bridge to the new one. The therapist and patient review the homework assignment and discuss problems and successes. Next they turn to the issues on the agenda, which may or may not all get addressed. New homework is set. The session ends with the therapist summarizing the session and getting feedback from the patient. A typical session lasts 50 minutes to an hour. What Does It Mean to Say That Cognitive Behavioral Therapy Is Time-Limited? Some other types of therapy are open ended in that there is no clear end date established. With CBT, the goal is to terminate therapy at a certain point, usually after 14 to 16 weeks. It takes about eight weeks for the patient to become competent at the skills that are being taught in therapy and to reasonably understand the model. While this is going on, the patient usually experiences a significant reduction of symptoms. Between eight and 12 weeks patients often experience a remission of symptoms. During the remaining time, they continue to practice the skills learned and to address issues related to ending the sessions. More severe cases of depression may take longer to resolve, but for most patients, 14 to 16 weeks with occasional sessions during the first year to reinforce the new skills is adequate.

Interpersonal Therapy for Depression

Interpersonal therapy, or ITP, is a short-term, limited-focus treatment for depression. Studies have shown that ITP, which addresses interpersonal issues, may be at least as effective as short-term treatment with antidepressants. Originally developed to treat depression in adults, it has been shown to be effective in treating adolescent depression and is commonly recommended as a treatment for depression in children. Events surrounding interpersonal relationships do not cause depression. But depression occurs within an interpersonal context and affects relationships and the roles of people within those relationships. By addressing interpersonal issues, interpersonal therapy for depression puts emphasis on the way symptoms are related to a person's relationships, including family and peers. The immediate goals of treatment are rapid symptom reduction and improved social adjustment. The long-term goal is to enable people with depression to make their own needed adjustments. When they can do that, they are better able to cope with and reduce depressive symptoms.

What Are the Ideas Behind Interpersonal Therapy for Depression? Interpersonal therapy is a manual-based treatment. That means the therapist strictly adheres to a treatment process whose effectiveness is supported by evidence. According to the International Society for Interpersonal Therapy, there are three components to depression. y y y symptom formation social functioning personality issues ITP is a short-term treatment option that typically consists of 12 to 16 one-hour weekly sessions. Because it is so brief, ITP does not address personality issues. Instead, the therapist focuses on identifiable problems in how an individual interacts with or doesn't interact with others. When those problems are addressed, the patient realizes a benefit in his or her experience of symptoms. Except to check on their severity and the effect of the various treatments, symptoms are not addressed in therapy sessions. Instead the therapist works collaboratively with the patient, either individually or in a group, to identify and then address one or two significant problems in his or her interactions. The number of problems addressed is deliberately limited to one or two for the whole course of treatment. The result is an intense focus on how to make the necessary adjustments in interpersonal situations that will help reduce symptoms of depression. The types of problems addressed fall into four categories: Interpersonal disputes or conflicts. These disputes occur in marital, family, social, school, or work settings. The disputes emerge from differing expectations of a situation. They become a problem that needs to be addressed when the conflicts that come from the expectations lead to significant distress. Role transitions. Changing circumstances, whether they're developmental, stem from shifts in work or social settings, or result from a life event or end of a relationship, require adaptations from the individual. With depression, those changes are felt as losses and contribute to the depression. Grief . In ITP, grief is the experience of loss through death. Grief becomes a problem when it is delayed or becomes excessive so that it lasts beyond the normal time for bereavement. Interpersonal deficits. This refers to the patient reporting "impoverished" personal relationships either in number or in quality. By focusing on issues from these categories, the therapist can help the person with depression learn how to make the adjustments that are needed to address the interpersonal issue and improve relationships. What Kind of Adjustments Might Be Made Through ITP to Resolve Interpersonal Issues? With issues involving interpersonal disputes, the therapist works with the patient to define how serious the issue has become in terms of how difficult it is to move beyond it. For instance, there might be a dispute between husband and wife that stems from the wife's attempts to be more independent. The therapist would lead the patient, in this case the husband, in an effort to discover the sources of misunderstanding. Then the therapist might use problem-solving approaches, communication training, or some other technique to enable the patient to resolve the conflict in a way that doesn't worsen the symptoms of depression. In role transition issues, the therapist helps the patient determine the differences between the old and the new roles. Then together they would focus on identifying exactly what is causing the difficulties and work to find a solution for the problem.

For issues involving grief, the therapist facilitates the grieving process to help the patient move beyond it. Two important techniques used to do this are: y y Empathetic listening, which provides support and a safe outlet for the patient's feelings. Clarification, which is a technique for helping the patient examine his or her own misconceptions about the situation. With interpersonal deficits, the therapist will work with the patient to explore past relationships or the current relationship the patient has with the therapist. The goal is to identify patterns, such as excess dependency or hostility that interfere with forming and maintaining good relationships. Once those patterns are distinguished, the focus turns to modifying them. Then, with the therapist's guidance and assistance, the patient is urged to make new relationships and to apply the therapeutic adjustments that have been made. As the sessions progress, the therapist gradually lessens his or her level of intervention. The goal is for the patient to self-intervene more and make more of his or her own adjustments. This becomes easier as time goes on, and the patient's ability to self-intervene continues to improve after the sessions end, often not peaking until three to six months after therapy is over. What Is the Process for Interpersonal Therapy? Interpersonal therapy typically takes place in one-hour sessions, usually weekly, that continue for 12 to 16 weeks. Depending on the severity of the depression, sessions might be continued for additional four or more weeks. If you were being treated for depression with interpersonal therapy, the first few sessions, usually from one to three weeks, would be used for assessing your depression, orienting you to the ITP focus and process, and identifying specific interpersonal issues or problems you have. Together, you and the therapist would create a record of your interpersonal issues, rank them, and decide which one or two issues seemed most important to address in terms of your depression. At least the next eight sessions would be focused on addressing those issues -- understanding them more, looking for adjustments that you can make, and then applying those adjustments. Throughout this portion of the therapy, the therapist would use a number of different techniques, including among others: y y y y y Clarification, which has the purpose of helping you recognize and get beyond your own biases in understanding and describing your interpersonal issues. Supportive listening. Role playing. Communication analysis. Encouragement of affect, which is a process that will let you experience unpleasant or unwanted feelings and emotions surrounding your interpersonal issues in a safe therapeutic environment. When you do, it becomes easier to accept those feelings and emotions as part of your experience. The entire focus of the sessions will be on addressing the identified issues. This is hard for some individuals to get used to -- especially those who are familiar with more traditional, open-ended and introspective approaches to therapy. It may take you several weeks before your own primary focus shifts to the ITP approach. Another important aspect of the ITP process is an emphasis on terminating therapy. From the beginning the patient is aware that therapy is defined by a limited amount of time. In the final four or so weeks of therapy, the sessions will turn to termination issues. With ITP, termination of therapy is seen as a loss to be experienced by the patient. So you would be asked to consider what the loss means to you. What issues does it bring up, and how can you apply the

interpersonal adjustments that you've learned to make over the course of therapy to evaluating and getting through the loss? The idea is for the patient to become more aware of his or her ability to deal with interpersonal problems that have kept him or her from being able to actively manage the symptoms of depression. Can ITP Work in a Group Setting? There are several advantages to interpersonal therapy being applied to group therapy. First, the members of the group have an opportunity to learn through observing what other members in the group are learning. Learning also takes place through a process of modeling the adjustments and behavior of others in the group. There is also more opportunity to see various types of interpersonal interactions and associations. These can help the individual better understand various approaches to making interpersonal adjustments. Before you would join a group, you would have one or two individual sessions in order to learn about the group process. You would also use those sessions to identify the one or two interpersonal issues that you will want to focus on during therapy. Initially, the group would go through a process of engagement. This would involve identifying the common goals and common focus of the group. The therapist would then facilitate the group's establishment of a collaborative approach. That would be followed by members of the group differentiating themselves and figuring out how to work on their individual issues. During this second phase, conflicts are likely to arise and partnerships or alliances formed. As the sessions progress, each individual's focus would be addressed and both the therapist and the other group members would help that person learn how to adjust his or her approach to the issues. The therapist might suggest role playing or brainstorming to help find the right intervention. Or the therapist might suggest communication training among members of the group. When conflict arises between group members, the therapist will often allow the group members to resolve it themselves while serving as a mediator to help avoid excessive negativity or criticism. As with the individual therapy, termination is an important part of the process. There is still the same sense of loss, and members of the group are asked to confront that loss and to make themselves aware of the evolution of their own adjustments and how to use them to manage symptoms that may emerge when the sessions end. What Happens After Interpersonal Therapy Ends? Because depression is sometimes a recurrent condition, and because some people may experience multiple recurrences, patients are encouraged to supplement ITP with ongoing maintenance. Maintenance takes the form of once-monthly sessions in which the adjustments made during the shortterm IPT are reinforced. The goal is to prevent the stress of increased social interaction from leading to new episodes of depression, and to help the individual continue to function at least at the level he or she was at when regular sessions ended.

Getting Started: Talk Therapy for Depression

By Ellen Greenlaw WebMD Feature Many studies have found that talk therapy, or psychotherapy, can help treat depression. Talk therapy can help you learn about your depression and help you find ways to manage your symptoms. Talk therapy can give you the skills to help handle your depression, so for many people its a very empowering experience, says Larry Christensen, PhD, professor of psychology at the University of South Alabama in Mobile. This makes it effective over a long period of time. What Type of Talk Therapy Is Best for Depression? There are many different kinds of talk therapy. The two most commonly used for depression are cognitive-behavioral therapy (CBT) and interpersonal therapy. CBT focuses on looking at how negative thought patterns may be affecting your mood. The therapist helps you learn how to make positive changes in your thoughts and behaviors. Interpersonal therapy focuses on how you relate to others and helps you make positive changes in your personal relationships. Both types of therapy can be effective in treating depression. What Kind of Therapist Should I See for Depression? Various kinds of mental health specialists offer talk therapy: y Psychiatrists. A psychiatrist is a medical doctor who treats mental illnesses. While some psychiatrists only see patients to prescribe medication, others also provide talk therapy. In most states, psychiatrists are the only mental health professionals who can prescribe medication. Psychologists. A psychologist can help you learn how to manage your depression and teach you ways to cope. Social workers, counselors, or therapists. These mental health professionals can also help you learn to manage depression and teach you coping skills. No matter what type of therapist you see, look for someone you feel comfortable talking to. Your comfort level with the therapist is much more important than what kind of degree that person has, says Eric Endlich, PhD, a Boston-based clinical psychologist. Therapy is generally much more successful if you like your therapist and have a good relationship with that person. How to Find a Therapist If you need help finding a therapist, try these suggestions: y Ask family and friends. Chances are some of your family or friends have seen a therapist. Ask those you trust for a recommendation. If a therapist you contact cant see you, ask if she can recommend another therapist. Ask your doctor. Your doctor likely has referrals to mental health specialists in your area. Ask your clergy person. Most clergy members will be able to provide you with referrals for mental health providers. Check with your employee assistance program (EAP). If you work for a large company, your EAP may be able to provide a referral. Check with your insurance company. If you have insurance, your insurance company likely has a list of therapists in their network. Making an Appointment With a Therapist

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After youve collected a few names, call at least two therapists and talk with them about your situation. Feel free to ask them questions about their experience dealing with depression and their approach to treatment. If you like what you hear, make an appointment. But dont feel that you have to commit to the first therapist you speak with or even the first one you see. When youre looking for a therapist, its important to do some comparison shopping, Endlich tells WebMD. If you dont think the therapist is the right fit for you, look for someone else. Its really important to feel comfortable and find the right fit, and this might take a few phone calls or visits. What to Expect at a Therapy Session At your first session, be prepared to tell your therapist about your depression and what led you to seek help. It may be helpful to think about what youd like to get out of the therapy. For example, are you looking for ways to better deal with personal relationships, or are you hoping to set goals for yourself and make changes? Its helpful to be as honest as you can with your therapist about your depression and your goals for therapy. After listening to your situation, the therapist should be able to tell you what type of treatment he recommends and come up with a treatment plan for you. If the therapist thinks you might benefit from medication, he may recommend that you also meet with a psychiatrist or doctor. When Will I Feel Better From Talk Therapy? You may not feel better right away from talk therapy, but over time, you should start to notice some improvement. You might notice that relationships are getting easier or that your overall mood has improved. Or you might feel better able to understand your feelings or actions. If you arent feeling any better, talk with your therapist. She may be able to try another approach to therapy or refer you for other kinds of treatment. Or you might benefit from seeing someone else. You may need to see more than one therapist to find the type of therapy thats right for you. Therapy is not always easy and can sometimes even be painful as you work through difficult problems. But if you stick with it, talk therapy can also be gratifying and rewarding -- and can give you the tools you need to help ease your depression.

Depression and Your First Therapy Session

It's easy to get flustered when you're first meeting with a doctor. You might have a lot of questions that you want to ask but your mind may go blank when you step into the office. So be prepared. Before you first see your doctor or therapist, sit down and decide what you'd like to talk about. Think about what you want from treatment. Go in armed with information and questions. Here are some suggestions for how to prepare. y Write down questions. Come up with some specific things you want to ask. Don't assume that your doctor will tell you everything you need to know. For instance, you might ask your doctor: Do I need medicine for my depression? What kind of medicine will you prescribe? What are the side effects and risks? How often do I need to take it? How quickly will the drug work? Will any of my other medications, herbs, or supplements interact with this drug? You could ask your therapist: o o o o o y What kind of approach do you use? What will our goals be? What will you expect of me? Will you give me specific assignments to do between sessions? How often will we meet? Will this therapy be short-term or long-term? How much does each session cost? Keep a log or journal. Keeping track of your mood changes in a diary can be helpful both to you and your doctor or therapist. Just jot down a few lines each day. In each entry, include: How you're feeling that day Your current symptoms Any events that might have affected your mood How much sleep you got the night before The exact doses of any drugs you took Bring in your journal to your first appointment. Show it to your doctor or therapist. If you keep a journal for a few weeks or months, you may start to see patterns to your mood changes that you never noticed before. y Don't forget about your physical symptoms. You might not think that they're relevant, but physical symptoms are often signs of depression. Make sure to tell your health care provider about pain, stomach problems, sleep problems, or any other physical symptoms. In some cases, you might need medicines specifically for these symptoms. Get help from friends or family members. Ask them about changes they've noticed in your behavior. They may have seen symptoms that you missed. And if you're nervous about your first appointment, ask for a friend or family member to come along.

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Generalized Anxiety Disorder

It's natural to worry during stressful times. But some people feel tense and anxious day after day, even when there is little to worry about. When this lasts for six months or longer, it may be generalized anxiety disorder or GAD. This illness affects nearly seven million Americans. Unfortunately, many people don't know they have it. So they can miss out on treatments that lead to a better, happier life.

GAD: Emotional Symptoms

The main symptom of GAD is a constant and exaggerated sense of tension and anxiety. You may not be able to pinpoint a reason why you feel tense. Or you may worry too much about ordinary matters, such as bills, relationships, or your health. All this worrying can interfere with your sleep and your ability to think straight. You may also feel irritable due to poor sleep or the illness itself.

GAD: Physical Symptoms

Body problems usually come along with the excess worry. They can include:

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Muscle tension or pain Headaches Nausea or diarrhea Trembling or twitching

GAD vs. Everyday Worries

Most people spend some time worrying about their troubles, whether money, job demands, or changing relationships. What sets GAD apart is the feeling that you can't stop worrying. You may find it impossible to relax, even when you're doing something you enjoy. In severe cases, GAD can interfere with work, relationships, and daily activities.

Who Gets GAD?

People of any age can develop GAD, even children. The disorder tends to appear gradually, with the first symptoms most likely to occur between childhood and middle age. GAD affects twice as many women as men.

What Causes GAD?

The genes passed down through a family may put some people at a higher risk for anxiety, but that's not the whole picture. Scientists think that a mix of DNA, environment, and psychological factors are to blame. Researchers are looking at brain chemicals called neurotransmitters, as well as a pair of structures inside the brain called the amygdalae.

Diagnosing GAD
There's no lab test for GAD, so the diagnosis is made based on your description of your symptoms. It's important to be specific when telling your doctor about your anxiety. What do you worry about? How often? Does your anxiety interfere with any activities? You may have GAD if you have been feeling anxious or worrying too much for at least six months.

Treating GAD: Psychotherapy

One kind of talk therapy is very effective in treating anxiety. It's called cognitive behavioral therapy or CBT. A counselor helps you identify your negative thoughts and actions. CBT may include homework, such as writing down the thoughts that lead to excess worry. You will also learn calming strategies. People can feel better in three to four months. A combination of medicine and CBT often works best.

Treating GAD: Medicine

Some antidepressant drugs work well to lower anxiety. Brand names include Cymbalta, Effexor XR, Lexapro, and Paxil. It may take four to six weeks to feel better. Your doctor might prescribe a benzodiazepine for a short while. Brand names include Ativan, Klonopin, Valium, and Xanax. These drugs carry a risk of dependence. A newer drug called Buspar can also treat GAD. Be sure to discuss the pros and cons of medications with your doctor.

Self-Care for GAD

You can support your treatment for GAD by making a few simple changes in your habits. Avoid caffeine, street drugs, and even some cold medicines, which can boost anxiety symptoms. Try to get enough rest and eat healthy foods. Try relaxation techniques, such as yoga or meditation. And be sure to exercise; there's evidence that moderate physical activity can have a calming effect.

Complementary Remedies for GAD

It hard to know whether any non-traditional remedies for GAD work because they have not been well researched. Massage is relaxing for most people. But one study found massage didn't control the symptoms of GAD any better than listening to your favorite music. Research into acupuncture as a treatment for anxiety has not yet shown whether it works.

Herbal Remedies for GAD

Among herbal remedies, there is some evidence that kava may help ease mild to moderate anxiety. There's not enough evidence yet to say whether valerian or St. John's wort can help ease the symptoms of GAD. Be sure to talk with your doctor before starting any herbal remedy. Some have harmful side effects or interact with medications.

GAD and Other Disorders

People who have GAD may also develop depression, alcoholism, or drug addiction. If one of these illnesses occurs, a second treatment plan may be needed. It's also common for people with GAD to have another anxiety disorder. These can include panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and social phobia.

Panic Disorder
People with panic disorder have sudden attacks of terror. Symptoms can include a pounding heart, sweating, dizziness, nausea, or chest pain. You may think you're having a heart attack, dying, or losing your mind. Panic disorder affects about six million American adults, and it's one of the most treatable of all anxiety disorders.

Posttraumatic Stress Disorder

Some people develop posttraumatic stress disorder (PTSD) after living through a terrifying ordeal. Rape, abuse, war, or a natural disaster can lead to this type of anxiety. The symptoms include vivid flashbacks and a loss of interest in activities that were once enjoyable. People may also have trouble being affectionate. They may feel irritable or even become violent. PTSD affects almost eight million Americans. It's treated with medicine and counseling.

Obsessive-Compulsive Disorder
People with obsessive-compulsive disorder (OCD) have troubling thoughts they can't control. Some people feel that they must perform senseless rituals. Common compulsions include excessive hand-washing and locking the door repeatedly. They may get dressed in a certain order or count objects for no good reason. Many people with OCD know their rituals don't make sense but can't stop doing them. OCD affects about two million Americans and is often treated with medication and psychotherapy.

Social Anxiety Disorder

People with social phobia feel overly panicky and self-conscious in ordinary social situations. Symptoms include a sense of dread before social events and sweating, blushing, nausea, or difficulty talking during the events. In severe cases, people with social phobia may avoid school or work. The disorder affects 15 million American adults and can be treated with psychotherapy or medications.

Other Phobias
A phobia is an intense fear of something that is not likely to cause you any harm. Common phobias include heights, closed-in spaces like elevators or tunnels, dogs, flying, and water. About 19 million Americans have specific phobias. Many don't seek help because the feared situation or object is easy to avoid. But phobias respond very well to a type of therapy involving desensitization.

Where to Get Help for Anxiety

Start by discussing your anxiety with your family doctor. He or she can rule out other illnesses that can mimic GAD. If an anxiety disorder seems likely, you'll probably be sent to a mental health professional. This specialist should have training in psychotherapy. It's important to choose someone you're comfortable with to guide your progress as you work to feel better.

Understanding Generalized Anxiety Disorder -- Prevention

How Can I Prevent Anxiety? If you suffer from an anxiety disorder, you may need professional help. See your doctor for a referral to a mental health specialist. Though not a treatment for anxiety disorders, the following tips can help reduce symptoms of anxiety:

y y y y y

Take care of your body by eating a well-balanced diet. Include a multivitamin when you can't always eat right. Avoid alcohol, and reduce or eliminate your consumption of sugar and caffeine. Take time out for yourself every day. Even 20 minutes of relaxation or doing something pleasurable for yourself can be restorative and decrease your overall anxiety level. Trim a hectic schedule to its most essential items, and do your best to avoid activities you don't find relaxing. Keep an anxiety journal. Rank your anxiety on a 1-to-10 scale. Note the events during which you felt anxious and the thoughts going through your mind before and during the anxiety. Keep track of things that make you more anxious or less anxious. If you begin to hyperventilate, exhale into a paper bag and inhale the air within the bag. This increases the amount of carbon dioxide you are inhaling, which can reduce the urge to hyperventilate. Inhaling from a bag will help relieve any dizziness or tingling you might feel. Some clinicians have a "rough rule of thumb" for prevention of any anxiety disorder: try to avoid any food (red meat, chocolate, for example) or drinks (such as tea, coffee, soda, or red wine) that is brown in color.

Understanding Generalized Anxiety Disorder -- Symptoms

What Are the Symptoms of Anxiety? The hallmark of generalized anxiety disorder is excessive, out-of-control worrying about everyday things. Symptoms include: y y y y y y y y Persistent fear, sometimes without any obvious cause, that is present everyday Inability to concentrate Muscle tension; muscle aches Diarrhea Eating too little or too much Insomnia Irritability Loss of sex drive For school-age children, symptoms include: y y y y y Fear of being away from the family Refusal to go to school Fear of strangers Fear of falling asleep or having recurrent nightmares Unnecessary worry Call Your Doctor About Anxiety If: y y y y Your anxiety seems irrational or more extreme than the situation warrants. Your anxiety interferes with your work or your social life. Low-level anxiety persists for many weeks. Your symptoms suddenly become severe or uncontrollable. You may be experiencing a panic attack. Anxiety is accompanied by weight loss and bulging of the eyes; you may have thyroid problems.

Panic Attack Symptoms

Panic Attack Symptoms Panic attacks are sudden feelings of terror that strike without warning. These episodes can occur at any time, even during sleep. A person experiencing a panic attack may believe that he or she is having a heart attack or that death is imminent. The fear and terror that a person experiences during a panic attack are not in proportion to the true situation and may be unrelated to what is happening around them. Most people with panic attacks experience several of the following symptoms: y y y y y y y y "Racing" heart Feeling weak, faint, or dizzy Tingling or numbness in the hands and fingers Sense of terror, of impending doom or death Feeling sweaty or having chills Chest pains Breathing difficulties Feeling a loss of control Panic attacks are generally brief, lasting less than ten minutes, although some of the symptoms may persist for a longer time. People who have had one panic attack are at greater risk for having subsequent panic attacks than those who have never experienced a panic attack. When the attacks occur repeatedly, a person is considered to have a condition known as Panic Disorder. People with panic disorder may be extremely anxious and fearful, since they are unable to predict when the next episode will occur. Panic Disorder is fairly common and affects about 2.4 million people in the U.S., or 1.7% of the adult population between the ages of 18 and 54. Women are twice as likely as men to develop the condition, and its symptoms usually begin in early adulthood. It is not clear what causes Panic Disorder. In many people, its symptoms develop in association with major life changes (such as getting married, having a child, starting a first job, etc.) and major lifestyle stressors. There is also some evidence that suggests that the tendency to develop Panic Disorder may run in families. People who suffer from Panic Disorder are also more likely than others to suffer from depression, attempt suicide, or to abuse alcohol or drugs. Luckily for sufferers of frequent panic attacks, Panic Disorder is a treatable condition. Psychotherapy and medications have both been used, either singly or in combination, for successful treatment of Panic Disorder. If medication is necessary, your doctor may prescribe anti-anxiety medications, antidepressants, or a class of heart medications known as beta blockers to help control the episodes in Panic Disorder.

Understanding Panic Attack -- Treatment

What Are the Treatments for Panic Attacks? The cause of most panic attacks is not clear, so treatment may be different for each person. Medication is used for prevention and/or immediate alleviation of symptoms and is usually the main line of treatment. In addition, psychotherapy, cognitive-behavioral therapy, relaxation, and/or meditation are often used to help relax the body and relieve anxiety. If you're in the middle of a panic attack, immediate relief of anxiety symptoms can come from sedative type antianxiety medications such as Xanax, Klonopin, andAtivan. These drugs are provided at least in the beginning of medical therapy, but are not for long-term use.

Antidepressants often help prevent anxiety and reduce the frequency and severity of panic attacks, but are not used for immediate relief during an attack. Frequently used antidepressants are the selective serotonin reuptake inhibitors (SSRIs, such as Prozac,Paxil, Celexa, Lexapro, and Zoloft). This group of medications is often considered the first line of treatment for panic disorders. For preventive or maintenance care, psychotherapy offers support and helps minimize fear. In some cases, psychotherapy alone can clear up the disorder. Cognitive-behavioral therapy helps people learn to deal with panic symptoms, using techniques like muscle and breathing relaxation. Patients also gain reassurance that panic will not lead to the catastrophic events they fear, since many people fear they are having a heart attack or going crazy. Important note regarding medications: Some of these drugs can actually produce the anxiety symptoms of a panic attack. It is often best to start with a low dose and slowly increase medication for this disorder. How Can I Prevent Panic Attacks? You can take steps to lessen the chance of having panic attacks and learn to manage them better. Learn to recognize a panic attack. When you sense the first symptoms, know that other symptoms may follow. You have survived them before and can do so again. Try slow, deep breaths. y y y y y Take your time. It's important not to hope for a quick cure. Therapy takes time, and improvement comes in small steps. Go easy on yourself. People who feel panic tend to be overly critical of themselves. Learn to lower your level of everyday anxiety through a variety of techniques, including meditation and exercise. Learn other relaxation techniques, like deep breathing or guided imagery. Avoid stimulants, such as nicotine and caffeine, which can be found not only in coffee, but many teas, colas, and chocolate.

Sexual Performance Anxiety

Sex is supposed to be a pleasurable experience, but it's hard to feel sexy or intimate with your partner when you have sexual performance anxiety. When you're constantly wondering, "Am I doing this right?" "Is my partner enjoying this?" or "Do I look fat?" you become too preoccupied to enjoy sex. Constant worry over your appearance or ability in bed can make sex stressful and nerve-wracking. It can even make you want to avoid having sex. Sex is more than just a physical response. Arousal is tied into your emotions too. When your mind is too stressed out to focus on sex, your body can't get excited either. In this article, you'll learn what causes sexual performance anxiety and discover treatments that will help bring the spark back into your relationship. Causes of Sexual Performance Anxiety Many different kinds of worries can lead to sexual performance anxiety, including: y y y y y y Fear that you won't perform well in bed and satisfy your partner sexually. Poor body image, including concern over your weight. Difficulties in your relationship. A mans worry that his penis won't 'measure up. A mans concern about ejaculating prematurely or taking too long to reach orgasm. A womans anxiety about not being able to have an orgasm or enjoy the sexual experience. These anxieties cause your body to launch a response called fight or flight. Stresshormones like epinephrine and norepinephrine are released in a series of reactions that were actually designed to prepare your body to run or confront a threat. Of course, your partner isn't a threat, which is why this response is so counterproductive to intimacy. Symptoms of Sexual Performance Anxiety Your state of mind can have a big impact on your ability to get aroused. Even if you're with someone who you find sexually appealing, worrying about whether you'll be able to please your partner can make it impossible for you to do just that. In men, one of the effects of the stress hormones is to constrict blood vessels. Less blood flowing into the penis makes it more difficult to have an erection. Even men who normally don't have any trouble getting excited can become unable to get an erection when they're overcome by sexual performance anxiety. Sexual performance anxiety isn't diagnosed as often in women as it is in men, but it can affect arousal in women too. Anxiety can prevent women from getting lubricated enough to have sex, and it can take away the physical desire to make love. Anxiety can take both men and women out of the mind-set needed to have sex. When you're focused on whether you'll perform well, you can't concentrate on what you're doing in bed. A distracted lover is an inattentive lover, which can make you feel like even more of a failure. Even if you are able to get aroused, you may be too distracted to reach orgasm. Sexual performance anxiety leads to a perpetual cycle. You become so anxious about sex that you can't perform, which leads to even more sexual performance anxiety. Overcoming Sexual Performance Anxiety If you've got sexual performance anxiety, see a doctor -- someone with whom you feel comfortable discussing your sex life. The doctor can examine you and do some tests to make sure a health condition

or medication isn't causing your sexual performance issues. During the exam the doctor will ask about your sexual history to find out how long you've had sexual performance anxiety and what kinds of thoughts are interfering with your sex life. Medications and other therapies can help treat erectile dysfunction and other sexual problems that are due to physical causes. If a medical issue isn't to blame, your doctor might suggest trying one of these approaches: Talk to a therapist. Make an appointment with a counselor or therapist who is experienced in treating sexual problems. Therapy can teach you to become more comfortable with your own sexuality, and it can help you understand -- and then reduce or eliminate -- the issues that are causing your sexual performance anxiety. Men who are worried about premature ejaculation, for example, can try some techniques that help them gain more control over ejaculation. Be open with your partner. Talking with your partner about your anxiety can help ease some of your worries. Trying to reach a solution together might actually bring you closer as a couple and improve your sexual relationship. Get intimate in other ways. There are many ways to be intimate without actually having sex. Give your partner a sensual massage or take a warm bath together. Take turns pleasing each other with masturbation so you don't always have to feel pressured to perform sexually. Exercise. Not only will working out make you feel better about your body, but it will also improve your stamina in bed. Distract yourself. Try putting on some romantic music or a sexy movie while you make love. Think about something that turns you on. Taking your mind off of your sexual performance can remove the worries that are stopping you from getting excited. Finally, take it easy on yourself. Don't beat yourself up about your appearance or ability in bed. Get help for sexual performance anxiety so you can get back to having a healthy and enjoyable sex life.

Stage Fright (Performance Anxiety)

If you dread the thought of getting up in front of a group of people and performing, you are not alone. Millions of people suffer from performance anxiety, commonly called "stage fright." In fact, most people would rather get the flu than perform. Athletes, musicians, actors, and public speakers often get performance anxiety. Performance anxiety can prevent you from doing what you enjoy and can affect your career. Worst of all, performance anxiety can negatively affect your self-esteem and self-confidence. Although it may be impossible to totally overcome performance anxiety, there are many things you can do to control your emotions and reduce anxiety. Performance Anxiety Symptoms Being the center of attention and having all eyes on you can be stressful. Your body reacts to this situation in much the same way as it would if you were being attacked. Your body's "fight-or-flight" mechanism kicks in, which is why symptoms of stage fright are similar to symptoms that occur when you are in real danger. Performance anxiety symptoms may include: y y y y y y Racing pulse and rapid breathing Dry mouth and tight throat Trembling hands, knees, lips, and voice Sweaty and cold hands Nausea and an uneasy feeling in your stomach Vision changes Performance Anxiety Causes Simply put, stress and anxiety about performing in front of people causes performance anxiety. Confronting your fears and vulnerabilities, accepting yourself for who you are, and not feeling like you have to prove yourself to others, is the first step toward overcoming performance anxiety. Keep in mind that nobody is perfect, nobody expects you to be perfect, and it is OK to make mistakes. The second step is learning how to redirect your negative thoughts, beliefs, images, and predictions about performing in public. Doing this is not as hard as you might think. Performance Anxiety Treatments Here are 10 tips to help you overcome your fears and shine on stage, on the field, or at the podium: y y Be prepared: practice, practice, and practice. Limit caffeine and sugar intake the day of the performance. Eat a sensible meal a few hours before you are to perform so that you have energy and don't get hungry. A low-fat meal including complex carbohydrates -- whole-grain pasta, pizza, or a bean and rice burrito -- is a good choice. Shift the focus off of yourself and your fear to the enjoyment you are providing to the spectators. Close your eyes and imagine the audience laughing and cheering, and you feeling good. Don't focus on what could go wrong. Instead focus on the positive. Visualize your success. Avoid thoughts that produce self-doubt. Practice controlled breathing, meditation, biofeedback, and other strategies to help you relax and redirect your thoughts when they turn negative. It is best to practice some type of relaxation technique every day, regardless of whether you have a performance, so that the skill is there for you when you need it.

y y y y

y y y y

Take a walk, jump up and down, shake out your muscles, or do whatever feels right to ease your anxious feelings before the performance. Connect with your audience -- smile, make eye contact, and think of them as friends. Act natural and be yourself. Exercise, eat a healthy diet, get adequate sleep, and live a healthy lifestyle. Keep in mind that stage fright is usually worse before the performance and often goes away once you get started. Overcoming Performance Anxiety: Tricks of the Trade There are also mental tricks you can play to help you perform with less anxiety. These include:

y y y

Focus on the friendliest faces in the audience. Laugh when you can, it can help you relax. Make yourself look good. When you look good, you feel good. These tips should help reduce performance anxiety. But if they don't, talk to a counselor or therapist trained in treating anxiety issues. You may benefit from more intensive therapy, such as cognitive behavioral therapy, to help overcome performance anxiety. In addition, medications, such as betablockers, a heartmedicine that lowers heart rate, are sometimes used by people with performance anxiety. Confronting your fears and learning ways to reduce and manage them can be empowering. Not only will it make you feel good about yourself, you may discover that you are a more confident performer, too.

Find Your Smoking Triggers

By Peter Jaret WebMD Feature If youre a smoker, you know the drill. Finish a meal and you suddenly feel a powerful craving for a cigarette. Get up from your desk to take a break and all at once you want to light up. Certain times of the day, certain places, and even particular foods can spark a strong urge to smoke. Experts call these triggers. For long-time smokers, daily life can be filled with triggers, says Steven Schroeder, MD, director of the Smoking Cessation Leadership Center at the University of California, San Francisco. Drinking tea or coffee, sitting down to a cocktail or glass of wine, driving in the car, getting up during intermission at a concert, checking email, feeling bored, talking on the telephone -- all of them can trigger a powerful urge to smoke. Being angry or under stress can trigger a craving to smoke. But even positive feelings of happiness or pleasure can be triggers. Learn to Recognize Your Own Smoking Triggers Triggers make it tough for smokers to quit. But once you recognize your own personal smoking triggers, you can use a few simple strategies to avoid or defuse them before they wear down your resolve. Before your quit date, keep a journal for several days or a week. Use a small notebook that you can easily carry with you. Every time you light a cigarette, record: y y y y y y The time of day How intense your craving feels (on a scale of 1 to 5) What youre doing at that moment Where you are Who youre with How you feel (happy, stressed, bored, etc.) Be as precise in your notes as possible. Keep your journal for at least one weekday and one weekend day, since your routine is likely to be different on those days. Once youre done, review your journal. Make a list of the most powerful triggers, based on the intensity of your craving. List the triggers that occur most frequently. Note places, people, situations, and moods that set off a craving to smoke. Defuse Smoking Triggers in Advance Triggers are a form of conditioned response. If youre used to smoking a cigarette during a coffee break, for example, you begin to associate even the smell of coffee with smoking. But conditioned responses like these can be broken, says Scott McIntosh, PhD, associate professor of community and preventive medicine at the University of Rochester in New York and director of the Greater Rochester Area Tobacco Cessation Center. His advice: before your quit date, de-fuse triggers by changing your routines. If youre used to smoking in the car, for example, practice driving short distanceswithout smoking. If coffee triggers a craving, practice taking your coffee break without having a cigarette. Have a glass of wine but dont accompany it with a cigarette. Focus on breaking your own most powerful triggers in advance of quitting. Avoid Situations That Spark a Craving to Smoke Before your quit date, look over your list of triggers and put a checkmark beside those that you can reasonably avoid. If you have friends youre used to smoking with, for example, decide in advance not to see them during the first few weeks of quitting. If drinking coffee is a strong trigger for you, switch to tea. If

you associate smoking with watching TV, skip television for a couple of weeks and take a brisk walk around the neighborhood instead. If youre used to lighting up a cigarette when you take the dog for a walk, alter your route into unfamiliar territory. The more thoroughly you change your usual routine, the easier it will be to steer clear of triggers. Instead of breakfast and a cigarette first thing in the morning, take a short walk around the neighborhood. If you usually step outside to smoke a cigarette during a break at work, do a few simple exercises such as deep knee bends or stretches at your desk instead. Whenever possible, go to places where you cant smoke, such as libraries, museums, or theaters. Plan Ways to Resist Smoking Triggers You Cant Avoid Some situations or feelings cant be avoided, of course. By acknowledging in advance that theyre likely to spark a craving, you can be better prepared to ride it out. Bring along something else to put in your mouth instead of a cigarettea mint-flavored toothpick or some carrot sticks, for example. While youre walking, take deep breaths, focusing on how good the fresh air feels in your lungs. Other useful strategies to ride out a craving include sipping ice-cold water through a straw, taking deep breaths, keeping your hands busy by squeezing a rubber ball or doing a crossword puzzle, or taking a brisk walk. Remember, each time you resist a trigger and dont light up, youve lessened its power over you. Most cravings only last a few minutes. If you can ride them out, youll be one step closer to a lifetime free of nicotine.

Quit-Smoking Drugs and Nicotine Patches and Gums

What can help you quit smoking?
By Peter Jaret WebMD Feature Quitting smoking is never easy. But a growing number of smoking cessation aids make it easier than ever for smokers to break their addiction to nicotine. Research suggests that medications and nicotine replacement therapies can double and sometimes even triple the chances that a smoker will successfully quit. Some of these treatments also help to minimize weight gain while quitting -- an important plus for many smokers who want to kick the habit. With a growing number of options available, doctors are now able to create personalized treatment plans tailored to an individual smokers needs and preferences. Whats right for you? Here are stop-smoking aids and drugs to consider: Nicotine Replacement Therapies The idea is simple. To help smokers manage nicotine withdrawal, nicotine replacement therapies deliver the potent drug in ways that are far healthier and safer than cigarettes. Ideally, ex-smokers can gradually reduce the amount of nicotine or stop nicotine replacement therapy all at once after theyve broken the habit of smoking. Even when used for long periods of time, nicotine replacement therapies are far safer than smoking. Quit rates range from 19% to 26%. Is it right for you? If youve tried to quit before and failed because the craving for nicotine was too strong, nicotine replacement therapies may help. Gum, lozenges, and patches are available over-thecounter. Nasal sprays and inhalers require a prescription. Gums and lozenges are handy to use and offer something for smokers to put in their mouths instead of a cigarette. Some smokers prefer inhalers because the process of inhaling mimics smoking a cigarette. All of these forms are about equally effective and they can be used in combination. Indeed, evidence suggests that combining patches with inhalers,

gum, or nasal sprays improves long-term quit rates. But you cannot continue to smoke while using nicotine replacement therapy. You must quit tobacco before you take alternate forms of nicotine. Expert advice: Dont be in too much of a hurry to go off nicotine replacement, says Scott McIntosh, PhD, associate professor of community and preventive medicine at the University of Rochester in New York and director of the Greater Rochester Area Tobacco Cessation Center. One common problem we see is people stopping too early and then experiencing cravings that they cant resist. McIntosh recommends using nicotine replacement therapies for two to three months. And after youve stopped using them, he recommends keeping some gum or lozenges handy just in case you suddenly experience an intense craving. Chantix (Varenicline) Varenicline, the latest antismoking drug to win FDA approval, works by blocking nicotine receptors in the brain. It is sold under the trade name Chantix in the U.S. and Champix in other parts of the world. Chantix is usually prescribed for a 12-week period, with the option of another 12-week maintenance course. About 33% of smokers who use the drug successfully quit. Is it right for you? Chantix is effective in lessening nicotine cravings and has helped many smokers successfully quit. Unlike Zyban, it should not be used in combination with nicotine replacement therapies (unless under a doctors supervision.) Chantix was approved in 2006. Side effects include nausea, vomiting,abnormal dreams, constipation, and flatulence. In 2009, the FDA required Chantix to have a boxed warning about serious neuropsychiatric events, including depression, suicidal thoughts, suicidal behavior, agitation, and hostility. Some serious side effect symptoms may be related to nicotine withdrawal. Expert advice: If you and your doctor decide to try Chantix, its important to monitor your moods and alert your doctor immediately if you notice any change, says Steven Schroeder, MD, director of the Smoking Cessation Leadership Center at the University of California, San Francisco. Some of the less serious but still unpleasant side effects of the drug, such as nausea, often go away over time. Zyban (Bupropion SR) Approved in 1997, Zyban acts on chemicals in the brain to ease nicotine withdrawal symptoms, making it easier for smokers to resist the craving to light up. The pills are usually taken twice a day for a period of seven to 12 weeks. Some ex-smokers may need to remain on Zyban for longer periods. About 24% of smokers who use Zyban successfully quit. Is it right for you? Zyban is especially helpful for people with intense nicotine withdrawal symptoms. It can be used alone or in combination with nicotine replacement therapies such as patches or gum. The FDA has required Zyban to have a boxed warning for serious neuropsychiatric events, including depression, suicidal thoughts, suicidal behavior, agitation, and hostility. Some serious side effect symptoms may be related to nicotine withdrawal. The drug is not recommended for people with seizure disorders, bulimia, anorexia, or patients who are abruptly stopping use of alcohol or sedatives, or are using a monoamine oxidase (MAO) inhibitor. The most common side effects are dry mouth and insomnia. Expert advice: Zyban should be started a week or two before your quit date to tame nicotine withdrawal symptoms. Like all drugs, it should be taken as recommended. Contact a health care provider right away if agitation, hostility, depressed mood, suicidal thoughts/behavior, or other changes in thinking or behavior develop. Counseling and Support Counseling and support groups have been shown to improve a smokers odds of successfully quitting. Counseling takes many forms, from a doctors advice to a formal smoking cessation program such as

those offered by medical centers and community health organizations. Online support in the form of quitlines has also proved very helpful. Counseling typically includes advice on how to recognize smoking triggers, strategies to resist cravings, how to prepare for your quit day, ongoing support during the first few months of quitting, and other assistance. Counseling can be combined with all forms of smokingcessation aids. Is it right for you? Counseling and support is invaluable for almost all smokers who want to quit. Personal preference is the most important criteria, so choose the kind of program that feels right for you. If you thrive in the company of other people, look for a smoking-cessation program that meets in your community. If you want to go it alone, check out the growing number of online support groups and quitlines. Good places to start include the National Cancer Institutes web site on smoking cessation or the North American Quitline Consortium. You can also call the federal governments quitline at 800QUITNOW. Expert advice: The more support and counseling you receive, research suggests, the better your odds of success. Stop Smoking With a Combination of Aids The best combination of approaches is the one that feels right to you. Experts say a few guidelines can help you and your doctor choose the most effective strategies. y y y If youve tried and failed to quit using one particular smoking cessation aid, such as nicotine replacement patches, for example, its wise to try another on your next attempt. If previous attempts have ended because you gave into intense cravings, talk to your doctor about combining therapies such as nicotine replacement inhalers with drugs that will minimize those cravings. If youre reluctant to quit because youre worried about weight gain, talk to your doctor about treatments that can minimize weight gain, and check out support groups that will encourage you to become more active. Whatever combination of approaches you choose, make sure that you begin with a positive mental attitude. Optimism and the belief that you can do it is one of the most powerful indicators for success, says Bruce S. Rabin, MD, PhD, medical director of the University of Pittsburgh Medical Center Healthy Lifestyle Program.

Quitting Tobacco: Help for the First Hard Days

1. Sip Cold Water and Eat Small Meals Sipping cold water can help replace the act of sucking on a cigarette. New research shows that sipping cold water through a straw releases dopamine, a feel-good brain chemical that can help ease negative moods. Eating small meals can also help you get past the urge to smoke. Choose lean, healthy foods to avoid any possible weight gain. 2. Recognize Instant Rewards You don't have to wait long to begin enjoying the benefits of a smoke-free life. Keep a written list of the benefits as you begin to experience them. These may include feeling in control, saving money, smelling better, tasting food more vividly, and feeling more energetic. When the urge to smoke strikes, look at the benefits you're already experiencing. 3. Brush Your Teeth Frequently One of the immediate benefits of quitting is that your mouth tastes better and your breath smells better. Brush your teeth frequently. That way, you'll be less inclined to light up a cigarette and foul that clean, fresh mouth. 4. Avoid Alcohol

Drinking alcohol is one of the most common reasons people go back to smoking. There are several reasons why. By breaking down inhibitions, the effect of alcohol can erode your commitment to quitting. The act of drinking alcohol is also associated with smoking for many people, so it may serve as a trigger.

5. Find Your Own No-Smoking Zones

When the urge to smoke strikes, go somewhere where you can't light up -- a movie, the library, or a store for example. The more distracting the location is, the easier it will be to ride out cravings. 6. Remember Your Reasons for Quitting Write down a list of all your reasons for quitting. Make copies and post them wherever you spend time -- in the kitchen, at the office, beside the bathroom mirror. Be sure they are prominently displayed so that you are reminded wherever you go. Some ex-smokers say they found it useful to put photographs of family and loved ones alongside their reasons.

7. Be Active Every Day

Physical activity offers a powerful distraction from cravings. When your body is active, it sends out natural chemicals that help your mood and reduce your stress. Walking is one of the easiest exercises for most people, but choosing a variety of activities may help you stay motivated. Especially during the first few weeks after quitting, set aside time to be physically active every day.

8. Fill Your Calendar

During the first few weeks of quitting, make sure your days are filled with things you want or need to do. Make plans to eat meals with family or friends. Try to steer clear of smoking temptations. Also include activities that you enjoy. The busier you are, the more distracted you'll be from the urge to smoke.

9. Put Something Else in Your Mouth

Part of the urge to smoke is having something in your mouth. In place of a cigarette, pop chewing gum, hard candy, or a healthy snack in your mouth when the urge strikes. Be sure to have something with you at all times. If you're concerned about gaining weight, stick with sugar-free alternatives.

10. Secure a Lifeline

Ask someone to be there for you when you need support. The best choice is a friend who is also a former smoker who has kicked the habit. But anyone who cares for you and wants you to quit smoking can help when times get tough. 11. Limit Caffeine Caffeine helps some people get going in the morning and stay alert when they're tired. But caffeine can make some people feel tense, jittery, and stressed. These effects can be amplified when youre in the process of breaking nicotine addiction. If caffeine negatively affects you, try cutting back to see if it helps reduce your anxiety.

12. Be Alert to Bad Moods

Negative emotions -- depression, anger, frustration -- are another common reason people go back to smoking. Bad moods happen to everyone. And chances are you'll experience more than your fair share of negative emotions during the first few weeks of quitting. Find ways to distract yourself. Useful strategies include getting together with friends or doing something you really enjoy.

13. Avoid Troublemakers

Although friends and family should be supportive, they aren't always. Some people may be threatened by your decision to quit. They may even try to undermine your best efforts. If you sense that there are people like this in your life, avoid them. If that isn't possible, sit down and explain to them why quitting is so important to you. Ask for their support.

14. Be Patient and Stay on Track

Once you make it through the first two weeks, you're on your way to a lifetime free of nicotine addiction. But be prepared in case you falter. Remember: one lapse does not signal a collapse. Analyze what went wrong. Then brainstorm strategies to prevent the same problem from happening again.

10 Persistent Myths About Smoking

Have you bought into these smoking myths? Experts set the record straight.
By David Freeman WebMD Feature Smoking in America is down -- but not out. Today, 20% of U.S. adults are smokers, compared to 45% in 1965, when smoking was at its peak. But even at the current level of tobacco use, an estimated 440,000 Americans per year lose their lives to lung cancer, heart disease, emphysema, or other smoking-related illnesses. On average, smokers die 14 years before nonsmokers, and half of all smokers who don't quit are killed by their habit. People start smoking for many reasons. Many continue to puff away because they buy into certain persistent myths about tobacco use. Here are 10 of those myths, and the truth about each. Myth: My other healthy habits may make up for my smoking. Some smokers justify their habit by insisting that proper nutrition and lots of exercise are enough to keep them healthy. Not so. "Research shows that eating a healthy diet and exercising don't reduce the health risks associated with smoking," says Ann M. Malarcher, PhD, senior scientific advisor in the CDC's Office on Smoking and Health. "Smoking affects every organ system in the body, and thinking that you're going to find the perfect lifestyle to counteract the effects of smoking is just not realistic." "You could take a truckload of vitamins a day and still not undo the deadly effects of tobacco," says Michael C. Fiore, MD, professor of medicine and director of the Center for Tobacco Research and Intervention at the University of Wisconsin in Madison, Wis.

Myth: Switching to 'light' cigarettes will cut my risk. Smokers who switch to brands labeled "light" or "mild" inevitably compensate for the lower levels of tar and nicotine by inhaling smoke more deeply or by smoking more of each cigarette. "Most people who smoke them wind up getting the same amount of the killing components in tobacco smoke," Fiore tells WebMD. "People who smoke light cigarettes are dying of lung cancer, stroke, heart attack, and emphysema every day." Similarly, cigarettes labeled "natural" or "organic" are no safer than ordinary cigarettes. "You don't need to add anything to tobacco for it to kill you," Fiore says.

Myth: I've smoked for so long; the damage is already done. The damage caused by smoking is cumulative, and the longer a person smokes, the greater his/her risk for life-threatening ailments. But quitting smoking at any age brings health benefits. "Your health will improve even if you quit at 70," says Norman H. Edelman, MD, chief medical officer of the American Lung Association.

The benefits of quitting start the day you stop. "Within a month, you will feel like you have more air, because you do," Fiore says. "Within a year, your risk of having a heart attack will be cut by 50%." According to the American Cancer Society, smokers who quit before age 35 prevent 90% of the risk of health problems from smoking. A smoker who quits before age 50 halves his/her risk of dying within the next 15 years compared to someone who continues to smoke. Myth: Trying to quit smoking will stress me out -- and that's unhealthy. True, tobacco withdrawal is stressful. But there's no evidence that the stress has negative long-term effects. In fact, research shows that smokers who quit begin eating better, exercising more, and feeling better about themselves. "They're in a better mental place," Fiore says. "So many smokers today hate the fact that they are addicted, and that they are taking money out of the family budget and putting it toward deadly cigarettes." On average, a pack-a-day smoking habit costs $2,000 a year, Edelman says. Myth: The weight gain that comes with quitting is just as unhealthy as smoking. Smokers who quit gain an average of 14 pounds, Malarcher says. But the risk posed by carrying the extra pounds "is miniscule compared to the risk of continuing to smoke," Fiore says. Myth: Quitting "cold turkey" is the only way to go. Some smokers think that quitting abruptly is the best approach and that willpower is the only effective tool for curbing tobacco cravings. They're partly right: Commitment is essential. But smokers are more likely to succeed at quitting if they take advantage of counseling and smoking cessation medications, including nicotine (gum, patches, lozenges, inhaler, or nasal spray) and the prescription drugs Zyban (buproprion) and Chantix (varenicline), Malarcher says. Counseling increases the odds of success by 60%, and taking medication doubles the odds, Malarcher says. For information on ways to quit smoking, visit WebMD's smoking cessation health center. Myth: Nicotine products are just as unhealthful as smoking. Nicotine is safe when used as directed. Even using nicotine every day for years would be safer than smoking, Fiore says. After all, nicotine products deliver only nicotine. Cigarettes deliver nicotine along with 4,000 other compounds, including more than 60 known carcinogens, according to the American Lung Association. Nicotine replacement therapy versus smoking? "It's a no-brainer," Fiore says. Myth: Cutting back on smoking is good enough. "Cutting down on the number of cigarettes is not an effective strategy," Malarcher says. "Smokers who cut back draw more deeply and smoke more of each cigarette." So even though they smoke fewer cigarettes, they get the same dose of toxic smoke. "The data suggest that the only [smoking cessation strategy] that works consistently is getting to the point of not even a single puff," Fiore says. Myth: I'm the only one who is hurt by my smoking. Tobacco smoke also harms the people around you. In the U.S., secondhand smoke causes about 50,000 deaths deaths a year, the American Lung Association estimates. It's been estimated that a waiter or waitress who works a single eight-hour shift in a smoky bar inhales as much toxic smoke as a pack-a-day smoker, Fiore says.

Myth: I tried quitting once and failed, so it's no use trying again. Most smokers try several times before quitting for good. So if you've failed previously, don't let that deter you from trying again. "Each time people quit, they learn things that could be useful for their next attempt at quitting," Malarcher says. Edelman says, "We like to say the first time you try to quit is practice, the second time is practice, and the third or fourth time, you get it right. You have to keep trying."

Video on Quit Smoking Aids:

http://www.webmd.com/smoking-cessation/video/quit-smoking-aids

Video on How to Quit Smoking Forever:

http://www.webmd.com/smoking-cessation/quit-smoking-11/how-to-quit-smoking

13 Best Quit-Smoking Tips Ever

No. 1: Know Why You Want to Quit
So you want to quit smoking, but do you know why? "Because it's bad for you" isn't good enough. To get motivated, you need a powerful, personal reason to quit. Maybe you want to protect your family from secondhand smoke. Maybe the thought of lung cancer frightens you. Or maybe you'd like to look and feel younger. Choose a reason that is strong enough to outweigh the urge to light up.

No. 2: Don't Go Cold Turkey

It may be tempting to toss your cigarettes and declare you've quit, plain and simple. But going cold turkey isn't easy to do. Ninety-five percent of people who try to stop smoking without therapy or medication end up relapsing. The reason is that nicotine is addictive. The brain becomes used to having nicotine and craves it. In its absence, the symptoms of nicotine withdrawal occur.

No. 3: Try Nicotine-Replacement Therapy

When you stop smoking, nicotine withdrawal may make you feel frustrated, depressed, restless, or irritable. The craving for "just one drag" may be overwhelming. Nicotine-replacement therapy can help reduce these feelings. Studies suggest nicotine gum, lozenges, and patches can help double your chances of quitting successfully when used with an intensive behavioral program. But using these products while smoking is generally not recommended.

No. 4: Ask About Prescription Pills

To ease nicotine withdrawal without using products that contain nicotine, ask your doctor about prescription medications. There are pills that help reduce cravings by affecting chemicals in the brain. They may also make smoking less satisfying if you do pick up a cigarette. Other drugs can help reduce troubling withdrawal symptoms, such as depression or inability to concentrate.

No. 5: Don't Go It Alone

Tell your friends, family, and co-workers that you're trying to quit. Their encouragement could make the difference. You may also want to join a support group or talk to a counselor. Behavioral therapy is a type of counseling that helps you identify and stick to quit-smoking strategies. Combine behavioral therapy with nicotine replacement products and/or medication to boost your odds of success.

Is Smoking Dragging You Down?

10 reasons to quit smoking beyond the big health threats.
By Lisa Zamosky WebMD Feature If you smoke, you've likely heard the pleas from friends and family to quit. You probably know that smoking makes heart disease, stroke, cancer, emphysema, chronic bronchitis, and other killers more likely. You might even know that smoking is the No. 1 cause of preventable death in the U.S. and worldwide. But knowing about long-term risks may not be enough to nudge you to quit, especially if you're young. It can be hard to feel truly frightened by illnesses that may strike decades later. And quitting smoking is hard. As many as 75%-80% of smokers say they'd like to quit. But it takes the average smoker five to 10 attempts before successfully quitting. For some smokers, it's the little things that motivate quitting. Things like the smell it leaves on your clothes, the way people react when they find out you're a smoker, the stains it leaves on your teeth -everyday aggravations that can add up to a tipping point to kick the habit. Here are 10 common daily side effects of smoking that often create the incentive to quit. 1. Smelling like smoke There's no mistaking the smell of cigarette smoke, and it's not one many people describe favorably. Steven Schroeder, MD, director of the Smoking Cessation Leadership Center at the University of California at San Francisco, says that smokers are commonly self-conscious about the smell of smoke on their clothes and in their hair. And the smell of their breath is one of particular sensitivity to most smokers. "Some of the media campaigns have compared kissing a smoker to licking an ashtray," Schroeder says. Enough said. 2. Sense of smell and taste Smelling like an ashtray isn't the only impact smoking has on the nose. Smokers also experience a dulling of their senses; smell and taste in particular take a hit when you smoke. Smokers can't appreciate the taste of many foods as intensely as they did before smoking, but it's really the loss of the sense of smell that diminishes the ability to taste, notes Andrew Spielman, DMD, PhD, associate dean for academic affairs and professor of basic science and craniofacial biology at the NYU School of Dentistry. Breathing in the hot fumes of cigarette smoke is toxic to the senses. Some smokers realize that foods don't taste the way they used to, but the process can be quite gradual, making it difficult to detect. Quitting brings a swift return of the senses. "I can't tell you how many smokers who have successfully quit come back to the clinic and say eating is a totally different experience," says Michael Fiore, MD, MPH, founder and director of the University of Wisconsin Center for Tobacco Research and Intervention. "The pleasure of eating is dramatically enhanced when smokers quit. And it happens within a few days but can continue for up to three to six months."

3. Premature aging "One of the chief and significant causes of premature aging of the face is smoking," Fiore says. Skin changes, like leathery skin and deep wrinkling, are more likely in people who are regular smokers. According to the American Academy of Dermatology, smoking leads to biochemical changes in the body that speed the aging process. For example, smoking deprives the living skin tissue of oxygen by causing constriction of the blood vessels. As a result, blood doesn't get to your organs as easily, and that includes the skin. Another classic smoker giveaway is tar staining of the hands and skin from holding cigarettes. "Burning cigarette smoke is most apparent around the face and I think that what we sometimes see is staining of the skin from the tars and other deadly toxins in tobacco smoke," Fiore says. Fiore also points out that the muscle actions required to inhale lead to the classic smoker's wrinkles around the mouth. 4. Social pressures Schroeder cites a study published in The New England Journal of Medicine in 2008, which looked at the dynamics of smoking in large social networks as a part of the Framingham Heart Study. The study, which took place during the period between 1971 and 2003, examined smoking behavior and the extent to which groups of widely connected people have an affect on quitting. One of the findings was that smokers have increasingly moved to the fringes of social networks. "Smokers have become marginalized," Schroeder says. Joyce Wilde, a small business owner and former smoker in Pittsburgh, remembers feeling marginalized when she smoked heavily. "Smoking really messed with my self-concept," Wilde tells WebMD. "I usually hid somewhere and smoked so no one would see me. The experience of smoking embarrassed me and I felt weakened by it, both physically and emotionally." The reasons for the increasing unpopularity of smoking and diminished social standing of those who continue to light up likely has roots in our increased understanding of the health implications of smoking, not just for the smoker, but for those breathing in secondhand smoke as well. "The reason for [clean indoor air] ordinances is to protect the healthy nonsmoker from the known danger of toxins of secondhand smoke," Fiore says. "It's not just the inconvenience of it makes my clothes smell bad when I go to get a drink, it's that risk from the carcinogens and side stream smoke, some of which are at higher concentrations than direct smoke." 5. Finding a mate Anyone who has perused the dating advertisements in papers, magazines or online, has seen more than his or her fair share of the phrase, "No smokers, please." Long after quitting smoking on a daily basis, Wilde found herself once again reaching for cigarettes during the stressful time of her divorce. She was a decade older than when she last smoked and at the time, living in Southern California where she felt the competition in the singles market was stiff. Smoking, she says, only added to the challenge of finding a new mate after her marriage ended. "After I crossed 40, the dating scene became harder because my peers were looking at people much younger, so if you add smoking into that, it's even harder," Wilde says. That's not surprising to Fiore. "There is a general sense that I'd rather be with someone who did not smell like a dirty ashtray," he says. 6. Impotence

If smoking generally adds a hurdle to finding a new partner, impotence sure doesn't help. Yet smoking increases the chances of impotence dramatically for men by affecting blood vessels, including those that must dilate in order for an erection to occur. "It's been said in the scientific literature that one of the most powerful messages to teenage boys is that not only does it make you smell like an ashtray and no one wants to kiss a smoker, but it can cause impotence or impact your erections. It's a message that is frequently used to motivate adolescent boys to step away from cigarettes," Fiore says. 7. Increased infections You may know about the long-term health risks associated with smoking, but did you realize that smoking also makes you more susceptible to seasonal flus and colds? "People don't realize how much more frequently smokers get viral, bacterial and other infections," Fiore says. Tiny hairs called cilia that line the respiratory tract, including the trachea and bronchial tubes, are designed to protect us from infection. "Cilia are constantly waving in a way that grabs bacteria and viruses that get into the trachea and pushes them up and out so we cough them out and swallow them and destroy them with our stomach acids," Fiore explains. One of the toxic effects of cigarette smoke is that it paralyzes the cilia, thereby destroying this core protective mechanism. That's why smokers have so many more infections. Within a month of quitting, however, your cilia start performing their protective role once again. 8. You're a danger to others Secondhand smoke is estimated to cause 50,000 deaths every year. It's no wonder: More than 4,500 separate chemicals are found in a puff of tobacco smoke, and more than 40 of those are known carcinogens. "It takes very little secondhand smoke to trigger a heart attack or stroke in someone who is predisposed to that condition," Schroeder says. The ingredients in smoke cause platelets, the material in our blood that helps it clot, become sticky. This increases the risk of heart attacks. "There have been a number of studies to show that when a community goes smoke-free the proportion of heart attacks seen at the hospitals goes down by 20% or 30%," Schroeder says. 9. Impact on physical activity Many smokers report a diminished ability over time to comfortably do things as simple as climbing a set of stairs or enjoying sports activities they once easily took part in such as volleyball or jogging. According to Schroeder, even young athletes in otherwise top physical condition don't perform as well if they smoke because over time, smoking causes the lungs and heart to work harder. 10. Cost If you're a smoker, it's no surprise that smoking is downright expensive. The price of a pack of cigarettes varies greatly by location, but Fiore says the average cost is about $5 per pack, and in some states it can be as high as $10 per pack, including federal and state taxes. "Who today has [that kind of money] that they can put aside this way?" Fiore asks. "If you're in a place where it costs $7 for a pack [of cigarettes], you're approaching $3,000 a year. That's putting aside the fact that the average smoker has three extra sick days a year, is 8% less productive, and has $1,600 in extra health care costs per year," he says. "The annual economic costs [of smoking] are over $200 billion nationally."

And of course, those figures don't capture the toll smoking takes in the long run. "It's important to think of this not as a bad habit to put aside but as a chronic disease that for almost all smokers needs to be addressed their whole lives," Fiore says. And there's no better time to start that process than now.

Surviving Without Smoke: Month 1

By Gina Shaw WebMD Feature You just quit smoking. Literally. Five minutes ago you put out your last cigarette. Now what? How do you get through the next few hours and days, which will be among the toughest youll experience, in your journey to becoming an ex-smoker? You need practical strategies to help you survive the nicotine cravings and nicotine withdrawal, and help you break the psychological addiction to cigarettes. After You Stop Smoking: Whats Happening? After you quit smoking, a lot of good things happen to your body very quickly. Within just 20 minutes, your heart rate and blood pressure go down. Within 12 hours, the carbon monoxide levels in your body go back to normal. And within a couple of weeks, your circulation improves and youre not coughing or wheezing as often. But some pretty unpleasant things happen right away, too. The symptoms of nicotine withdrawal include: y y y y y y Anxiety Irritability Headache Trouble sleeping Fatigue Hunger And they kick in fast. Research has found that the typical smoker begins to feel the symptoms of withdrawal within an hour of putting out his last cigarette. Feelings of anxiety, sadness and difficulty concentrating appear within the first three hours. These unpleasant -- some people might say intolerable -- symptoms of nicotine withdrawal usually hit a peak within the first three days of quitting, and last for about two weeks. So before you can stop smoking for good, you have to quit for the first two weeks. After that, it gets a little easier. What can you do? Be Prepared You should actually start making plans before you quit, says Coral Arvon, PhD, MFT, LCSW, a behavioral health specialist at the Pritikin Longevity Center in Miami, who is also a former smoker. During the week before your Quit Day, make the following preparations: y y Put together a list of all the reasons you want to quit smoking. Print it out on index cards and stash the cards where you used to put your cigarettes -- in your purse, in your desk drawer, in your nightstand. Pay attention to when you smoke, where, and with whom. Then make specific plans for what you can do instead. Do you usually have a cigarette with a cup of coffee in the morning? Do you take a smoke break mid-morning with a co-worker? Write down alternatives that will keep your mind and body occupied. Dont wait until after youve quit and the craving strikes!

Pick a good quit day. Were all under stress in our busy lives, but some times are more stressful than others. Dont choose a day to quit smoking thats in the middle of your most intense month at work, or right before finals, or while a loved one is seriously ill. Try to quit at a time when you can avoid major stress for at least a week or two, says Arvon. For one week, gather the contents of your ashtrays. Put them in a jar with a lid, and pour some water on the resulting mess. Seal the jar. Well talk about what to do with it later. After You Quit Smoking So youve made your preparations, youve thrown away your packs, and youve smoked your last cigarette. Now its time to act like an ex-smoker. What next? First, you need to learn to delay the urge. There will be an urge to smoke -- almost immediately. Any given urge to smoke lasts about 30 seconds before diminishing again, Arvon says, so you need to do things to keep your mind and body busy until the urge fades again. Some options:

y y y

y y

Take 10 deep breaths, walk to the sink, pour yourself a glass of ice water, and drink it slowly. Fix a healthy snack. Something that makes your breath and teeth feel fresh is great, such as carrot sticks or a citrus fruit. Or suck on a peppermint. Keep a paperback book with you on a subject you want to learn about. When you feel the urge to smoke, pull the book out along with a pen or highlighter and read a few pages while making notes or highlighting passages. Youre occupying your mind and your hands with something other than a cigarette, says Arvon. Take out your list of reasons why youre no longer a smoker and read it to yourself. Out loud if you have to. Call a friend or a family member who supports your efforts to quit smoking. You dont have to talk to them about smoking or quitting -- just hold the phone in your hand instead of a cigarette, and talk about sports, the weather, or your next vacation until the craving passes. Go high-tech. Download a quit smoking application for your smartphone that helps you delay your urges. Try Quitter, which tracks how long youve been smoke-free and shows you the money youve saved. Next time you want a cigarette, check out your riches instead. Remember that jar with all your old ashtray contents? Keep it handy, in your desk drawer or under the kitchen sink. When a craving hits hard, pull out that jar, open it up and take a big whiff. Its really disgusting, says Arvon. It makes you want to never see a cigarette again. Many people, knowingly or unknowingly, sabotage themselves during the first weeks of quitting, says Arvon. During this time when youre very vulnerable, dont put yourself in situations that will up the pressure to smoke. For example:

Dont go out with friends who are smokers for a few weeks. This doesnt mean to drop your smoking friends completely. Just tell them youll be taking a break while youre in the early, difficult days of quitting and back when youre feeling stronger. Change your habits. If sitting outside your favorite coffee shop with your morning coffee and a cigarette is an old familiar routine, you might find it almost impossible not to light up there. Instead, have tea or juice on the front porch with your morning paper. Many people associate alcohol with having a cigarette, so you might want to stay away from happy hour for a few weeks. Instead of sabotaging yourself, reward yourself every time you succeed. Many people recommend rewards after the first week or two of quitting, but, Arvon says, why wait that long? Give yourself small rewards for every single day you make it through the first two weeks, and bigger ones at the end of week one and week two.

Small Rewards: y y y y y A new book, DVD, or video game. A dozen golf balls. New earrings. A manicure (for your hands that will look so much more attractive without a cigarette in them). A box of expensive, artisan chocolates. To avoid quitters weight gain, indulge in just one per evening. Bigger Rewards: y y y y y y A fancy dinner out. Go to a sports event or concert. Have your car detailed. An evening at the movies or theater. A full-body massage and facial. A weekend away. You know the things that motivate you. Dole them out to yourself for every day you dont put a cigarette in your mouth. Finally, says Arvon, you have to learn to overcome the learned ways of thinking that lead you to pick up a cigarette. A lot of times, we smoke when were feeling stressed, anxious, or depressed. When that feeling comes on, stop and think about why youre feeling that way. For example, if youve missed a deadline at work, you may fear getting in trouble with your boss and losing your job. A smoker will think, I need a cigarette! But youre not a smoker anymore. So instead of grabbing a cigarette, argue with yourself. Be your own devils advocate and dispute your irrational thoughts. Im going to lose my job! No, youre not. Youve done a lot of good work and your boss wont fire you for one missed deadline. Keep up that argument until the immediate feeling of stress or depression passes and you arent feeling that intense need to run out for a smoke. The hardest part of quitting is the first two weeks, says Arvon. We call the first week after quitting Hell Week. The second week is Heck Week. After that, it gets easier. The urges dont go away, but most of them are lighter and you can get through them.

Quitting Smoking - Dealing With Relapse

If you slip or smoke a little, don't give up. Talk to someone who has quit smoking, or to a counselor, to get ideas of what to do. If you are taking medicine or using nicotine replacement, keep doing so unless you go back to regular smoking. You're not alone in going back to smoking. Most people who quit try 8 to 10 times before they quit for good.2 Don't feel bad about yourself. A relapse is just a sign that you need to try a different approach to quitting smoking. If you tried to quit without medicines or a program, think about trying them next time. Medicines and nicotine replacement (gum, patches, lozenges) can double your chances of success.1 Think about what made you start smoking again. Maybe you couldn't handle the cravings. Or maybe you didn't have enough support from family or friends. Maybe something stressful happened that triggered the urge to smoke, and then you couldn't stop. Whatever it was, remember that help is here when you are ready to try again. You might want to read Thinking About Quitting? or Planning Your Strategy to Quit in this topic.