Panic Attacks

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PANIC ATTACKS
What are panic attacks?

How do panic attacks become a problem?

What causes these attacks?

How can I help myself?

Which therapies are effective?

Symptoms

What to do if you are having a Panic Attack

Finding Help for Panic Disorders

Help for the family

Coexisting conditions

Useful organisations

Further reading

What are panic attacks?

Panic attacks are extremely frightening. They seem to come out of the blue, strike at random, make people feel powerless, out of control, and as if they are about to die or go mad. Many people experience this problem, but many also learn to cope and, eventually, to overcome it successfully.

A panic attack is an exaggeration of the bodys normal response to fear, stress or excitement. When faced with a situation seen as potentially threatening, the body automatically gears itself up for danger, by producing quantities of adrenalin for 'fight or flight'. This would have prepared our cave-dwelling ancestors to fight or run away from danger, but its much less appropriate to the stresses we encounter today.

Adrenalin has the following effects on your body:

The muscles tense up.
Breathing becomes faster to take in more oxygen, which muscles need to help them transform sugar into energy.
The heart pumps harder to get blood to where its needed.
Blood is diverted to the muscles, away from areas that don't need it, so you become pale.
Digestion slows down and salivary glands dry up, causing a dry mouth.
Your senses become more alert; the slightest sound or touch provokes a reaction.
Sweating increases.
These reactions occur in a matter of seconds, and can happen in moments of pleasurable excitement, as well as in fear-provoking and threatening situations. When adrenalin floods your body, it can cause a number of different physical and emotional sensations that may affect you during a panic attack.

These may include:

very rapid breathing or feeling unable to breathe
very rapid heartbeat
pains in your chest
feeling faint or dizzy
sweating
ringing in your ears
tingling or numbness in your hands and feet
hot or cold flushes
feeling nauseous
wanting to go to the toilet
feelings of absolute terror
feelings of unreality, called depersonalisation and derealisation.
(During depersonalisation, people feel detached from their body and surroundings, strange and unreal. During derealisation, they feel grounded in themselves, but the world seems distant or strange, and they may feel unsteady on their feet.)

Panic attacks come on very quickly, symptoms usually peaking within 10 minutes. Most panic attacks last for between five and 20 minutes. Some people report attacks lasting for up to an hour, but they are likely to be experiencing one attack after another, or a high level of anxiety after the initial attack. You may have one or two panic attacks and never experience another. Or you may have attacks once a month or several times each week.

Panic attacks can come in the night when you are asleep. These night-time attacks occur as your body is on 'high alert' and can detect small, normal changes in your body which it then takes as a sign of danger. (The fact that you can be monitoring your bodily sensations while asleep is perfectly normal and automatic  just think about the times you have woken up and needed to go to the toilet.) Night-time attack may be particularly frightening, as you may feel confused and helpless to do anything to spot it coming. This is one of the most distressing aspects of suffering from panic attacks  they may seem completely unpredictable, and therefore uncontrollable.

During an attack, you may fear that the world is going to come to an end, or that you are about to die or go mad. The most important thing to remember is that, however dreadful you may feel during an attack, this is not going to happen. The bodily effects of panic attacks, such as breathlessness, are just part of the panic. If you would like further reassurance, see your GP, so he or she can rule out any physical cause for your symptoms.

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How do panic attacks become a problem?

A high level of adrenalin is not in itself a bad thing. It can give you the extra energy to deal with difficult demands and challenges. The damage is done when the levels of adrenalin don't fall, naturally, after a stressful event. Stress becomes prolonged and tension becomes a habit.

For many people, their first panic attack comes out of the blue and creates a state of arousal. You may find yourself becoming more nervous, impatient and irritable as you feel, understandably, apprehensive about having another attack.

If you experience panic attacks over a period of time, you may develop a fear of fear. Because you have become hyper-aware of the sensations associated with fear, sensitised to them, you tense up whenever anything at all reminds you of the original panic. This can include your own bodily sensations. So someone feeling hot, or with sweaty hands (perhaps because they are in a meeting in a warm room), may assume, automatically, that they are in for another panic attack. Anticipating this makes them tense up and produces the very panic response they feared.

Agoraphobia and similar problems
You may start to associate particular places and situations with having an attack. In an attempt to avoid another one, you may steer clear of places where attacks have previously occurred. But this may put more and more restrictions on your day-to-day activities, and could lead to agoraphobia or social phobia. (See Minds booklet Understanding phobias.)

Depression
As you feel more out of control and restrict your activities, your enjoyment of life and your self-confidence is undermined. Many people who experience panic attacks become very depressed.

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What causes these attacks?

There are many physical and psychological factors, which may be interwoven. You may experience panic only in response to a particular situation, such as flying or visiting the dentist. Or you may feel perfectly fine during a stressful event, but may have an attack later. This is because adrenalin levels dont drop straight away. Any major life changes and events can trigger panic attacks.

Childhood influences
Incidents in childhood, and the way you were brought up and taught to think about yourself, can make you vulnerable to panic attacks later on. If you experienced great fear at being separated from a parent, you may have gone on to develop school phobia. As an adult, you may then have panic attacks when threatened with the loss of a support system or of someone who is important to you. Adult survivors of abuse in childhood also frequently suffer panic attacks.

Personality traits
If you are always anxious, you are more likely to have panic attacks. Being over-critical and disapproving of yourself, and striving to conform to the expectations of others, is common in people who panic. You may have difficulties in expressing your own needs and asserting yourself.

Physical causes
There are a number of physical causes that could be causing or contributing to your panic attacks:

Unstable blood sugar levels (hypoglycaemia) can be the result of poor eating habits, dieting and fasting.
Over-breathing (hyperventilation) happens when you are under stress, though you may not be aware of it. Your breathing becomes more rapid, in order to meet the body's demand for more oxygen for the muscles. As a result, you breathe out more carbon-dioxide than normal, which can bring on panic symptoms.
Digestive problems, particularly food allergies, may be to blame.
Taking antidepressants, particularly the newer ones, may produce panic attacks, especially at first.
Caffeine, cigarettes, alcohol, and certain street drugs (such as LSD, marijuana and cocaine) can bring on a panic reaction.
Withdrawing from any drug that has a sedative effect, such as nicotine, alcohol and tranquillisers, can do the same.
Some prescription medication, including some amphetamines, steroids, anti-asthma drugs, and even nasal decongestants have been reported to increase anxiety.
Sometimes, problems with the way the brain works (known as organic brain dysfunction) will cause balance, coordination and visual difficulties that make people very vulnerable to stress, and may contribute to agoraphobia.
Being in chronic pain can be another cause of panic attacks, as can simple jet lag.

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How can I help myself?

Your panic attacks are likely to make you feel out of control and dependent; the victim of your bodily reactions and outside circumstances. The first step along the road to recovery is recognising that you have the power to control your symptoms.

Take control
Start by really looking, in detail, at your panic attacks. When did they happen? Where were you? What were you thinking? See if you can identify particular thoughts that trigger a panic reaction.

A number of experts have emphasised the need to accept the panic attacks when they occur and that it may in fact be most helpful if you try and ride out the attacks to learn that no harm will come to you. This may sound strange, but fighting them only increases your level of fear and allows your panic to take on tremendous proportions. Accept that a panic attack is unpleasant and embarrassing, but that it isn't life-threatening or the end of the world. By going with the panic, you are reducing its power to terrify you.

Creative visualisation and affirmations
Creative visualisation and affirmations are techniques that may be helpful. You can use them to re-train your imagination and to get yourself moving in a more positive direction.

Many people who suffer panic attacks have a vivid imagination, which they use to conjure up disaster, illness and death. You can train your imagination to focus on situations that give you a sense of wellbeing. You can imagine you are in a place that symbolises peace and relaxation for you, such as drifting on a lake. You can practise this anywhere but, until you have got used to doing this, try sitting in a chair with your limbs as floppy as possible, and think of calming images.

You can use visualisation to focus on situations that you fear. Imagine the situation and speak positively to yourself: 'I am doing well', 'This is easy'. These simple, positive, present-tense affirmations are messages that you can say silently or out loud. These techniques do not provide a quick fix. If you have been used to thinking negatively, over a long period of time, you will need to practise every day. You may then gradually notice positive changes in the way you think of yourself and others.

Assertiveness
You may be having panic attacks because there are aspects of your life that are undermining your confidence. It may be useful to look at your family life, your job, and so on, and identify changes you would like to make. If you feel trapped in a situation, and find it very difficult to express your true feelings (to say 'no' or to set proper limits in relationships, for example), you may find assertiveness training helpful.

Learn a relaxation technique
If you habitually clench your jaw, and your shoulders are up around your ears, this will generate further tension. Relaxation techniques focus on easing muscle tension and slowing down your breathing. It helps your mind to relax. (See The Mind guide to relaxation.)

Breathing
Hyperventilation (over-breathing) commonly leads to panic attacks. Many people get into the habit of breathing shallowly, from the upper chest, rather than more slowly from the abdomen. Put one hand on your upper chest and the other on your stomach. Notice which hand moves as you breathe. The hand on your chest should hardly move, if you are breathing correctly from the diaphragm, but the hand on your stomach should rise and fall. Practise this breathing, slowly and calmly, every day.

Diet
Unstable blood sugar levels can contribute to symptoms of panic. Eat regularly and avoid sugary foods and drinks, white flour and junk food. Instead, choose complex carbohydrates, such as potatoes, rice and pasta. Caffeine, alcohol and smoking all contribute to panic attacks and are best avoided.

First aid
If you are having a panic attack, try cupping your hands over your nose and mouth, or holding a paper bag (not plastic!) and breathing into it, for about 10 minutes. This should raise the level of carbon-dioxide in the bloodstream and relieve symptoms.

Other first-aid tips include running on the spot during a panic attack. If you feel unreal, carry an object, such as the photograph of a loved one, to anchor you in reality, or finger a heavily textured object, such as a strip of sandpaper. You could also distract yourself, by trying to focus on what is going on around you.

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Which therapies are effective?

Drug therapy
The NICE (National Institute for Health and Clinical Excellence) guidelines on the treatment of anxiety state that benzodiazepine tranquillisers, such as diazepam (Valium), are associated with a less good outcome in the long-term and should not be used to treat panic disorder. If drug treatment is used, SSRI antidepressants, such as Prozac, should be used first, and if these are not effective, the tricyclic antidepressants imipramine or clomipramine (Anafranil) may be tried instead. SSRI antidepressants are difficult to come off for many people, so when you are ready to stop taking them, you should always withdraw slowly. When starting antidepressants, the side effects may include anxious, jittery feelings. The longer you are on them, the more likely you are to experience withdrawal symptoms, which can cause panic attacks. (See Minds Making sense of series.)

Psychotherapy
Emotional conflicts and past difficulties may lead to anxiety, which is released through panic attacks. Without realising it, you may be experiencing these bodily sensations and physical reactions as a way of avoiding painful emotions. Psychotherapy can help you to understand your present reactions in the light of past difficulties, and to overcome them. (For more information, see Useful organisations.)

Cognitive behaviour therapy (CBT)
Our thoughts have a very powerful impact on our behaviour. You may be unaware of seemingly automatic thoughts and misinterpretations that provoke attacks. This is because thoughts happen so quickly and may take the form of images and sensations, rather than words. The way we interpret things can cause extreme distress. But it is possible to bring about a state of wellbeing by changing habitual thought patterns. If we think that our racing heart is a sign of a possible heart attack we'll be very frightened, but if we think that it is due to excitement or too much coffee, we'll feel very differently about it.

CBT aims to identify and change the negative thought patterns and misinterpretations that are feeding your panic attacks. If you are interested in this kind of therapy, ask your GP to refer you to a clinical psychologist. Its also possible to apply self-help techniques. (See Making sense of cognitive behaviour therapy.)

Behaviour therapy
Many people develop a pattern of avoiding situations that have previously provoked a panic attack. They may become withdrawn and phobic. A clinical psychologist can address the problem using behavioural therapy. The therapy concentrates on encouraging you to imagine anxiety-provoking situations, at the same time as practising relaxation. You will be encouraged to confront your fears, in fantasy, and then move on to facing your fears in reality. In learning to relax and face up to feared situations, you will unlearn your feelings of panic.

Complementary and alternative therapies
Complementary and alternative therapies have proved to be helpful when people are experiencing stress-related symptoms, anxiety and depression. They can be a useful tool in promoting relaxation and inducing a state of wellbeing. Complementary health practitioners stress the connections between mind and body, and arent concerned with merely treating symptoms. There is an enormous number of different therapies: acupuncture, aromatherapy, autogenic training and homeopathy, to name but a few. (See Useful organisations and Further reading for more information.)

Other treatments

Treatment can bring significant relief to 70 to 90 percent of people with panic disorder, and early treatment can help keep the disease from progressing to the later stages where agoraphobia develops.

Before undergoing any treatment for panic disorder, a person should undergo a thorough medical examination to rule out other possible causes of the distressing symptoms. This is necessary because a number of other conditions, such as excessive levels of thyroid hormone, certain types of epilepsy, or cardiac arrhythmias, which are disturbances in the rhythm of the heartbeat, can cause symptoms resembling those of panic disorder.

Several effective treatments have been developed for panic disorder and agoraphobia. In 1991, a conference held at the National Institutes of Health (NIH) under the sponsorship of the National Institute of Mental Health and the Office of Medical Applications of Research, surveyed the available information on panic disorder and its treatment. The conferees concluded that a form of psychotherapy called cognitive-behavioral therapy and medications are both effective for panic disorder. A treatment should be selected according to the individual needs and preferences of the patient, the panel said, and any treatment that fails to produce an effect within 6 to 8 weeks should be reassessed.

Cognitive-Behavioral Therapy.   This is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient's symptoms, and behavioral therapy, which aims to help the patient change his or her behavior.

Typically the patient undergoing cognitive-behavioral therapy meets with a therapist for 1 to 3 hours a week. In the cognitive portion of the therapy, the therapist usually conducts a careful search for the thoughts and feelings that accompany the panic attacks. These mental events are discussed in terms of the "cognitive model" of panic attacks.

The cognitive model states that individuals with panic disorder often have distortions in their thinking, of which they may be unaware, and these may give rise to a cycle of fear. The cycle is believed to operate this way: First the individual feels a potentially worrisome sensation such as an increasing heart rate, tightened chest muscles, or a queasy stomach. This sensation may be triggered by some worry, an unpleasant mental image, a minor illness, or even exercise. The person with panic disorder responds to the sensation by becoming anxious. The initial anxiety triggers still more unpleasant sensations, which in turn heighten anxiety, giving rise to catastrophic thoughts. The person thinks "I am having a heart attack" or "I am going insane," or some similar thought. As the vicious cycle continues, a panic attack results. The whole cycle might take only a few seconds, and the individual may not be aware of the initial sensations or thoughts.

Proponents of this theory point out that, with the help of a skilled therapist, people with panic disorder often can learn to recognize the earliest thoughts and feelings in this sequence and modify their responses to them. Patients are taught that typical thoughts such as "That terrible feeling is getting worse!" or "I'm going to have a panic attack" or "I'm going to have a heart attack" can be replaced with substitutes such as "It's only uneasiness  it will pass" that help to reduce anxiety and ward off a panic attack. Specific procedures for accomplishing this are taught. By modifying thought patterns in this way, the patient gains more control over the problem.

Often the therapist will provide the patient with simple guidelines to follow when he or she can feel that a panic attack is approaching. One therapist has offered a set of strategies that have helped some of her patients to cope with panic attacks.
 
 
 
 

Strategies for Coping with Panic
Remember that although your feelings and symptoms are very frightening, they are not dangerous or harmful.
Understand that what you are experiencing is just an exaggeration of your normal bodily reactions to stress.
Do not fight your feelings or try to wish them away. The more you are willing to face them, the less intense they will become.
Do not add to your panic by thinking about what "might" happen. If you find yourself asking "What if?" tell yourself "So what!"
Stay in the present. Notice what is really happening to you as opposed to what you think might happen.
Label your fear level from zero to ten and watch it go up and down. Notice that it does not stay at a very high level for more than a few seconds.
When you find yourself thinking about the fear, change your "what if" thinking. Focus on and carry out a simple and manageable task such as counting backward from from 100 by 3's or snapping a rubber band on your wrist.
Notice that when you stop adding frightening thoughts to your fear, it begins to fade.
When the fear comes, expect and accept it. Wait and give it time to pass without running away from it.
Be proud of yourself for your progress thus far, and think about how good you will feel when you succeed this time.
(Courtesy Jerilyn Ross, M.A., L.I.C.S.W., The Ross Center for Anxiety and Related Disorders, Inc., Washington, DC. Adapted from Mathews et al., 1981.)
 

In cognitive therapy, discussions between the patient and the therapist are not usually focused on the patient's past, as is the case with some forms of psychotherapy. Instead, conversations focus on the difficulties and successes the patient is having at the present time, and on skills the patient needs to learn.

The behavioral portion of cognitive-behavioral therapy may involve systematic training in relaxation techniques. By learning to relax, the patient may acquire the ability to reduce generalized anxiety and stress that often sets the stage for panic attacks.

Breathing exercises are often included in the behavioral therapy. The patient learns to control his or her breathing and avoid hyperventilation  a pattern of rapid, shallow breathing that can trigger or exacerbate some people's panic attacks.

Another important aspect of behavioral therapy is exposure to internal sensations called interoceptive exposure. During interoceptive exposure the therapist will do an individual assessment of internal sensations associated with panic. Depending on the assessment, the therapist may then encourage the patient to bring on some of the sensations of a panic attack by, for example, exercising to increase heart rate, breathing rapidly to trigger lightheadedness and respiratory symptoms, or spinning around to trigger dizziness. Exercises to produce feelings of unreality may also be used. Then the therapist teaches the patient to cope effectively with these sensations and to replace alarmist thoughts such as "I am going to die," with more appropriate ones, such as "It's just a little dizziness  I can handle it."

Another important aspect of behavioral therapy is "in vivo" or real-life exposure. The therapist and the patient determine whether the patient has been avoiding particular places and situations, and which patterns of avoidance are causing the patient problems. They agree to work on the avoidance behaviors that are most seriously interfering with the patient's life. For example, fear of driving may be of paramount importance for one patient, while inability to go to the grocery store may be, at most, handicapping for another.

Some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car.

The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable.

Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual.

Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Cognitive-behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

Treatment with Medications.   In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication.

The three groups of medications most commonly used are the tricyclic antidepressants, the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs and preferences of the patient. Some information about each of the classes of drugs follows.

The tricyclic antidepressants were the first medications shown to have a beneficial effect against panic disorder. Imipramine is the tricyclic most commonly used for this condition. When imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of imipramine helps minimize side effects such as dry mouth, constipation, and blurred vision. People with panic disorder, who are inclined to be hypervigilant about physical sensations, often find these side effects disturbing at the outset. Side effects usually fade after the patient has been on the medication a few weeks.

It usually takes several weeks for imipramine to have a beneficial effect on panic disorder. Most patients treated with imipramine will be panic-free within a few weeks or months. Treatment generally lasts from 6 to 12 months. Treatment for a shorter period of time is possible, but there is substantial risk that when imipramine is stopped, panic attacks will recur. Extending the period of treatment to 6 months to a year may reduce this risk of a relapse. When the treatment period is complete, the dosage of imipramine is tapered over a period of several weeks.

The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take effect rapidly, have few bothersome side effects, and are well tolerated by the majority of patients. However, some patients, especially those who have had problems with alcohol or drug dependency, may become dependent on benzodiazepines.

Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually increases it until panic attacks cease. This procedure minimizes side effects.

Treatment with high-potency benzodiazepines is usually continued for 6 months to a year. One drawback of these medications is that patients may experience withdrawal symptoms  malaise, weakness, and other unpleasant effects  when the treatment is discontinued. Reducing the dose gradually generally minimizes these problems. There may also be a recurrence of panic attacks after the medication is withdrawn.

Of the MAOIs, a class of antidepressants which have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day.

Use of phenelzine or any other MAOI requires the patient to observe exacting dietary restrictions, because there are foods and prescription drugs and certain substances of abuse that can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications.

As in the case of the high-potency benzodiazepines and imipramine, treatment with phenelzine or another MAOI generally lasts 6 months to a year. At the conclusion of the treatment period, the medication is gradually tapered.

Newly available antidepressants such as fluoxetine (one of a class of new agents called serotonin reuptake inhibitors) appear to be effective in selected cases of panic disorder. As with other anti-panic medications, it is important to start with very small doses and gradually increase the dosage.

Scientists supported by NIMH are seeking ways to improve drug treatment for panic disorder. Studies are underway to determine the optimal duration of treatment with medications, who they are most likely to help, and how to moderate problems associated with withdrawal.

Combination Treatments.   Many believe that a combination of medication and cognitive-behavioral therapy represents the best alternative for the treatment of panic disorder. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. However, there is a need for more research studies to determine whether this is in fact the case.

Comparing medications and psychological treatments, and determining how well they work in combination, is the goal of several NIMH-supported studies. The largest of these is a 4-year clinical trial that will include 480 patients and involve four centers at the State University of New York at Albany, Cornell University, Hillside Hospital/Columbia University, and Yale University. This study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone.

Psychodynamic Treatment.   This is a form of "talk therapy" in which the therapist and the patient, working together, seek to uncover emotional conflicts that may underlie the patient's problems. By talking about these conflicts and gaining a better understanding of them, the patient is helped to overcome the problems. Often, psychodynamic treatment focuses on events of the past and making the patient aware of the ramifications of long-buried problems.

Although psychodynamic approaches may help to relieve the stress that contributes to panic attacks, they do not seem to stop the attacks directly. In fact, there is no scientific evidence that this form of therapy by itself is effective in helping people to overcome panic disorder or agoraphobia. However, if a patient's panic disorder occurs along with some broader and pre-existing emotional disturbance, psychodynamic treatment may be a helpful addition to the overall treatment program.

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Symptoms

Palpitations, heart pounding or a rapid pulse

Palpitations are heartbeat sensations that feel like pounding or racing. You may simply have an unpleasant awareness of your own heartbeat. You may feel skipped or stopped beats. The heart's rhythm may be normal or abnormal. Palpitations can be felt in your chest, throat, or neck.

Normally the heart beats between 60-100 times per minute. In people who exercise routinely or take medications that slow the heart, the rate may drop below 55 beats per minute.

If your heart rate is very fast (over 100 beats per minute), this is called tachycardia. An unusually slow heart rate is called bradycardia, and an occasional extra heart beat is known as extrasystole.

Palpitations are often not serious. However, it depends on whether or not the sensations represent an abnormal heart rhythm (called an arrhythmia). You are more likely to have an abnormal heart rhythm if you have:
Known heart disease at the time the palpitations begin
Significant risk factors for heart disease
An abnormal heart valve
An electrolyte abnormality -- for example, low potassium

Heart palpitations can be caused by:
Exercise
Anxiety, stress, fear
Fever
Caffeine, nicotine, cocaine, diet pills
Overactive thyroid
Anemia
Hyperventilation
Low levels of oxygen in your blood
Medications such as thyroid pills, asthma drugs, beta blockers for high blood pressure or heart disease, or anti-arrhythmics (medications to treat an irregular heart rhythm can sometimes cause a different irregular rhythm)
Mitral valve prolapse -- the valve that separates the left upper chamber (atrium) from the left lower chamber (ventricle) of the heart does not close properly
Heart disease

Reducing stress and anxiety can help lessen your heart palpitations. Try breathing exercises or deep relaxation (a step-by-step process of tensing and then relaxing every muscle group in your body) at the time of your heartbeat sensations. Also, consider practicing yoga or tai chi on a regular basis to reduce the frequency of your palpitations.

Keep a record of how often you have palpitations, when they happen, how long they last, your heart rate at the time of the palpitations, and what you are feeling at the time. This information may help your doctor figure out both their seriousness and the cause.

Once a serious cause has been ruled out by your doctor, try NOT to pay attention to heart palpitations, unless you notice a sudden increase or a change in them.

If you have never had heart palpitations before, bring them to the attention of your doctor. He or she will do a work up to determine the cause and whether they are treatable or not.

Sweating

Sweat, also called perspiration, is a salty liquid produced by the sweat glands. Sweating is an essential function that helps the body stay cool. Sweat is commonly found under the arms, on the feet, and on the palms of the hands.

How much you sweat depends on how many sweat glands you have. A person is born with about two to four million sweat glands. The glands start to become fully active during puberty. Women actually have more sweat glands then men -- the men's glands are just more active.

Because sweating is the body's natural way of regulating temperature, people sweat more in when it's hot outside. People also sweat more when they exercise, or in response to situations that make them nervous, angry, embarrassed, or afraid.

If sweating is accompanied by fever, weight loss, chest pain, shortness of breath, or a rapid, pounding heartbeat, talk to a doctor. These symptoms may indicate an underlying problem, such as hyperthyroidism. Excessive sweating may also be a symptom of menopause.

Common Causes

Warm temperatures
Fever
Menopause Overactive thyroid gland
Low blood sugar
Infection
Cancer (sweating at night without an obvious cause)
Emotional or stressful situations
Exercise
Spicy foods (known as "gustatory sweating")
Drugs, including antipyretics, some antipsychotics, sympathomimetics, caffeine, morphine, alcohol and thyroid hormone
Withdrawal from alcohol or narcotic pain killers

After an episode of sweating, a person should:

Wash the face and body
Change clothes and bed sheets
Replace lost body fluids by drinking plenty of water
Slighly adjust room temperature to prevent additional sweating

Trembling or shaking

A tremor is an involuntary movement or shaking of any body part (even your head or voice may be involved). It is often most noticeable in your hands. There are three main types of tremors:

Resting or static tremors -- occur when your hand or affected body part is at rest.
Intention tremors -- occur when you are moving your hand or affected body part and disappear at rest.
Postural tremors -- occur when you are holding your hand or affected body part in a particular position for a period of time.

Tremors can happen at any age but tend to be more common in older people.

You can develop a tremor from fatigue, stress, anxiety, or even rage. However, an ongoing tremor that is not associated with a change in your emotional state may be a sign of an underlying medical condition and should be evaluated. You may learn, as many do, that your tremors are perfectly normal, but eliminating medical reasons for the shaking is important.

It is especially important to have tremors evaluated if body parts other than the hands are involved, like your tongue or head, or if you have other types of involuntary movements other than shaking.

Essential tremor is common in older people. Essential tremor is rarely present when the hands are not being used. It becomes most apparent when the affected person is trying to do something, like reaching for an object or writing. It is not caused by an underlying disease.

Another common type of tremor is called familial tremor which, as the name implies, tend to run in families.

Both essential and familial tremors may be suppressed by drinking alcohol. This is a useful fact for making the diagnosis, but alcohol is not a desirable treatment.

Tremors may be caused by:

Too much coffee or other caffeinated drink
Excessive alcohol consumption, alcoholism, or alcohol withdrawal
Stress, anxiety, or fatigue -- these can cause a postural tremor
Normal aging
A variety of drugs and prescription medicines
Low blood sugar
Parkinson's disease -- this is the classic cause of a resting tremor and is often accompanied by slowness of movement, muscle rigidity, and an abnormal gait
Multiple sclerosis -- can cause an intention tremor
Over active thyroid -- can cause a postural tremor

For tremors caused by stress, try relaxation techniques like meditation, deep relaxation, or breathing exercises. For tremors of any cause, avoid caffeine and get enough sleep.

For tremors caused by a medication, consult with your doctor about stopping the drug, reducing the dosage, or switching medications. DO NOT change or stop medications on your own.

For certain types of tremors, like essential tremor and familial tremor, medications such as beta-blockers, gabapentin, primidone, and others may be an option. If medication doesn't work, your doctor may even consider surgery. Also, botulinum toxin injections have been used for essential hand tremors.

For tremors caused by alcohol abuse, seek treatment and support to help you avoid alcohol.

Severe tremors may interfere with your ability to perform daily activities. Assistance with these activities may be necessary. Precautions should be taken to avoid injury during activities such as walking or eating.

Shortness of breath

Definition

Breathing difficulties involve a sensation of difficult or uncomfortable breathing or a feeling of not getting enough air. See also difficulty breathing - first aid.

Considerations 

No standard definition exists for difficulty breathing. For some individuals, a sense of breathlessness may occur with only mild exercise (for example, climbing stairs) without an indication of the presence of a specific disorder. Others may have advanced lung disease and difficulty exchanging air but may never feel a sensation of shortness of breath.

In some circumstances, a small degree of breathing difficulty may be normal. Severe nasal congestion is one example. Strenuous exercise, especially when a person does not exercise regularly, is another. In many situations, however, difficulty breathing represents the presence of significant disease and should be evaluated by a health care provider immediately.

Wheezing is one form of breathing difficulty. See also rapid breathing, apnea, and other lung diseases.

Common Causes

Shortness of breath has many different causes. Obstruction of the air passages of the nose, mouth, or throat may lead to difficulty breathing. Heart disease can cause breathlessness if the heart is unable to pump enough blood to supply oxygen to the body. If the brain, muscles, or other body organs do not receive enough oxygen, a sense of breathlessness may occur. Sometimes emotional distress, such as anxiety, can lead to difficulty breathing. Specific causes include the following:

Lung disease
Cigarette smoking
Asthma
Emphysema
Coronary artery disease
Heart attack (myocardial infarction)
Interstitial lung disease
Pneumonia
Pulmonary hypertension
Rapid ascent to high altitudes, with less oxygen in the air
Airway obstruction
Inhalation of a foreign object
Dust-laden environment
Allergies (such as to mold, dander, or pollen)
Congestive heart failure (CHF)
Heart arrhythmias
Deconditioning (lack of exercise)
Obesity
Compression of the chest wall
Panic attacks

Home Care

Breathing difficulty, whether sudden or long term, should always be taken seriously. Though many causes are harmless and are easily corrected, any difficulty breathing requires a thorough medical evaluation.

Follow prescribed therapy to treat the underlying cause.

Dizziness

Definition

Dizziness is lightheadedness, feeling like you might faint, being unsteady, loss of balance, or vertigo (a feeling that you or the room is spinning or moving).

Most causes of dizziness are not serious and either quickly resolved on their own or are easily treated.

Common Causes

Lightheadedness happens when there is not enough blood getting to the brain. This can happen if there is a sudden drop in your blood pressure or you are dehydrated from vomiting, diarrhea, fever, or other causes. Many people, especially as they get older, experience lightheadedness if they get up too quickly from a lying or seated position. Lightheadedness often accompanies the flu, common cold, or allergies.

More serious conditions that can lead to lightheadedness include heart problems (such as abnormal heart rhythm or heart attack), stroke, and severe drop in blood pressure ( shock). If any of these serious disorders is present, you will usually have additional symptoms like chest pain, a feeling of a racing heart, loss of speech, change in vision, or other symptoms.

The most common causes of vertigo are benign positional vertigo and labyrinthitis. Benign positional vertigo is vertigo that happens when you change the position of your head. Labyrinthitis usually follows a cold or flu and is caused by a viral infection of the inner ear. Meniere's disease is another common inner ear problem. It causes vertigo, loss of balance, and ringing in the ears.

Much less commonly, vertigo or feeling unsteady is a sign of stroke, multiple sclerosis, seizures, a brain tumor, or a bleed in your brain. In such conditions, other symptoms usually accompany the vertigo or imbalance.

Home Care

If you tend to get lightheaded when you stand up, avoid sudden changes in posture.

If you are thirsty or lightheaded, drink fluids. If you are unable to keep fluids down from nausea or vomiting, you may need intravenous fluids. These are delivered to you at the hospital.

Most times, benign positional vertigo and labyrinthitis go away on their own within a few weeks. During attacks of vertigo from any cause, try to rest and lie still. Avoid sudden changes in your position as well as bright lights. Be cautious about driving or using machinery.

Some vertigo can be reduced by working with a physical therapist. Medications from your doctor may help you feel better.

Such medications include antihistamines, sedatives, or pills for nausea. For Meniere's disease, surgery may be necessary.

Faintness

Definition

Fainting is a temporary loss of consciousness due to a drop in blood flow to the brain. The episode is brief (lasting less than a couple of minutes) and is followed by rapid and complete recovery. You may feel lightheaded or dizzy before fainting.

A longer, deeper state of unconsciousness is often called a coma.

Considerations

When you faint, you not only experience loss of consciousness, but also loss of muscle tone and paling of color in your face. You may also feel weak or nauseated just prior to fainting, and you may have the sense that surrounding noises are fading into the background.

Common Causes

Fainting may occur while you are urinating, having a bowel movement (especially if straining), coughing strenuously, or when you have been standing in one place too long. Fainting can also be related to fear, severe pain, or emotional distress.

A sudden drop in blood pressure can cause you to faint. This may happen if you are bleeding or severely dehydrated. It can also happen if you stand up very suddenly from a lying position.

Certain medications may lead to fainting by causing a drop in your blood pressure or for another reason. Common drugs that contribute to fainting include those used for anxiety, high blood pressure, nasal congestion, and allergies.

Other reasons you may faint include hyperventilation, use of alcohol or drugs, or low blood sugar.

Less common but more serious reasons include heart disease (like abnormal heart rhythm or heart attack) and stroke.

Home Care

If you have a history of fainting and have been evaluated medically, follow your doctor's instructions for how to prevent fainting episodes. For example, if you know the situations that cause you to faint, avoid or change them. Avoid sudden changes in posture. Get up from a lying or seated position slowly and gradually. When having blood drawn (if this makes you faint), tell the technician and make sure that you are lying down.

Immediate treatment for someone who has fainted includes:

Checking the person's airway and breathing. If necessary, call 911 and begin rescue breathing and CPR.
Loosening tight clothing around the neck.
Keeping the affected person lying down for at least 10 - 15 minutes, preferably in a cool and quiet space. If the person cannot lie down, have him sit forward and lower his head below the levels of the shoulders, between the knees.
If vomiting has occurred, turning the person onto one side to prevent choking
Elevating the feet above the level of the heart (about 12 inches).

Feeling of choking

Often one of the first symptoms of anxiety. People complain of feeling as though they will choke or being strangled. In reality its not nearly so dramatic - the muscles in the throat contract and salivary glands produce thick mucus leading to a feeling of restriction around the throat, it can produce a feeling that you are having difficulty swallowing or breathing. In fact you are not having difficulty, it just feels as though you are. You also get a dry mouth and it can feel like you cannot drink but you can.

You feel as though there is something stuck in your throat or sometimes feel there is a lump in your throat. Other times you may feel that you can barely swallow or that there is a tightness in the throat, or that you have to really force yourself to swallow. Sometimes this feeling can lead you to think that you may suffocate or get something stuck in your throat.

When in danger, stress biology produces a tightening in the throat muscles which produces the choking or 'something stuck in the throat' feeling. When in a nervous or stressful situation, many people will experience this feeling. It is often referred to as 'a lump on your throat'.

There is minimal danger of choking or suffocating under normal conditions, however, some people are very sensitive to things in their throat and therefore caution should always be observed when eating. Chewing food thoroughly and slowly will prevent inadvertently swallowing something that may provoke someone to gag. This symptom can come and go, and may seem to intensify if one becomes focused on it.

Nausea

Definition

Nausea is the sensation of having an urge to vomit. Vomiting is forcing the contents of the stomach up through the esophagus and out of the mouth.

Considerations

Your body has a few main ways to respond to an ever-changing, wide variety of invaders and irritants. Sneezing ejects the intruders from the nose, coughing from the lungs and throat, diarrhea from the intestines, and vomiting from the stomach.

Vomiting is a forceful action accomplished by a fierce, downward contraction of the diaphragm. At the same time, the abdominal muscles tighten against a relaxed stomach with an open sphincter. The contents of the stomach are propelled up and out.

You may have more saliva just before vomiting.

Vomiting is a complex, coordinated reflex orchestrated by the vomiting center of the brain. It responds to signals coming from:

The mouth, stomach, and intestines
The bloodstream, which may contain medicines or infections
The balancing systems in the ear (motion sickness)
The brain itself, including unsettling sights, smells, or thoughts
An amazing variety of stimuli can trigger vomiting, from migraines to kidney stones. Sometimes, just seeing someone else vomit will start you vomiting, in your body's effort to protect you from possible exposure to the same danger.

Vomiting is common. Almost all children will vomit several times during their childhood. In most cases, it is due to a viral gastrointestinal infection.

Spitting up, the gentle sloshing of stomach contents up and out of the mouth, sometimes with a burp, is an entirely different process. Some spitting up is normal for babies, and usually gets gradually better over time. If spitting up worsens or is more frequent, it might be reflux disease. Discuss this with your child's doctor.

Most of the time, nausea and vomiting do not require urgent medical attention. However, if the symptoms continue for days, they are severe, or you cannot keep down any food or fluids, you may have a more serious condition.

Dehydration is the main concern with most vomiting. How fast you become dehydrated depends on your size, frequency of vomiting, and whether you also have diarrhea.

Common Causes

The following are possible causes of vomiting:

Viral infections
Medications
Seasickness or motion sickness
Migraine headaches
Morning sickness during pregnancy
Food poisoning
Food allergies
Brain tumors
Chemotherapy in cancer patients
Bulimia
Alcoholism
These are possible causes of vomiting in infants (0 - 6 months):
Congenital pyloric stenosis, a constriction in the outlet from the stomach (the infant vomits forcefully after each feeding but otherwise appears to be healthy)
Food allergies or milk intolerance
Gastroenteritis (infection of the digestive tract that usually causes vomiting with diarrhea)
Gastroesophageal reflux
An inborn error of metabolism
Hole in the bottle nipple may be wrong size, leading to overfeeding
Infection, often accompanied by fever or runny nose
Intestinal obstruction, evidenced by recurring attacks of vomiting and crying or screaming as if in great pain
Accidentally ingesting a drug or poison
Call the doctor immediately or take the child to an emergency care facility if you suspect poisoning or drug ingestion!

Home Care

It is important to stay hydrated. Try steady, small amounts of clear liquids, such as electrolyte solutions. Other clear liquids -- such as water, ginger ale, or fruit juices -- also work unless the vomiting is severe or it is a baby who is vomiting.

For breastfed babies, breastmilk is usually best. Formula-fed babies usually need clear liquids.

Dont drink too much at one time. Stretching the stomach can make nausea and vomiting worse. Avoid solid foods until there has been no vomiting for six hours, and then work slowly back to a normal diet.

An over-the-counter bismuth stomach remedy like Pepto-Bismol is effective for upset stomach, nausea, indigestion, and diarrhea. Because it contains aspirin-like salicylates, it should NOT be used in children or teenagers who might have (or recently had) chickenpox or the flu.

Most vomiting comes from mild viral illnesses. Nevertheless, if you suspect the vomiting is from something serious, the person may need to be seen immediately.

There is currently no treatment that has been approved by the FDA for morning sickness in pregnant women.

The following may help treat motion sickness:

Lying down
Over-the-counter antihistamines (such as Dramamine)
Scopolamine prescription skin patches (such as Transderm Scop) are useful for extended trips, such as an ocean voyage. Place the patch 4 - 12 hours before setting sail. Scopolamine is effective but may produce dry mouth, blurred vision, and some drowsiness. Scopolamine is for adults only. It should NOT be given to children.

Chest pain or discomfort

Definition

Chest pain is discomfort or pain that you feel anywhere along the front of your body between your neck and upper abdomen.

Considerations

Many people with chest pain fear a heart attack. However, there are many possible causes of chest pain. Some causes are mildly inconvenient, while other causes are serious, even life-threatening. Any organ or tissue in your chest can be the source of pain, including your heart, lungs, esophagus, muscles, ribs, tendons, or nerves.

Angina is a type of heart-related chest pain. This pain occurs because your heart is not getting enough blood and oxygen. Angina pain can be similar to the pain of a heart attack.

Angina is called stable angina when your chest pain begins at a predictable level of activity. (For example, when you walk up a steep hill.) However, if your chest pain happens unexpectedly after light activity or occurs at rest, this is called unstable angina. This is a more dangerous form of angina and you need to be seen in an emergency room right away.

Common Causes

Other causes of chest pain include:

Asthma, which is generally accompanied by shortness of breath, wheezing, or cough.
Pneumonia, a blood clot to the lung (pulmonary embolism), the collapse of a small area of a lung (pneumothorax), or inflammation of the lining around the lung ( pleurisy). In these cases, the chest pain often worsens when you take a deep breath or cough and usually feels sharp.
Strain or inflammation of the muscles and tendons between the ribs.
Anxiety and rapid breathing.
Chest pain can also be related to problems with your digestive system. These include stomach ulcer, gallbladder disease, gallstones, indigestion, heartburn, or gastroesophageal reflux (when acid from your stomach backs up into your esophagus).

Ulcer pain burns if your stomach is empty and feels better with food. Gallbladder pain often gets worse after a meal, especially a fatty meal.

In children, most chest pain is not caused by the heart.

Home Care

If injury, over-exertion, or coughing have caused muscle strain, your chest wall is often tender or painful when you press a finger at the location of the pain. This can often be treated at home. Try acetaminophen or ibuprofen, ice, heat, and rest.

If you know you have asthma or angina, follow the instructions of your doctor and take your medications regularly to avoid flare-ups.

Hyperventilation

Definition

Hyperventilation is rapid or deep breathing, usually caused by anxiety or panic. This overbreathing, as it is sometimes called, may actually leave you feeling breathless.

When you breathe, you inhale oxygen and exhale carbon dioxide. Excessive breathing may lead to low levels of carbon dioxide in your blood, which causes many of the symptoms that you may feel if you hyperventilate.

Considerations

Feeling very anxious or having a panic attack are the usual reasons that you may hyperventilate. However, rapid breathing may be a symptom of an underlying disease, such as a heart or lung disorder, bleeding, or an infection. (See rapid shallow breathing.)

Your doctor will determine the cause of your hyperventilation. Rapid breathing may be considered a medical emergency -- unless you have experienced this before and have been reassured by your doctor that your hyperventilation can be self treated. (See below.).

Often, panic and hyperventilation become a vicious cycle -- panic leads to rapid breathing while breathing rapidly can make you feel panicked.

If you frequently overbreathe (sometimes referred to as hyperventilation syndrome), this may be triggered by ongoing emotions of stress, anxiety, depression, or anger. However, hyperventilation from panic is generally related to a specific fear or phobia, such as a fear of heights, dying, or closed-in spaces (claustrophobia).

If you have hyperventilation syndrome -- that is, if you regularly hyperventilate -- you might not be aware of it. But you will be aware of having many of the associated symptoms, including dizziness or lightheadedness, shortness of breath, belching, bloating, dry mouth, weakness, confusion, sleep disturbances, numbness and tingling in your arms or around your mouth, muscle spasms in hands and feet, chest pain, and palpitations.

Common Causes

anxiety and nervousness
stress
panic attack
situations where there is a psychological advantage in having a sudden, dramatic illness (for example, somatization disorder)
stimulant use
lung disease such as asthma, chronic obstructive pulmonary disease (COPD), or pulmonary embolism (blood clot in the lung)
infection such as pneumonia or sepsis
cardiac disease such as congestive heart failure or heart attack
severe pain
bleeding
drugs (such as an aspirin overdose)
pregnancy
ketoacidosis and similar medical conditions

Home Care

Assuming that a more serious, underlying cause of hyperventilation has been eliminated and your doctor has explained that you hyperventilate from anxiety, stress, or panic, there are steps you can take at home. You, your friends, and family can learn techniques to stop you from hyperventilating when it happens and to prevent future attacks.

If you start hyperventilating, the goal is to raise the carbon dioxide level in your blood, which will put an end to most of your symptoms. There are several ways to do this:

Reassurance from a friend or family member can help relax your breathing. Words like "you are doing fine," "you are not having a heart attack," and "you are not going to die" are very helpful. It is extremely important that the person helping you remain calm and deliver these messages with a soft, relaxed tone.
To increase your carbon dioxide, you need to take in less oxygen. To accomplish this, you can breathe through pursed lips (as if you are blowing out a candle) or you can cover your mouth and one nostril, breathing through the other nostril.
Over the long term, there are several important steps to follow to try to eliminate your tendency to overbreathe:

If anxiety or panic has been diagnosed, see a psychologist or psychiatrist to help you understand and treat your condition.
Learn breathing exercises that help you relax and breathe from your diaphragm and abdomen, rather than your chest wall.
Practice relaxation techniques regularly, such as progressive muscle relaxation or meditation.
Exercise regularly.
If these methods alone are not preventing your overbreathing, your doctor may recommend a beta blocker medication.

Eyes, Blurred vision, Eyes sensitive to light, Dry, watery or itchy eyes

You may see stars or movements out of the corner of your eyes that don't exist. You may also see flashing lights in your eyes or your vision may seem almost kaleidoscope-like. Sometimes you may feel that there is a dark object or something just on the outside edge of your vision, or that your vision is narrowing.

It seems your vision is blurry or out of focus, and it's more apparent now than before.

There are times when your eyes seem more sensitive to light than at others, even to a point of regular light being too bright so that you have to wear sunglasses or squint.

You feel as though your eyes are either always dry, constantly watering or itchy. And often, your eyes are red or 'glossy' looking. Even a good night's rest doesn't help.

Ciliary muscles relax - pupils dilate focusing on distant items sometimes disturbing your vision or allowing odd colours or floaters to be noticed.

Eyes are nerves. The nerves in the eyes send their information to the brain through the nervous system. When the nervous system is over active, the nerves in the eyes can play tricks on you which means we sometimes receive false information. These symptoms are some of the ways we receive this false information.
None of these symptoms are serious when they are attributed to anxiety disorder. However, it is important that you get a professional medical evaluation completed to ensure your condition is related to anxiety disorder.

Ear ringing

Definition

Tinnitus is the medical term for "hearing" noises in your ears when there is no outside source of the sounds. The noises you hear can be soft or loud. They may sound like ringing, blowing, roaring, buzzing, hissing, humming, whistling, or sizzling. You may even think you are hearing air escaping, water running, the inside of a seashell, or musical notes.

Considerations

Tinnitus is common. Almost everyone experiences a mild form of tinnitus once in awhile that only lasts a few minutes. However, constant or recurring tinnitus is stressful and can interfere with your ability to concentrate or sleep.

Common Causes

It is not known exactly what causes a person to "hear" sounds with no outside source of the noise. However, tinnitus can be a symptom of almost any ear problem, including ear infections, foreign objects or wax in the ear, and injury from loud noises. Alcohol, caffeine, antibiotics, aspirin, or other drugs can also cause ear noises.

Tinnitus may occur with hearing loss. Occasionally, it is a sign of high blood pressure, an allergy, or anemia. Rarely, tinnitus is a sign of a serious problem like a tumor or aneurysm.

Home Care

Tinnitus can be masked by competing sounds, such as low-level music, ticking clocks, or other noises. Tinnitus is often more noticeable when you go to bed at night because your surroundings are quieter. Any noise in the room, like a humidifier, white noise machine, or dishwasher, can help mask tinnitus and make it less irritating.
Learn ways to relax. Feeling stressed or anxious can worsen tinnitus.
Avoid caffeine, alcohol, and smoking.
Get enough rest. Try sleeping with your head propped up in an elevated position. This lessens head congestion and noises may become less noticeable.

Lack of appetite

Definition

This symptom describes a decreased or lack of appetite despite basic caloric needs.

Considerations

Any illness can adversely affect a previously hearty appetite. If the disease is treatable, the appetite should return when the disease is cured.

Loss of appetite can cause unintentional weight loss.

Common Causes

Emotional upset, nervousness, loneliness, boredom, tension, anxiety, bereavement, and depression
Anorexia nervosa
Acute and chronic infections
HIV
Pregnancy (first trimester)
Cancer
Hypothyroidism
Medications and street drugs
Chemotherapeutic agents
Amphetamines
Sympathomimetics including ephedrine
Antibiotics
Cough and cold preparations
Codeine
Morphine
Demerol
Digitalis

Home Care

Protein and calorie intake can be increased by intake of high-calorie, nutritious snacks or several small meals during the day. Liquid protein drinks may be helpful. Family members should try to supply favorite foods to help stimulate the person's appetite.

A 24-hour diet history should be recorded each day. If an anorexic person consistently exaggerates food intake (a common occurrence in anorexia nervosa), strict calorie and nutrient counts should be maintained by someone else.

For loss of appetite caused by taking medications, talk to your health care provider about adjusting the dosage or changing drugs. NEVER CHANGE MEDICATIONS WITHOUT FIRST CONSULTING YOUR HEALTH CARE PROVIDER.

Urgency to urinate

You have an urgent need to go to the toilet, even though you may have just gone. Starts decreasing urine output but initially wants to get rid of everything already waiting to be excreted. May need to visit the loo urgently.

High stress biology produces the need to eliminate. It does so because when the body prepares for action, it wants to eliminate all waste matter in order to make the body as well prepared for action as possible. Having all excess baggage removed, the individual will be at their peak readiness in order to fight or run - the fight or flight response, produced by the Emergency alarm.

This symptom is very common and often experienced by stage performers just before they are to perform. Unfortunately, for those who experience anxiety disorder, a high level of stress biology will produce this symptom, and as long as the stress biology is high, the symptom will be produced. Thats just how the body was engineered.

Some remedies include ant-acids, diarrhoea medication, relaxation and deep breathing.

The primary symptom of stress incontinence is leakage due to activities that apply pressure to a full bladder. High-impact exercise poses the greatest risk for leaking. But stress incontinence can occur with even minor activities, such as:

Coughing
Sneezing
Laughing
Running (sometimes even standing can produce leakage)
Lifting
Leakage stops when the activity stops. If the condition persists, it is more likely to be urge incontinence.

Causes of Stress Incontinence in Women
Stress incontinence occurs because the internal sphincter does not close completely. In both men and women, the aging process causes a general weakening of the sphincter muscles and a decrease in bladder capacity. Causes of stress incontinence, however, may differ between men and women.

In women, stress incontinence is nearly always due to one or both of the following:

The urethra fails to close and becomes overly movable ( urethral hypermobility).
The muscles around the bladder neck weaken ( intrinsic sphincteric deficiency or ISD). Some experts believe that this problem is present to some degree in nearly all women with stress incontinence. (ISD can also occur in anyone from an inborn disorder or injury from surgery or radiation.)
Many women are prone to one or both of these problems, which can occur under the following circumstances:

Having had many children through vaginal deliveries. In such cases, pregnancy and childbirth strain the muscles of the pelvic floor. Prolapsed uterus, in which the uterus protrudes into the vagina, occurs in about half of all women who have given birth. This condition can often cause incontinence.
Menopause. Estrogen deficiencies after menopause can cause the urethra to thin out so that it may not close properly.
Urethral Hypermobility. In urethral hypermobility the urethra does not close properly and it moves too much (hypermobile). This condition typically occurs when the pelvic floor muscles in women become weak and the following events occur:

The weakened pelvic floor muscles stretch.
This allows the bladder to sag downward within the abdomen.
The sagging bladder pulls on the muscles surrounding the bladder neck (internal sphincter), which are connected to the urethra.
Stress incontinence associated with urethral hypermobility is sometimes categorized as type 1 or type 2.

Type 1 is the less severe form and the bladder neck and urethra remain incompletely closed.
In type 2, the angle of the bladder neck shifts. In such cases cystocele may occur, in which the bladder muscles bulge (herniate) into the vaginal wall.
Intrinsic sphincteric deficiency (ISD). Intrinsic sphincter deficiency (sometimes called type 3) is the other major cause of stress incontinence in women. It occurs when the bladder neck muscles are damaged or weakened. The result is twofold:

The bladder neck is open during filling
The closing pressure around the urethra is low
This is the most severe stress incontinence in women and usually occurs after previous surgeries for incontinence.

Causes of Stress Incontinence in Men
Prostate treatments can impair the sphincter muscles. Such treatments are the major causes of stress incontinence in men. They include the following:

Surgery or radiation for prostate cancer. Incontinence occurs in nearly all male patients for the first 3 to 6 months after radical prostatectomy. After a year of the procedure, most men retain continence, although leakage can occur.

Surgery for benign prostatic hyperplasia. Stress incontinence occurs in 1 - 5% of men after transurethral resection of the prostate (TURP), the standard treatment for severe benign prostatic hyperplasia.

Weak legs

Your legs feel so weak that you think they won't be able to support you. In some cases you might feel you won't be able to walk. Sometimes your legs may feel like jelly or rubber, or that you have to force yourself to walk. You may even feel as though your legs or knees are too stiff to move.

When people feel nervous, often they will feel weak in the knees, which means jelly legs or weak legs. This is a very common symptom of stress biology and most people who are placed in stressful situations will experience this. However, the degree of which is dependent upon the amount of stress biology. The higher your stress biology, the more your legs will feel weak.

Physically, your legs are fine. You may just feel weak. Sometimes people become played out by this condition because it taxes all of their strength, leaving them feeling weak. Through rest, this symptom will subside. Also, regular exercise helps to keep muscles and body tone in shape which helps to eliminate this symptom.

As with all symptoms, when the nervous system gets sufficient rest, this symptom will diminish and eventually subside.

Constant craving for sugar or sweets

For some reason you have an increased and ongoing craving for sugar, sweets or chocolate. Although you may have a 'sweet tooth', these cravings usually go unsatisfied, while ingesting even more sweets leaves you with the same result.

High stress biology and an over stimulated nervous system continually use up the bodys energy supply, even when the body is not physically active. Because of this continual energy consumption, the body requires more fuel in order to meet the demand. This fuel comes in the form of blood sugar. When you are feeling a craving for sugar, thats the bodys way of letting you know it requires more fuel.

This in itself is a good thing because your body is letting you know it needs fuel (symptoms let the body know something needs attention). However, if you respond to this request with raw sugar (sweets, chocolate, soft drink, milkshake, flavored coffee, etc.), two negative affects happen:
The ingested raw sugar rapidly increases the bodys blood sugar. As a result, you may feel a slight surge of energy and well being immediately after the ingestion of a raw sugar. However, this rapid increase in blood sugar causes the pancreas to stimulate an appropriate dose of insulin in order to keep the bodys blood sugar within a normal range. This may make you may feel fatigued, dizzy, weak and emotionally poor because the insulin has reduced the blood sugar level too much.

In addition, if the insulin reduces the bodys blood sugar too much, the brain may automatically trigger an emergency response alarm which then adds more stress biology which may also make you feel sick, anxious and can even trigger a panic attack. Its these types of blood sugar swings that can really upset you.

Usually these raw sugars also include caffeine (such as chocolate, cola, soft drinks, coffee, etc.). When they do, the blood sugar swing is magnified because in addition to the rapid increase and decrease of blood sugar, caffeine is a stimulant that activates the stress biology. So now you have two boosts of energy which the pancreas has to work extra hard to keep in the normal range.

In affect, you are giving your body and nervous system a double whammy. As well, because caffeine is longer lasting than raw sugar, the body has to work longer to stabilize the blood chemistry. This longer action can often play havoc with a persons symptoms and mental functions.

When you feel a craving for sugar, you should acknowledge it by ingesting natural foods such as vegetables and fruit. Since these foods contain natural sugars, they are broken down and slowly released into the blood stream. This prevents the sudden and rapid fluctuations in blood sugar. As well, these natural foods contain no artificial stimulants so you wont be subjected to an increase in stress biology.

Other Symptoms

Having difficulty concentrating
Insomnia, or waking up ill in the middle of the night
Excess of energy, you feel you cant relax
Dry mouth
Fear of losing control
Headaches

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Finding Help for Panic Disorders

Often the person with panic disorder must undertake a strenuous search to find a therapist who is familiar with the most effective treatments for the condition. A list of places to start follows. The Anxiety Disorders Association of America can provide a list of professionals in your area who specialize in the treatment of panic disorder and other anxiety disorders.

Self-help and support groups are the least expensive approach to managing panic disorder, and are helpful for some people. A group of about 5 to 10 people meet weekly and share their experiences, encouraging each other to venture into feared situations and cope effectively with panic attacks. Group members are in charge of the sessions. Often family members are invited to attend these groups, and at times a therapist or other panic disorder expert may be brought in to share insights with group members. Information on self-help groups in specific areas of the country can be obtained from the Anxiety Disorders Association of America.

Sources of Referral to Professional Help for Panic Disorder.

Here are the types of people and places that will make a referral to, or provide, diagnostic and treatment services for a person with symptoms resembling those described in this brochure. Also check the Yellow Pages under "mental health," "health," "anxiety," "suicide prevention," "hospitals," "physicians," "psychiatrists," "psychologists," or "social workers" for phone numbers and addresses.
 
 

Family doctors
Clergy
Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
Health maintenance organizations
Community mental health centers
Hospital psychiatry departments and outpatient clinics
University- or medical school-affiliated treatment or research programs
State hospital outpatient clinics
Family service/social agencies
Private clinics and facilities
Employee assistance programs
Local medical, psychiatric, or psychological societies

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What to do if you are having a Panic Attack

1. Remember that although your feelings and symptoms are very frightening they are not dangerous or harmful.

2. Understand that what you are experiencing is just an exaggeration of your normal bodily reactions to stress.

3. Do not fight the feelings or try to wish them away. The more you are willing to face them, the less intense they will become.

4. Do not add to your panic by thinking about what "might" happen. If you find yourself asking "what if?" tell yourself "so what!".

5. Stay in the present. Notice what is really happening to you as opposed to what you think might happen.

6. Label your fear level from zero to ten and watch it go up and down. Notice that it does not stay at a very high level for more than a few seconds.

7. When you find yourself thinking about the fear, change your "what if" thinking. Focus on and carry out a simple and manageable task such as counting backward from 100 by 3's or snapping a rubber band on your wrist.

8. Notice that when you stop adding frightening thoughts to your fear, it begins to fade.

9. When the fear comes, expect and accept it. Wait and give it time to pass without running away from it.

10. Be proud of yourself for your progress thus far, and think about how good you will feel when you succeed this time.

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Help for the family

When one member of a family has panic disorder, the entire family is affected by the condition. Family members may be frustrated in their attempts to help the affected member cope with the disorder, overburdened by taking on additional responsibilities, and socially isolated. Family members must encourage the person with panic disorder to seek the help of a qualified mental health professional. Also, it is often helpful for family members to attend an occasional treatment or self-help session or seek the guidance of the therapist in dealing with their feelings about the disorder.

Certain strategies, such as encouraging the person with panic disorder to go at least partway toward a place or situation that is feared, can be helpful. The director of one anxiety disorder clinic has developed a list of suggestions for family members who want to help loved ones cope with an anxiety disorder. By their skilled and caring efforts to help, family members can aid the person with panic disorder in making a recovery.

Also, it may be valuable for family members to join or form a support group to share information and offer mutual encouragement.
 

What to Do if a Family Member Has an Anxiety Disorder
Don't make assumptions about what the affected person needs; ask them.
Be predictable; don't surprise them.
Let the person with the disorder set the pace for recovery.
Find something positive in every experience. If the affected person is only able to go partway to a particular goal, such as a movie theater or party, consider that an achievement rather than a failure.
Don't enable avoidance: negotiate with the person with panic disorder to take one step forward when he or she wants to avoid something.
Don't sacrifice your own life and build resentments.
Don't panic when the person with the disorder panics.
Remember that it's alright to be anxious yourself; it's natural for you to be concerned and even worried about the person with panic disorder.
Be patient and accepting, but don't settle for the affected person being permanently disabled.
Say: "You can do it no matter how you feel. I am proud of you. Tell me what you need now. Breathe slow and low. Stay in the present. It's not the place that's bothering you, it's the thought. I know that what you are feeling is painful, but it's not dangerous. You are courageous."
Don't say: "Relax. Calm down. Don't be anxious. Let's see if you can do this (i.e., setting up a test for the affected person). You can fight this. What should we do next? Don't be ridiculous. You have to stay. Don't be a coward."

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Coexisting conditions

At the NIH conference on panic disorder, the panel recommended that patients be carefully evaluated for other conditions that may be present along with panic disorder. These may influence the choice of treatment, the panel noted. The following are among the conditions frequently found to coexist with panic disorder:

Simple Phobias.   People with panic disorder often develop irrational fears of specific events or situations that they associate with the possibility of having a panic attack. Fear of heights and fear of crossing bridges are examples of simple phobias. Generally, these fears can be resolved through repeated exposure to the dreaded situations, while practicing specific cognitive-behavioral techniques to become less sensitive to them.

Social Phobia.   This is a persistent dread of situations in which the person is exposed to possible scrutiny by others and fears acting in a way that will be embarrassing or humiliating. Social phobia can be treated effectively with cognitive-behavioral therapy or medications, or both.

Depression.   About half of panic disorder patients will have an episode of clinical depression sometime during their lives. Major depression is marked by persistent sadness or feelings of emptiness, a sense of hopelessness, and other symptoms.

When major depression occurs, it can be treated effectively with one of several antidepressant drugs, or, depending on its severity, by cognitive-behavioral therapies.
 
 

Symptoms of Depression
 
 

Persistent sadness or feelings of emptiness
A sense of hopelessness
Feelings of guilt
Problems sleeping
Loss of interest or pleasure in ordinary activities
Fatigue or decreased energy
Difficulty concentrating, remembering, and making decisions
 

 

Obsessive-Compulsive Disorder (OCD).   In OCD, a person becomes trapped in a pattern of repetitive thoughts and behaviors that are senseless and distressing but extremely difficult to overcome. Such rituals as counting, prolonged handwashing, and repeatedly checking for danger may occupy much of the person's time and interfere with other activities. Today, OCD can be treated effectively with medications or cognitive-behavioral therapies.

Alcohol Abuse.   About 30 percent of people with panic disorder abuse alcohol. A person who has alcoholism in addition to panic disorder needs specialized care for the alcoholism along with treatment for the panic disorder. Often the alcoholism will be treated first.

Drug Abuse.   As in the case of alcoholism, drug abuse is more common in people with panic disorder than in the population at large. In fact, about 17 percent of people with panic disorder abuse drugs. The drug problems often need to be addressed prior to treatment for panic disorder.

Suicidal Tendencies.   Recent studies in the general population have suggested that suicide attempts are more common among people who have panic attacks than among those who do not have a mental disorder. Also, it appears that people who have both panic disorder and depression are at elevated risk for suicide. (However, anxiety disorder experts who have treated many patients emphasize that it is extremely unlikely that anyone would attempt to harm himself or herself during a panic attack.)

Anyone who is considering suicide needs immediate attention from a mental health professional or from a school counselor, physician, or member of the clergy. With appropriate help and treatment, it is possible to overcome suicidal tendencies.

There are also certain physical conditions that are often associated with panic disorder:

Irritable Bowel Syndrome.   The person with this syndrome experiences intermittent bouts of gastrointestinal cramps and diarrhea or constipation, often occurring during a period of stress. Because the symptoms are so pronounced, panic disorder is often not diagnosed when it occurs in a person with irritable bowel syndrome.

Mitral Valve Prolapse.   This condition involves a defect in the mitral valve, which separates the two chambers on the left side of the heart. Each time the heart muscle contracts in people with this condition, tissue in the mitral valve is pushed for an instant into the wrong chamber. The person with the disorder may experience chest pain, rapid heartbeat, breathing difficulties, and headache. People with mitral valve prolapse may be at higher than usual risk of having panic disorder, but many experts are not convinced this apparent association is real.

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Useful organisations

British Association for Behavioural Cognitive Psychotherapies (BABCP)
T: 01254 875 277
Promote CBT and provides a list of private accredited therapists

British Association for Counselling and Psychotherapy (BACP)
BACP House, 3537 Albert Street, Rugby CV21 2SG
T: 0870 443 5252
See website or send A5 SAE for details of local practitioners

The Institute for Complementary Medicine (ICM)
T: 020 7237 5165
Has a register of professional, competent practitioners

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Further reading

Uk Store

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