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What is a panic attack?

A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. In addition to the anxiety, various other symptoms may also occur during a panic attack. These include one or more of the following:
•A thumping heart (palpitations).
•Sweating and trembling.
•Dry mouth.
•Hot flushes or chills.
•Feeling short of breath, sometimes with choking sensations.
•Chest pains.
•Feeling sick (nauseated), dizzy, or faint.
•Fear of dying or going crazy.
•Numbness, or pins and needles.
•Feelings of unreality, or being detached from yourself.

The physical symptoms that occur with panic attacks do not mean there is a physical problem with the heart, chest, etc. The symptoms mainly occur because of an overdrive of nervous impulses from the brain to various parts of the body during a panic attack. This overdrive of nervous impulses can lead to the body producing hormones which include adrenaline (epinephrine). This is sometimes referred to as a ‘fight or flight’ response. This kind of reaction is normal in people when we feel we are in danger. During a panic attack the body can react in the same way.

During a panic attack you tend to over-breathe (hyperventilate). If you over-breathe you blow out too much carbon dioxide which changes the acidity in the blood. This can then cause more symptoms such as confusion and cramps, and make palpitations, dizziness, and pins and needles worse. This can make the attack seem even more frightening, and make you over-breathe even more, and so on. It can sometimes result in a faint. A panic attack usually lasts 5-10 minutes, but sometimes they come in waves for up to two hours.

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What is panic disorder?

At least 1 in 10 people have occasional panic attacks. If you have panic disorder it means that you have repeated (recurring) panic attacks. The frequency of attacks can vary. About 1 in 50 people have panic disorder.

In panic disorder, there may be an initial event which causes panic but then the attacks after that are not always predictable. If you have panic disorder, you also have ongoing worry about having further attacks and/or worry about the symptoms that you get during attacks. For example, you may worry that the thumping heart (palpitations) or chest pains that you get with panic attacks are due to a serious heart problem. Some people worry that they may die during a panic attack.

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What causes panic attacks?

Panic attacks usually occur for no apparent reason. The cause is not clear. Slight abnormalities in the balance of some brain chemicals (neurotransmitters) may play a role. This is probably why medicines used for treatment work well. Anyone can have a panic attack, but they also tend to run in some families. Stressful life events such as bereavement may sometimes trigger a panic attack.

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Panic disorder, agoraphobia and other fears

Some people with panic disorder worry about having a panic attack in a public place where it is difficult to get out of, or where help may not be available, or where it can be embarrassing. This may cause them to develop agoraphobia. About 1 in 3 people with panic disorder also develop agoraphobia. See separate leaflet called Agoraphobia.

If you have agoraphobia you have a number of fears of various places and situations. So, for example, you may be afraid to:
•Be in an open place.
•Enter shops, crowds, and public places.
•Travel in trains, buses, or planes.
•Be on a bridge or in a lift.
•Be in a cinema, restaurant, etc, where there is no easy exit.
•Be anywhere far from your home – many people with agoraphobia stay inside their home for most or all of the time.

You may also develop other irrational fears. For example, you may think that exercise or certain foods cause the panic attacks. Because of this you may fear (develop a phobia) for certain foods, or avoid exercise, etc.

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Dealing with a panic attack

To ease a panic attack, or to prevent one from getting worse, breathe as slowly and as deeply as you can. Really focus on your breathing. Learning and using relaxation techniques may help. Many people find that deep breathing exercises are useful. This means taking a long, slow breath in, and very slowly breathing out. If you do this a few times, and concentrate fully on breathing, you may find it quite relaxing.

Some people find that moving from chest breathing to tummy (abdominal) breathing can be helpful. Sitting quietly, try putting one hand on your chest and the other on your abdomen. You should aim to breathe quietly by moving your abdomen with your chest moving very little. This encourages the lower chest muscle (diaphragm) to work efficiently and may help you avoid over-breathing.

What is the treatment for panic attacks and panic disorder?

No treatment is needed if you have just an occasional panic attack. It may help if you understand about panic attacks. This may reassure you that any physical symptoms you get during a panic attack are not due to a physical disease. It may help to know how to deal with a panic attack.

Treatment can help if you have repeated (recurring) attacks (panic disorder). The main aim of treatment is to reduce the number and severity of panic attacks.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a type of specialist talking treatment. It is probably the most effective treatment. Studies show that it works well for over half of people with panic disorder (and agoraphobia).
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as panic attacks and agoraphobia. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have. For example, the ideas that you may have at the beginning of a panic attack, wrong beliefs about the physical symptoms, how you react to the symptoms, etc. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks.
•Behavioural therapy aims to change behaviours which are harmful or not helpful. This may be particularly useful if you have agoraphobia with panic disorder where you avoid various situations or places. The therapist also teaches you how to control anxiety when you face up to the feared situations and places. For example, by using breathing techniques.
•Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours.

If you have CBT and it works, the long-term outlook may be better than with treatment with antidepressants. However, CBT may not be available in every area, and does not suit everyone.

Antidepressant medicines

These usually work well to prevent panic attacks in more than half of cases. (These medicines are often used to treat depression, but have been found to work well for panic disorder too, even if you are not depressed.) They work by interfering with brain chemicals (neurotransmitters) – such as serotonin – which may be involved in causing symptoms of panic.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and may take up to eight weeks to work fully. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. You need to give them time to work.
•Antidepressants are not tranquillisers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used to treat panic disorder.
•If SSRIs do not work, imipramine or clomipramine is sometimes used.

Note: after first starting an antidepressant, in some people some anxiety symptoms become worse for a few days before they start to improve.

If it works, it is usual to take an antidepressant for panic disorder for at least a year. At the end of a course of treatment, you should not stop an antidepressant suddenly, but you should reduce the dose gradually under the supervision of a doctor. In about half of people who are successfully treated, there is a return of panic attacks when treatment is stopped. An option then is to take an antidepressant long-term. The attacks are less likely to return once you stop antidepressants if you have had a cognitive behavioural course (see below).

A combination of CBT and antidepressants may work better than either treatment alone.

What is agoraphobia?

Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations. So, for example, you may have a fear of:
•Entering shops, crowds, and public places.
•Travelling in trains, buses, or planes.
•Being on a bridge.
•Being in a lift.
•Being in a cinema, restaurant, etc, where there is no easy exit.
•Being anywhere far from your home.

But, they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home).

When you are in a feared place you become very anxious and distressed, and have an intense desire to get out. The anxiety usually causes physical symptoms, such as:
•A fast heart rate.
•A thumping heart (palpitations).
•Shaking (tremor).
•Sweating.
•Dry mouth.
•Feeling sick (nauseated).
•Chest pain.
•Headaches.
•Stomach pains.
•A ‘knot in the stomach’.
•Fast breathing.

You may even have a panic attack (see separate leaflet called Panic Attack and Panic Disorder).

Even thinking about going to such places can make you anxious. To avoid this anxiety, you tend to avoid feared places.

The severity of agoraphobia can vary greatly. Some people with agoraphobia can cope quite well outside their home by sticking to familiar areas and routines. Some people with agoraphobia can go out from their home and travel on buses, trains, etc, without getting anxious if they go with a friend or family member. There may be times when they have good spells where they cope better than at other times.

However, to prevent anxiety, many people with agoraphobia stay inside their home for most or all of the time. But, by avoiding the feared situations, this can often cause the fear to grow stronger and the problem may get worse. So, agoraphobia can be disabling and greatly affect your life.

Who has agoraphobia?

Agoraphobia typically develops between the ages of 25 and 35 and is usually a lifelong problem unless treated. However, it can sometimes develop at a younger or older age than this.Twice as many women as men are affected.

Agoraphobia and panic disorder

Many, but not all, people with agoraphobia also have a condition called panic disorder. This is also discussed in the separate leaflet called Panic Attack and Panic Disorder. Briefly, people with panic disorder have panic attacks that occur suddenly, often without warning. A panic attack is like a sudden and severe attack of anxiety and fear.

If you have panic disorder you may worry about having a panic attack in a public place, which is embarrassing, difficult to get out of, or where help may not be available. Therefore, you may develop agoraphobia – a fear of being in such places – because you have panic disorder.

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How is agoraphobia diagnosed?

You are likely to have agoraphobia if:
•You avoid situations that cause anxiety, such as going out of the house and being in open spaces.
•Your symptoms are caused by anxiety and not related to some other condition such as depression.
•You feel anxiety in two or more of the following situations: crowds, public places, travelling alone, or away from home.

What are the treatment options for agoraphobia?

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) helps you to change certain ways that you think, feel and behave. It is a useful treatment for various mental health problems, including phobias.
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety, depression and phobias. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or attitudes which you have that can make you anxious. The aim is then to change your ways of thinking to avoid these ideas. It can help your thought patterns to be more realistic and helpful.
•Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour (your response to the feared object) is harmful, and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. For example, in agoraphobia, the therapist will usually help you to face up to feared situations, a little bit at a time. A first step may be to go for a very short walk from your home with the therapist who gives support and advice. Over time, a longer walk may be possible, then a walk to the shops, and then a trip on a bus, etc. The therapist teaches you how to control anxiety when you face up to the feared situations and places. For example, by using deep breathing techniques. This technique of behavioural therapy is called exposure therapy – where you are exposed more and more to feared situations, and learn how to cope.
•Cognitive behavioural therapy is a mixture of the two where you may benefit from changing both thoughts and behaviours.

CBT is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part, and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious.

Note: unlike other forms of psychotherapy, CBT does not look into the events of the past. CBT aims to deal with, and to change where appropriate, your current thought processes and/or behaviours.

CBT usually works well to treat most phobias, but does not suit everyone. However, it may not be available on the NHS in all areas.

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Antidepressant medicines

These are commonly used to treat depression, but also help to reduce the symptoms of phobias, even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) – such as serotonin – which may be involved in causing anxiety symptoms.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. You need to give it time. It is best to persevere if you are prescribed an antidepressant medicine.
•Antidepressants are not tranquillizers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety disorders.

Why do relaxation exercises?

Some people relax with sport, exercise, listening to music, watching TV, reading a book, etc. However, some people find it helpful to follow specific relaxation exercises. This leaflet gives a summary of two commonly used routines – muscular relaxing exercises, and deep breathing exercises. These two techniques are particularly useful to combat the two common physical symptoms of anxiety – muscular tension and over-breathing. There is some evidence that they may also help to ease symptoms of depression.

Like anything else, you need to practise these at first. However, hopefully, you can then use them in everyday life whenever you feel tense or anxious.

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Muscular relaxation

Planned times for regular positive relaxation

Find a quiet warm place where you won’t be disturbed. Choose a time of day when you do not feel pressured to do anything else. Lie down on your back, or sit in a well-supported chair if you are not able to lie down. Try to get comfortable and close your eyes. Perhaps lie on a firm bed of some cushions. The routine then is to work on each of your muscle groups. With each group of muscles, firstly tense the muscles as much as you can, then relax them fully. Breathe in when you tense the muscles, and breathe out when you relax.

To start with, concentrate on your breathing for a few minutes. Breathe slowly and calmly. Each time you breathe out say words to yourself such as ‘peace’ or ‘relax’. Then start the muscle exercises, working around the different muscle groups in your body.
•Hands – clench one hand tightly for a few seconds as you breathe in. You should feel your forearm muscles tense; then relax as you breathe out. Repeat with the other hand.
•Arms – bend an elbow and tense all the muscles in the arm for a few seconds as you breathe in; then relax as you breathe out. Repeat the same with the other arm.
•Neck – press your head back as hard as is comfortable and roll it slowly from from side to side; then relax.
•Face – try to frown and lower your eyebrows as hard as you can for a few seconds; then relax. Then raise your eyebrows (as if you were startled) as hard as you can; then relax. Then clench your jaw for a few seconds; then relax.
•Chest – take a deep breath and hold it for a few seconds; then relax and go back to normal breathing.
•Stomach – tense the stomach muscles as tightly as possible; then relax.
•Buttocks – squeeze the buttocks together as much as possible; then relax.
•Legs – with your legs flat on the floor, bend your feet and toes towards your face as hard as you can; then relax. Then bend them away from your face for a few seconds; then relax.

Then repeat the whole routine 3-4 times. Each time you relax a group of muscles, note the difference of how they feel when relaxed compared to when they are tense. Some people find it eases their general level of ‘tension’ if they get into a daily routine of doing these exercises.

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Everyday life

Obviously, you cannot do all the above when ‘out and about’. However, the principle of full tension followed by relaxation of a group of muscles can help to ease anxiety in everyday situations. Therefore, in situations when you feel tension or anxiety rising, try either of the following:
•Twisting your neck around each way as far as it is comfortable; then relax.
•Fully tensing your shoulder and back muscles for several seconds; then relax.

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Deep breathing exercises

Many people have a tendency to breathe faster than normal when they are anxious. Sometimes this can make you feel a little dizzy, which makes you more anxious and you breathe even faster, which can make you more anxious, etc. If you practise ‘deep breathing’ when you are relaxed, you should be able to do this when you feel tense or anxious to help you to relax.

Try the following for 2-3 minutes. Practise this every day until you can do it routinely in any stressful situation:
•Breathe slowly and deeply in through your nose, and out through your mouth in a steady rhythm. Try to make your breath out twice as long as your breath in. To do this, you may find it helpful to count slowly ‘one, two’ as you breathe in, and ‘one, two, three, four’ as you breathe out.
•Mainly use your lower chest muscle (your diaphragm) to breathe. Your diaphragm is the big muscle under the lungs. It pulls the lungs downwards which expands the airways to allow air to flow in. When we become anxious we tend to forget to use this muscle and often use the muscles at the top of the chest and our shoulders instead. Each breath is more shallow if you use these upper chest muscles. So, you tend to breathe faster, and feel more breathless and anxious, if you use your upper chest muscles rather than your diaphragm.
•You can check if you are using your diaphragm by feeling just below your breastbone (sternum) at the top of your tummy (abdomen). If you give a little cough, you can feel the diaphragm push out here. If you hold your hand here you should feel it move in and out as you breathe.
•Try to relax your shoulders and upper chest muscles when you breathe. With each breath out, consciously try to relax those muscles until you are mainly using your diaphragm to breathe.

What are the symptoms of phobia?

If you come near to, or into contact with, the feared situation you become anxious or distressed. In addition you may also have one or more unpleasant physical symptoms. These can be, for example, a fast heart rate, palpitations, feeling sick, shaking (tremor), sweating, dry mouth, chest pain, a ‘knot in the stomach’, and fast breathing.

The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.

You may even become anxious by just thinking of the feared situation. You end up avoiding the feared situation as much as possible, which can restrict your life and cause suffering.

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There are different types of phobia

Social anxiety disorder

This is also known as social phobia and it is possibly the most common phobia. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or ‘performing’ in front of other people, especially strangers. You fear that you will act in an embarrassing or humiliating way, and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. See separate leaflet called Social Anxiety Disorder for more details.

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Agoraphobia

This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations.

For example, you may have a fear of:
•Entering shops, crowds, and public places.
•Travelling in trains, buses, or planes.
•Being on a bridge or in a lift.
•Being in a cinema, restaurant, etc, where there is no easy exit.

But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become anxious and distressed, and have an intense desire to get out. Therefore, to avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time. See separate leaflet called Agoraphobia for more details.

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Other specific phobias

There are many other phobias of a specific thing or situation – for example:
•Fear of confined spaces or of being trapped (claustrophobia).
•Fear of certain animals.
•Fear of injections or needles.
•Fear of vomiting.
•Fear of being alone.
•Fear of choking.
•Fear of the dentist.
•Fear of flying.

However, there are many others, some quite rare.

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What is the treatment for phobias?

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) helps you to change certain ways that you think, feel and behave. It is a useful treatment for various mental health problems, including phobias.
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety, depression and phobias. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or attitudes which you have that can make you anxious. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful.
•Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your response to the feared object (anxiety and avoidance) is not helpful. The therapist helps you to change this. Various techniques are used, depending on the condition and circumstances. For example, for agoraphobia the therapist will usually help you to face up to feared situations, a little bit at a time. A first step may be to go for a very short walk from your home with the therapist who gives support and advice. Over time, a longer walk may be possible, and then a walk to the shops, then a trip on a bus, etc. The therapist may teach you how to control anxiety when you face up to the feared situations and places. For example, by using deep breathing exercises. This technique of behavioural therapy is called exposure therapy where you are exposed more and more to feared situations, and learn how to cope.
•Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours.

CBT is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part, and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious.

Note: unlike other forms of talking treatments (psychotherapy), CBT does not look into the events of the past. CBT aims to deal with your current thought processes and/or behaviours, and helps to change them where appropriate.

CBT usually works well to treat most phobias, but does not suit everyone. However, it may not be available on the NHS in all areas. See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.

Antidepressant medicines

These are commonly used to treat depression, but they also help to reduce the symptoms of phobias (particularly agoraphobia and social phobia), even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and anxiety is helped. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good and it is too early to tell if the medication is working.
•Antidepressants are not tranquillizers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons and they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety and phobic disorders. Examples of SSRIs are escitalopram and sertraline.
•Note: after first starting an antidepressant, in some people anxiety symptoms can become worse for a few days before they start to improve. Your doctor or practice nurse will want to keep a check on you in the first weeks of treatment to see how you manage.

A combination of CBT and an SSRI antidepressant may work better in some cases than either treatment alone.

Benzodiazepines

Benzodiazepines such as diazepam are sometimes called minor tranquilisers but they can have serious side effects. They often work well to ease symptoms of anxiety. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Therefore, they are not a useful long-term treatment of phobias. However, a short course, or even a single dose, may be useful for a phobia which occurs rarely. For example, if you have a fear of flying in a plane, a short course just before a flight may help.

Schizophrenia is a mental illness. Symptoms include hallucinations (such as hearing voices), false ideas (delusions), disordered thoughts and problems with feelings, behaviour and motivation. The cause is not clear. In many people symptoms come back (recur) or persist long-term but some people have just one episode of symptoms that lasts a few weeks. Treatment includes medication, talking treatments and social support.

What is schizophrenia and who gets it?

Schizophrenia is a serious mental health condition that causes disordered ideas, beliefs and experiences. In a sense, people with schizophrenia lose touch with reality and do not know which thoughts and experiences are true and real and which are not.

Some people have wrong ideas about schizophrenia. For instance, it has nothing to do with a split personality. Also, the vast majority of people with schizophrenia are not violent.

You should be aware that some people feel that schizophrenia should be abolished as a concept. They believe that the term is unscientific, stigmatising and does not address the root causes of serious mental distress. However, many members of the medical profession still find the term schizophrenia useful.

Schizophrenia develops in about 1 in 100 people. It can occur in men and women. The most common ages for it first to develop are 15-25 in men and 25-35 in women.

What are the symptoms of schizophrenia?

There are many possible symptoms. They are often classed into positive and negative. Positive symptoms are those that show abnormal mental functions. Negative symptoms are those that show the absence of a mental function that should normally be present.

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Positive symptoms include the following
•Delusions. These are false beliefs that a person has and most people from the same culture would agree that they are wrong. Even when the wrongness of the belief is explained, a person with schizophrenia is convinced that they are true. For example, a person with schizophrenia may believe that neighbours are spying on them with cameras in every room, or a famous person is in love with them, or that people are plotting to kill them, or there is a conspiracy about them. These are only a few examples and delusions can be about anything.
•Hallucinations. This means hearing, seeing, feeling, smelling, or tasting things that are not real. Hearing voices is the most common. Some people with schizophrenia hear voices that provide a running commentary on their actions, argue with them, or repeat their thoughts. The voices often say things that are rude, aggressive, unpleasant, or give orders that must be followed. Some people with schizophrenia appear to talk to themselves as they respond to the voices. People with schizophrenia believe that the hallucinations are real.
•Disordered thoughts. Thoughts may become jumbled or blocked. Thought and speech may not follow a normal logical pattern. For example, some people with schizophrenia have one or more of the following: •Thought echo. This means the person hears his or her own thoughts as if they were being spoken aloud.
•Knight’s-move thinking. This means the person moves from one train of thought to another that has no apparent connection to the first.
•Some people with schizophrenia may invent new words (neologisms), repeat a single word or phrase out of context (verbal stereotypy), or use ordinary words to which they attribute a different, special meaning (metonyms).
Symptoms called disorders of thought possession may also occur. These include: •Thought insertion. This is when someone believes that the thoughts in their mind are not their own and that they are being put there by someone else.
•Thought withdrawal. This is when someone believes that thoughts are being removed from their mind by an outside agency.
•Thought broadcasting. This is when someone believes that their thoughts are being read or heard by others.
•Thought blocking. This is when there is a sudden interruption of the train of thought before it is completed, leaving a blank. The person suddenly stops talking and cannot recall what he or she has been saying.

Negative symptoms include the following
•Lack of motivation. Everything seems an effort – for example, tasks may not be finished, concentration is poor, there is loss of interest in social activities and the person often wants to be alone.
•Few spontaneous movements and much time doing nothing.
•Facial expressions do not change much and the voice may sound monotonous.
•Changed feelings. Emotions may become flat. Sometimes the emotions may be odd, such as laughing at something sad. Other strange behaviours sometimes occur.

Negative symptoms can make some people neglect themselves. They may not care to do anything and appear to be wrapped up in their own thoughts. Negative symptoms can also lead to difficulty with education, which can contribute to difficulties with employment. For families and carers, the negative symptoms are often the most difficult to deal with. Persistent negative symptoms tend to be the main cause of long-term disability.

Families may only realise with hindsight that the behaviour of a relative has been gradually changing. Recognising these changes can be particularly difficult if the illness develops during the teenage years when it is normal for some changes in behaviour to occur.

Other symptoms

Other symptoms that occur in some cases include difficulty planning, memory problems and obsessive-compulsive symptoms.

How is the diagnosis made?

Some of the symptoms that occur in schizophrenia also occur in other mental health conditions such as depression, mania, or after taking some street drugs. Therefore, the diagnosis may not be clear at first. As a rule, the symptoms need to be present for several weeks before a doctor will make a firm diagnosis of schizophrenia.

Not all symptoms are present in all cases. Different forms of schizophrenia occur depending upon the main symptoms that develop. For example, people with paranoid schizophrenia mainly have positive symptoms which include delusions that people are trying to harm them. In contrast, some people mainly have negative symptoms and this is classed as simple schizophrenia. In many cases there is a mix of positive and negative symptoms.

Sometimes symptoms develop quickly over a few weeks or so. Family and friends may recognise that the person has a mental health problem. Sometimes symptoms develop slowly over months and the person may gradually become withdrawn, lose friends, jobs, etc, before the condition is recognised.

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What is the cause of schizophrenia?

The exact cause is not known. It is thought that the balance of certain brain chemicals (neurotransmitters) is altered. Neurotransmitters are needed to pass messages between brain cells. An altered balance of these may cause the symptoms. It is not clear why changes occur in the neurotransmitters.

Genetic (hereditary) factors are thought to be important. For example, a close family member (child, brother, sister, parent) of someone with schizophrenia has a 1 in 10 chance of also developing the condition. This is 10 times the normal chance. A child born to a mother and father who both have schizophrenia has a 1 in 2 chance of developing it too. However, one or more factors appear to be needed to trigger the condition in people who are genetically prone to it. There are various theories as to what these might be. For example:
•Stress such as relationship problems, financial difficulties, social isolation, bereavement, etc.
•A viral infection during the mother’s pregnancy, or in early childhood.
•A lack of oxygen at the time of birth that may damage a part of the brain.
•Illegal or street drugs may trigger the condition in some people. For example, those who use cannabis heavily are six times more likely to develop schizophrenia than non-users. Many other drugs of abuse such as amfetamines, cocaine, ketamine and lysergic acid diethylamide (LSD) can trigger a schizophrenia-like illness.

Are any tests needed?

Blood and urine tests may be done to rule out physical causes of the symptoms or drug/alcohol use. People already diagnosed with schizophrenia may also have tests done if they suddenly become worse.

What are the treatments for schizophrenia?

Treatment and care are usually based in the community rather than at hospitals. The National Institute for Health and Care Excellence (NICE) recommends that the patient’s social circumstances be assessed and their family involved as soon as possible. Most areas of the UK have a community mental healthcare team which includes psychiatrists, nurses, psychologists, social workers, etc. A key worker such as a community psychiatric nurse or psychiatric social worker is usually allocated to co-ordinate the care for each person with schizophrenia.

However, some people need to be admitted to hospital for a short time. This is sometimes done when the condition is first diagnosed so that treatment can be started quickly. Hospital admission may also be needed for a while at other times if symptoms become severe. A small number of people have such a severe illness that they remain in hospital long-term.

People with schizophrenia often do not realise or accept that they are ill. Therefore, sometimes when persuasion fails, some people are admitted to hospital for treatment against their will by use of the Mental Health Act. This means that doctors and social workers can force a person to go to hospital. This is only done when the person is thought to be a danger to themself or others.

Antipsychotic medication

The main medicines used to treat schizophrenia are called antipsychotics. They work by altering the balance of some brain chemicals (neurotransmitters). Antipsychotic medication is used to relieve the symptoms. Antipsychotic medicines tend to work best to ease positive symptoms and tend not to work so well to ease negative symptoms. Antipsychotic medicines are also used to prevent recurring episodes of symptoms (relapses). Therefore, antipsychotic medication is usually taken on a long-term basis. There are various antipsychotic medicines and different ones may be used in different circumstances. They are broadly divided into two categories:
•Newer or atypical antipsychotics. These are sometimes called second-generation antipsychotics and include amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole. One of these medicines is commonly used first-line for new cases. This is because they seem to have a good balance between chance of success and the risk of side-effects. However, if you are already taking a typical medicine and feel well on it, there is no need to change to a newer one.
•Older typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include chlorpromazine, trifluoperazine, haloperidol, flupentixol, zuclopenthixol and sulpiride.

There are some differences between the various antipsychotic medicines. Therefore, one may be better for an individual than another. For example, some are more sedating than others. A specialist in psychiatry usually advises on which to use in each case. In most cases, the specialist will start you on either risperidone or olanzapine. The others are usually kept in reserve for people who have problems or do not respond to these medicines.

A good response to antipsychotic medication occurs in about 7 in 10 cases. However, symptoms may take 2-4 weeks to ease after starting medication and it can take several weeks for full improvement. Even when symptoms ease, antipsychotic medication is normally continued long-term. This aims to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms that clears completely with treatment, one option is to try coming off medication after 1-2 years. Your doctor will advise.

Depot injections of an antipsychotic medicine. In some cases, an injection of a long-acting antipsychotic medicine is used once symptoms have eased. The medicine from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses. The main advantage of depot injections is that you do not have to remember to take tablets every day.

What about side-effects from antipsychotic medicines? Side-effects can sometimes be troublesome. There is often a trade-off between easing symptoms and having to put up with some side-effects from treatment. The different antipsychotic medicines can have different types of side-effects. Also, sometimes one medicine causes side-effects in some people and not in others. Therefore, it is not unusual to try two or more different medicines before one is found that is best suited to an individual.

The following are the main side-effects that sometimes occur. However, you should read the information leaflet that comes in each medicine packet for a full list of possible side-effects.
•Common side-effects include: dry mouth, blurred vision, flushing and constipation. These may ease off when you get used to the medicine.
•Drowsiness (sedation) is also common but may be an indication that the dose is too high. A reduced dose may be an option.
•Some people develop weight gain. Weight gain may increase the risk of developing diabetes and heart problems in the longer term. This appears to be a particular problem with the atypical antipsychotics, notably clozapine and olanzapine.

Movement disorders develop in some cases. These include:
•Parkinsonism – this can cause symptoms similar to those that occur in people with Parkinson’s disease. For example, tremor and muscle stiffness.
•Akathisia – which is like a restlessness of the legs.
•Dystonia – which means abnormal movements of the face and body.
•Tardive dyskinesia – which is a movement disorder that can occur if you take antipsychotics for several years. It causes rhythmical, involuntary movements. These are usually lip-smacking and tongue-rotating movements, although it can affect the arms and legs too. About 1 in 5 people treated with typical antipsychotics eventually develop tardive dyskinesia.

Atypical antipsychotic medicines are thought to be less likely to cause movement disorder side-effects than typical antipsychotic medicines. Reduced incidence of movement disorder is the main reason why an atypical antipsychotic medicine is often used first-line. Atypicals do, however, have their own risks. In particular, the risk of weight gain. If movement disorder side-effects occur then other medicines may be used to try to counteract them.

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Schizophrenia
Psychological treatments

Cognitive behavioural therapy (CBT). Psychological treatments include a variety of talking treatments, in particular a treatment called cognitive behavioural therapy (CBT). CBT is used as a treatment for various mental health and physical problems and is being increasingly used as a treatment for schizophrenia. CBT aims to help you to change the way that you think, feel and behave. CBT is actually a wide term which includes various types of therapy. You may be asked to keep a diary of important events in your life and the way you feel about them. Your therapist may challenge your beliefs and ask you to explain them. You may be asked to try out new ways of behaving and reacting.

CBT and other talking treatments are not alternatives to medicines. They are used in some cases in addition to medication. NICE recommends up to 16 CBT sessions. This is because studies have found that, on average, CBT reduces the chance of being admitted or re-admitted to hospital, can reduce symptom severity and can improve social functioning.

Family intervention. This may be offered and consists of about 10 therapy sessions for relatives of patients with schizophrenia. It has been found to reduce hospital admissions and the severity of symptoms for up to two years after treatment.

Art therapy. This has been found to be helpful, particularly if you have negative symptoms.

Social and community support

This is very important. Often the key worker plays a vital role. However, families, friends and local support groups can also be major sources of help. Contact details of the head offices of the main support organisations are listed in links at the end of this leaflet. However, these organisations also have many local groups throughout the UK.

Encouraging physical health

It is quite common for people with schizophrenia not to look after themselves so well. Such things as smoking, lack of exercise, obesity and an unhealthy diet are more common than average in people with schizophrenia. Weight gain may be a side-effect of antipsychotic medicines. All of these factors may lead to an increased chance of developing heart disease and diabetes in later life.

Therefore, as with everyone else in the population, people with schizophrenia are encouraged to adopt a healthy lifestyle – not to smoke, to take regular exercise, to eat healthily, etc.

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Rethink Mental Illness

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What is the outlook (prognosis)?
•In most cases there are recurring episodes of symptoms (relapses). Most people in this group live relatively independently with varying amounts of support. The frequency and duration of each relapse can vary. Some people recover completely between relapses. Some people improve between relapses but never quite fully recover. Treatment often prevents relapses, or limits their number and severity.
•In some cases, there is only one episode of symptoms that lasts a few weeks or so. This is followed by a complete recovery, or substantial improvement without any further relapses. It is difficult to give an exact figure as to how often this occurs. Perhaps 2 in 10 cases or fewer.
•Up to 2 in 10 people with schizophrenia are not helped much by treatment and need long-term dependent care. For some, this is in secure accommodation.
•Depression is a common complication of schizophrenia.
•It is thought that up to a third of people with schizophrenia abuse alcohol and/or illegal drugs. Helping or treating such people can be difficult.
•About 1 in 10 people with schizophrenia commit suicide.

The outlook is thought to be better if:
•Treatment is started soon after symptoms begin.
•Symptoms develop quickly over several weeks rather than slowly over several months.
•The main symptoms are positive symptoms rather than negative symptoms.
•The condition develops in a relatively older person (aged over 25).
•Symptoms ease well with medication.
•Treatment is taken as advised (that is, compliance with treatment is good).
•There is good family and social support which reduces anxiety and stress.
•Abuse of illegal drugs or alcohol does not occur.

Newer medicines and better psychological treatments give hope that the outlook is improving.

http://www.bipolar4lifesupport.co on line support group

If you have been taking a benzodiazepine or Z drug long-term (for more than four weeks) then it can be difficult to stop it because of withdrawal effects. However, this can be overcome by a variety of ways. One method is to switch whatever medicine you are on to an equivalent dose of diazepam. You can then gradually reduce the dose of diazepam at a pace that suits you. This keeps any withdrawal effects to a minimum. The dose reduction is commonly done over several months before coming off diazepam completely

What are benzodiazepines and Z drugs?

Benzodiazepines are a group of medicines that are sometimes used to treat anxiety. Examples include: diazepam, lorazepam (Ativan®), chlordiazepoxide, alprazolam and oxazepam. Some are also used as sleeping tablets. These include: temazepam, loprazolam, lormetazepam, nitrazepam.

Zaleplon, zolpidem, and zopiclone are other sleeping tablets but, strictly speaking, are not benzodiazepines. They are known as the Z drugs. However, they act in a similar way (they have a similar effect to benzodiazepines on the brain cells).

When you first start taking a benzodiazepine or Z drug, it usually works well to ease the symptoms of anxiety, or to cause sleep. You can usually stop a benzodiazepine or Z drug without any problems if you take it for just a short time (less than 2-4 weeks).

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What happens if you take a benzodiazepine or Z drug for longer?

Tolerance

After a few weeks of taking a benzodiazepine or Z drug each day, the body and brain often become used to the medicine. In many people it gradually loses its effect. The initial dose then has little effect and so a higher dose is needed for it to work. In time, the higher dose does not work, and so an even higher dose is needed, and so on. This effect is called tolerance.

Dependence (addiction)

There is a good chance that you will become dependent on a benzodiazepine or Z drug if you take it for more than four weeks. This means that withdrawal symptoms occur if the tablets are stopped suddenly. In effect, you need the medicine to feel ‘normal’. Possible withdrawal symptoms include:
•Psychological symptoms – such as anxiety, depression, panic attacks, odd sensations, nightmares, feeling as if you are outside your body, feelings of unreality, or just feeling awful. Rarely, a serious mental breakdown can occur (psychosis).
•Physical symptoms such as sweating, being unable to sleep, headache, tremor, feeling sick, feeling unsteady, palpitations, muscle spasms, and being oversensitive to light, sound and touch. Rarely, convulsions (seizures) occur.
•In some cases the withdrawal symptoms seem like the original anxiety symptoms.

The duration of withdrawal symptoms varies, but often lasts up to six weeks and sometimes longer. Some people who have taken these medicines for a long time continue to have minor withdrawal symptoms for several months after stopping. Withdrawal symptoms can start a few hours after but can be up to two days after stopping the tablets. They tend to be worst in the first week or so before gradually easing.

You may end up continuing to take the medicine to prevent withdrawal symptoms but, because of tolerance, it no longer helps the original anxiety or sleeping problem.

Some people who take a benzodiazepine or Z drug on a long-term basis believe that the medicine is still helping to ease anxiety or sleeping problems. However, in fact, in many people the medicine is just preventing withdrawal symptoms.

Why should I stop taking a benzodiazepine or Z drug?

Studies have shown that coming off benzodiazepines and Z drugs can have many benefits. For example, the benefits of stopping long-term benzodiazepines in elderly people were investigated in a trial of 139 people over the age of 65 years. This study found that stopping treatment:
•Had no long-term adverse effects on sleeping or anxiety symptoms.
•Improved memory and reaction times, while people who continued taking benzodiazepines declined in both these areas.
•Increased levels of alertness.
•Improved quality-of-life measures for physical and social functioning, and vitality.

Studies have shown that in people who continue to take benzodiazepines long-term, there is:
•An increased risk of fractured hips in older people, especially when they are on other medicines that increase the effect of benzodiazepines.
•Impairment of mental function and memory in older people. This has sometimes been wrongly diagnosed as dementia.
•An increased risk of injury in car crashes (due to the affect on alertness).

So, in summary, coming off a long-term benzodiazepine or Z drug:
•Is likely to improve your memory, reaction time, alertness, and quality of life.
•Reduces your risk of falls, accidents, fractured bones, and other injuries.

How should I stop taking a long-term benzodiazepine or Z drug?

If you have been taking a benzodiazepine or Z drug for over four weeks and want to stop it, it is best to discuss the problem with a doctor.

Some people can stop taking benzodiazepines and Z drugs without any difficulty, as they have only minor withdrawal effects which soon ease off. However, for a lot of people the withdrawal effects are too severe to cope with if the medicine is stopped suddenly. Therefore, it is often best to reduce the dose gradually over several months before finally stopping it. Your doctor can advise on dosages, time scale, etc.

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Diazepam withdrawal plan

A common plan is to switch from whatever benzodiazepine tablet or Z drug that you are taking to diazepam. Diazepam is a ‘long-acting’ benzodiazepine that is commonly used. With diazepam, the dose can be altered very gradually and with greater ease compared to other benzodiazepines.

Your doctor will be able to prescribe the dose of diazepam equivalent to the dose of your particular type of benzodiazepine or Z drug. After this, you can decide with your doctor a plan of how to reduce the dose gradually. A common plan is to reduce the dose by a small amount every 1-2 weeks. The amount the dose is reduced at each step may vary, depending on how large a dose you are taking to start with. Also, the last few dose reductions before finally stopping completely may be less than the original dose reductions, and done more gradually.

The gradual reduction of dose keeps any withdrawal symptoms to a minimum.

Sometimes other medication may be prescribed to help you cope with symptoms while you are coming off benzodiazepines. For example, you may be offered antidepressants if depression emerges whilst you are on a withdrawal programme, or beta-blockers if you need help to control anxiety.

Some tips that may help
•Before coming off a benzodiazepine or Z drug it may be best to wait until any life crisis has passed, and your level of stress is as low as can be.
•Consider starting whilst on holiday, when you have less pressure from work, fewer family commitments, less stress, etc.
•Consider telling family or friends that you are coming off a benzodiazepine or Z drug. They may give you encouragement and support.
•Consider joining a local self-help group. Advice and support from other people in similar circumstances, or who have come off a benzodiazepine or Z drug, can be very encouraging.
•If you are taking other addictive medicines in addition to benzodiazepines, then you may need specialist help for coming off the various medicines. Your doctor will be able to advise you or refer you on to local services which can help.

Other ways of tackling anxiety and sleeping problems

Benzodiazepines and Z drugs are not the long-term answer to anxiety or sleep problems.

If you have anxiety symptoms, there are other ways of tackling your symptoms. For example, learning to relax, or joining an anxiety management group. If anxiety symptoms persist or are severe, your doctor may advise on other treatments such as cognitive behavioural therapy (CBT).

There are separate leaflets that may help called ‘Anxiety – Generalised Anxiety Disorder’, ‘Anxiety Disorders’, ‘Cognitive Behavioural Therapy (CBT)’, and ‘Stress – Tips on How to Avoid It’.

Tips on how to improve sleep can be found in our leaflets ‘Insomnia (Poor Sleep)’, ‘Insomnia – Sleeping Tablets’, and ‘Sleeping Problems – Self Help Guides’.

A final note

Most people who have taken a benzodiazepine or Z drug can successfully come off it. After switching to diazepam (described above), the pace and speed of withdrawal varies greatly from person to person. Go at a pace that is comfortable for you after discussion with your doctor. For many people, the gradual withdrawal and eventual stopping of diazepam takes several months. However, some people take up to a year to reduce the dose gradually before finally stopping it.

http://www.bipolar4lifesupport on line support group

Tourette’s syndrome is a condition that causes you to have involuntary movements or noises called tics. It starts in childhood and is associated with various other problems such as behavioural problems and attention deficit hyperactivity disorder (ADHD). It can often be well managed with psychological treatments, and sometimes medication.

What is Tourette’s syndrome?

Tourette’s syndrome is a disorder that starts in childhood. The prime symptom is to have repeated tics. A tic is a sudden movement or sound that is repeated over and over. A tic has no purpose and, in general, you cannot help doing it. For example, repeated blinking, repeated throat clearing, repeated head nodding, etc. Tics are very common in children and usually last less than one year. However, children with Tourette’s syndrome have many types of tics of sudden movements and noises, and the tics persist for more than a year. The syndrome is named after the person who described the condition in 1885, Dr Georges Gilles de la Tourette.

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What causes Tourette’s syndrome?

The cause is not known. There are various theories which include the following:

Genetic. It is generally believed that abnormalities in genes are responsible for most cases of Tourette’s syndrome. Genes are passed on to a child from each parent and determine what we look like, how our body functions and even what diseases we may get. A child is more likely to develop Tourette’s syndrome if they have a father, mother, brother or sister with it also.

Neurological. Some studies have shown that there are some minor defects in the structure and working of the brain in children with Tourette’s syndrome. Studies also suggest that there may be a problem with one of the brain’s chemicals called dopamine. There is not a lot of information available about the detail or significance of these changes.

Environmental. Although it has not been proven, there is some evidence that problems during pregnancy or childbirth may increase the risk of a child developing Tourette’s syndrome. This may include problems such as prolonged labour, high levels of maternal stress in pregnancy, or babies with very low birthweight. There is also possibly a connection with a particular infection with the streptococcal germ in some children with Tourette’s syndrome. This is a fairly recent discovery and not very much is known about the link.

How common is Tourette’s syndrome?

Tourette’s syndrome is much more common than previously thought. About 1 in 100 children has the condition, although it varies in how mild or severe it is. It is about three times more common in boys than in girls.

What are the symptoms of Tourette’s syndrome?

The main symptom is multiple (many) tics. These are classified as either motor (movement) or vocal tics.
•Motor tics include things such as blinking, head turning, head nodding, kicking, mouth pouting, mouth opening, mouth twitches, etc.
•Vocal tics include things such as throat clearing, coughing, sniffing, yelling, or making animal sounds.

Tics occur very commonly in children who do not have Tourette’s syndrome. In fact, up to 1 in 5 children will develop a tic at some stage. These tics are often minor and of little significance, usually come and go, and often go away within a year.

In Tourette’s syndrome, a child develops multiple tics which occur many times a day (often in bouts), and the tics last for more than one year. The tics cause some degree of difficulty in school or social function. The condition begins between 2-14 years of age (the average age is 7).

There are several other symptoms that sometimes occur. These include:
•Coprolalia – the involuntary use of obscenities and swear words. This is perhaps the most famous symptom which the media tend to focus in on. However, this only occurs in about 1 in 10 children with Tourette’s syndrome. Note: it must be emphasised that if this occurs, the child cannot help swearing, and it is not a reflection on their moral character or upbringing.
•Echophenomena – copying what others say and do.
•Palilalia – repeating your own words.
•Non-obscene socially inappropriate (NOSI) behaviours – such as saying inappropriate or rude personal comments.

Are there any other problems?

If a child has Tourette’s syndrome they are also likely to have one or more related conditions. It is not clear why these other conditions occur at the same time. Only about 1 child in 10 with Tourette’s syndrome has no other associated problem. The most common conditions seen with Tourette’s syndrome are listed below with how often they occur in children with Tourette’s syndrome.
•Obsessive-compulsive disorder (OCD), or obsessive-compulsive behaviour (OCB). This occurs in about 5 in 10 children with Tourette’s syndrome.
•Attention deficit hyperactivity disorder (ADHD, or ADD). This occurs in about 6 in 10 children with Tourette’s syndrome.
•Learning difficulties. These occur in about 3 in 10 children with Tourette’s syndrome.
•Mood disorders such as depression or anxiety occur in about 2 in 10 children with Tourette’s syndrome.
•Conduct disorders. These occur in about 1-2 in 10 children with Tourette’s syndrome.
•Self-harming behaviours such as head banging occur in about 3 in 10 children with Tourette’s syndrome.
•Behavioural problems. Up to 8 in 10 children with Tourette’s syndrome will also have some degree of behavioural problems.

How is Tourette’s syndrome diagnosed?

There is no test for Tourette’s syndrome. The diagnosis is made after a careful discussion with you and your child as well as a physical examination to rule out other disorders. This will usually be done by a specialist neurologist (a doctor with a special interest in the brain and nervous system). Some tests may be done to make sure that there are no other conditions which could account for the tics.

What is the treatment for Tourette’s syndrome?

Psychological (talking) treatments

Various psychological treatments can help to ease the symptoms and problems of Tourette’s syndrome. These include cognitive behavioural therapy (CBT), habit reversal training and exposure and response prevention therapy. These treatments aim to help the child to recognise and control their tics. Often children are able to learn to suppress the tics during the day at school, but will need an outlet to release them at home.

Education and support

There is some evidence that providing parents and children with Tourette’s syndrome with information about the condition, results in better outcomes. It is recommended that you get in contact with the support group listed below, as they can provide further information on the condition and can even put you in contact with others in the same situation.

It is very important that your child’s school teacher and others who are involved in your child’s care should be informed and educated about the best way to manage this condition. Your child’s teacher can have a very positive impact on your child’s behaviour and development if they understand the problems that may be present.

In addition to any usual treatments, individual children may respond to different approaches. Parents and teachers can build on whatever works. For example, some children can gain more control of their lives through the medium of dance.

Medication

In more severe Tourette’s syndrome, medicines can sometimes help to reduce the occurrence of tics. The medicines that are mostly used are from the group known as antipsychotics: haloperidol, risperidone, pimozide, arpiprazole and sulpiride. The medicine clonazepam – a benzodiazepine – is also sometimes used. The aim of treatment with medicines is to control the tics to a point that will enable your child to function well while minimising side-effects. The tics may not disappear completely.

Management of other conditions

If your child has other conditions present with Tourette’s syndrome, then it is important that these should also be treated and managed well.

Other treatments

The use of surgery in Tourette’s syndrome is only recommended for people with severe symptoms who do not respond to other treatment. Deep brain stimulation using electrodes implanted into the brain has produced encouraging results in limited trials. However, more research is needed to see whether it is safe to be used more generally.

Some other thoughts and controversies about Tourette’s syndrome

There are various controversies and differences of opinion about certain aspects of Tourette’s syndrome. For example:
•Some people view any treatment to be controversial. Some children and teenagers do not want to change, and sometimes side-effects of medication can be worse than the condition itself.
•Some people would argue that it is not necessarily a disease and is a natural part of their personality, which has positive aspects to it. For example, some people with Tourette’s syndrome lead vivid lives ‘on the edge’, with extravagance, and audacity – sometimes with a rich fantasy world.

What is the outlook (prognosis)?

Many children with Tourette’s syndrome improve over time. By the time they are adults, in many cases the symptoms have eased considerably or have gone. However, some children with this condition will continue to have marked symptoms into adulthood and, although the tics tend to stabilise over time, some new tics may develop.

http://www.bipolar4lifesupport.co on line support group

Chronic fatigue syndrome/ME is a condition where you have long-term disabling tiredness (fatigue). Most people with chronic fatigue syndrome/ME also have one or more other symptoms such as muscular pains, joint pains, disturbed sleep patterns, poor concentration, headaches. The cause is not known. Treatments that may help in some cases (but not all) include a programme of graded exercise therapy (GET) and cognitive behavioural therapy (CBT).

What is chronic fatigue syndrome/ME?

Chronic fatigue syndrome (CFS)/ME is a condition that causes marked long-term fatigue and other symptoms which are not caused by any other known medical condition.
•CFS stands for chronic fatigue syndrome. Chronic means persistent or long-term.
•ME stands for myalgic encephalomyelitis. Myalgic means muscle aches or pains. Encephalomyelitis means inflammation of the brain and spinal cord.

However, there is controversy about the nature of this condition. There is no test to diagnose the condition. The diagnosis is made in people who have a certain set of symptoms (which can vary in their type and severity). There is even controversy about what to call this condition.
•The term CFS is often used by doctors. This is because the main symptom is often fatigue and the condition is chronic (persistent). Also, there is no evidence of inflammation in the brain or spinal cord which is implied by the term encephalomyelitis.
•The term ME is the preferred term by many people with the condition. Some people with this condition feel that the word fatigue is an everyday word which does not reflect the different and severe type of fatigue that they have. Also, although fatigue to some extent occurs in most cases, it may not be the main or only symptom.
•Some people believe that there are two separate conditions – CFS and ME. Other people believe that the two conditions are the same – but symptoms can vary.

Until these issues are resolved, many people now use the umbrella term of CFS/ME.

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What causes chronic fatigue syndrome/ME?

The cause of CFS/ME is not known. There are various theories – but none has been proved. A popular theory is that a viral infection may trigger the condition. It is well-known that fatigue is a symptom that can persist for a short time after having certain viral infections. For example, infection with the glandular fever virus or the influenza virus can cause fatigue for several weeks after other symptoms have gone. However, most people recover within a few weeks from the fatigue that follows known viral infections.

Even if a viral infection is a trigger of CFS/ME, it is not clear why symptoms persist when there is no evidence of persisting infection. Also, the symptoms of many people with CFS/ME do not start with a viral infection.

Factors that are thought to contribute to some people developing CFS/ME include:
•Inherited genetic susceptibility (it is more common in some families).
•Viral infections such as glandular fever.
•Exhaustion and mental stress.
•Depression.
•A traumatic event such as bereavement, divorce or redundancy.

The following factors are thought to make CFS/ME worse:
•Recurring viral or bacterial infections.
•Not being active enough, or even being too active.
•Stress.
•Poor diet.
•Being socially isolated and/or feeling frustrated and depressed.
•Environmental pollution.

It is hoped that research will clarify the cause of CFS/ME in the future.

Who gets chronic fatigue syndrome/ME?

CFS/ME can affect anyone. It is estimated that CFS/ME affects about 1 in 300 people in the UK, possibly more. It is about three times as common in women as in men. The most common age for it to develop is in the early twenties to mid-forties. In children the most common age for it to develop is 13-15 years, but it can develop at an earlier age.

How is chronic fatigue syndrome/ME diagnosed?

There is no test that proves that you have CFS/ME. A doctor will usually diagnose CFS/ME based on your symptoms. Some tests are usually done to rule out other causes of your fatigue or other symptoms. For example, blood tests may be done to rule out anaemia, an underactive thyroid gland, and liver and kidney problems. All these tests are normal in people with CFS/ME.

The medical definition of CFS/ME states that symptoms should have lasted for at least four months in adults and three months in children and young adults.

What are the symptoms of chronic fatigue syndrome/ME?

The onset of symptoms can be fairly sudden (over a few days or so), or more gradual.

Fatigue

The most common main symptom is persistent fatigue (tiredness). The fatigue is of new onset. That is, it has not been lifelong but started at a point in time and causes you to limit your activities compared with what you were used to. It is often felt to be both physical and mental fatigue, and said to be overwhelming, or to be like no other type of fatigue. For example:
•It is very different to everyday tiredness (such as after a day’s work).
•It is not eased much by rest.
•It is not due to, or like, tiredness following overexertion.
•It is not due to muscle weakness.
•It is not loss of motivation or pleasure which occurs in people who are depressed.

The fatigue is often made worse by activity. This is called post-exertional malaise. However, the post-exertional malaise usually does not develop until the day following the activity. It then takes several days to improve.

Other symptoms

In addition to fatigue, one or more of the following symptoms are common (but most people do not have them all). In some people, one of the following symptoms is more dominant than the fatigue and is the main symptom:
•Mental (cognitive) difficulties such as poor concentration, poor short-term memory, reduced attention span, poor memory for recent events, difficulty to plan or organise your thoughts, difficulty finding the right words to say, sometimes feeling disorientated.
•Sleeping difficulties. For example, early waking, being unable to sleep, too much sleep, disrupted sleep/wake patterns.
•Pains – most commonly, muscular pains (myalgia), joint pains and headaches.
•Recurring sore throat, often with tenderness of the nearby lymph glands.
•A range of other symptoms has been reported in some cases. For example, dizziness, nausea (feeling sick) and palpitations.

Physical or mental exertion will often make your symptoms worse.

Severity of symptoms

The severity of CFS/ME can roughly be divided into three levels:

Mild cases – you can care for yourself and can do light domestic tasks, but with difficulty. You are still likely to be able to do a job, but may often take days off work. In order to remain in work you are likely to have stopped most leisure and social activities. Weekends or other days off from work are used to rest in order to cope.

Moderate cases – you have reduced mobility and are restricted in most activities of daily living. The level of ability and severity of symptoms often varies from time to time (peaks and troughs). You are likely to have stopped work and require rest periods. Night-time sleep tends to be poor and disturbed.

Severe cases – you are able to carry out only minimal daily tasks such as face washing and cleaning teeth. You are likely to have severe difficulties with some mental processes such as concentrating. You may be wheelchair-dependent for mobility and may be unable to leave your home except on rare occasions, and usually have severe prolonged after-effects from effort. You may spend most of your time in bed. You are often unable to tolerate any noise, and are generally very sensitive to bright light.

Note: most cases are mild or moderate.

What is the treatment for chronic fatigue syndrome/ME?

There is no known cure for CFS/ME although treatment may help to ease symptoms. You are likely to be referred to a specialist who will be able to offer you support and treatment. Treatments that may be considered include the following.

Management of your symptoms

Painkillers may help if muscle or joint pains are troublesome symptoms. Eating little and often may help any nausea. Specific diets have not been shown to be beneficial.

Depression can occur in people with CFS/ME (as it is with many other chronic diseases). Depression can make many symptoms worse. Antidepressants may be prescribed if depression develops.

Management of your quality of life and function

Managing your sleep

It is likely you will be given advice about your sleep. Any changes to your sleep pattern (for example, having too little, or even too much, sleep) may actually make your fatigue worse. This includes sleeping in the daytime, which should ideally be avoided. Any changes to your sleep pattern should be done gradually.

Managing rest

Rest (rather than actual sleep) is very beneficial. You should introduce rest periods into your daily routine. These should ideally be limited to 30 minutes at a time and be a period of relaxation.

Relaxation

Relaxation can help to improve pain, sleep problems and any stress or anxiety you may have. There are various relaxation techniques (such as guided visualisation or breathing techniques) which you may find useful when there are built into your rest periods.

Diet

It is very important that you have a well-balanced diet. You should try to avoid any foods and drinks that you are sensitive to. Eating small, regular meals which contain some starchy foods is often beneficial.

Specific treatments

One or more of the following may be recommended as part of your treatment:

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Graded exercise therapy

Graded exercise therapy (GET) means a gradual, progressive increase in exercise or physical activity, such as walking or swimming. The level of exercise recommended will depend upon your symptoms and current level of activity. Graded exercise is a structured treatment during which you are closely monitored. It is not the same as going to the gym or doing more exercise by yourself. It should be tailored to suit each individual case. Ideally, it should be supervised by a physiotherapist or occupational therapist who is used to treating people with CFS/ME.

Graded exercise can improve symptoms for some people. However, some people report that they do not find it beneficial.

Cognitive behavioural therapy

Cognitive therapy is based on the idea that certain ways of thinking can fuel certain health problems. Behavioural therapy aims to change any behaviours that are harmful or not helpful. Cognitive behavioural therapy (CBT) is a combination of cognitive and behavioural therapy. The use of CBT does not imply that the cause of an illness is psychological. CBT is one of the most effective treatments for CFS/ME.

Although CBT does not aim to cure the condition, it helps to improve symptoms, coping strategies and day-to-day functioning. For people with CFS/ME the core components of CBT would normally include: energy/activity management, establishment of a sleep routine, goal setting, and psychological support.

So which specific treatment is most effective? A large research trial was published in 2011 which compared the two treatment options listed above. 641 people with CFS/ME (but who were not bed-bound) took part in the trial. They were split into four groups. One group received standard medical care alone. The other three groups received standard medical care plus Adaptive Pacing Therapy (APT), or CBT, or GET. Adaptive pacing therapy was invented for the trial and is used as a control, just for comparison. After one year the results showed that 41 in 100 people had improved with CBT, and 41 in 100 had improved with GET. With normal medical care, 25 in 100 people had improved and 31 in 100 for the APT group. The conclusion of this study was that CBT and GET were the most effective treatments, but there was only small benefit over normal medical care. Also, that APT was unlikely to give any extra benefit to normal medical care.

It was also worth noting in this trial that all the treatments had limited effects. Yes, it was found that a good number of people improved (had less severe symptoms) with each treatment. However, only about 3 in 10 people treated with CBT or GET in this trial (the treatments found to be most effective) recovered fully.

General support

Depending on the severity of illness, other support may be needed. For example, carers, nursing support, equipment and adaptations to the home to help overcome disability.

If you are employed, your doctor will be able to advise you about whether you should take time off work. And, if you take time off work, when you may be ready to go back to work. It may be that you need to work doing slightly different hours or even with different duties. If you have an occupational health department at work, they are likely to be involved with you also regarding work and going back to work if you take time off.

Complementary treatments

As there is only limited success with conventional treatments, it is understandable that people turn to complementary practitioners. Many people with CFS/ME find various therapies helpful. However, there is not enough research evidence to support the use of complementary therapies for the treatment of CFS/ME.

There is also insufficient evidence to recommend the use of supplements (for example, vitamins).

Managing setbacks (relapses)

It can be common to have setbacks when symptoms become worse for a while. These can have various triggers – for example, poor sleep, infection or stress.

Your doctor may discuss with you strategies which may help during a setback. These may include relaxation techniques, talking with your family, and maintaining your activity and exercise levels, if possible. However, it may be necessary for you to reduce or even stop some of your activities and increase the amount of rest you have during a setback.

Following a setback you should usually be able gradually to return to your previous activity level.

What is the outlook (prognosis)?

In most cases, the condition has a fluctuating course. There may be times when symptoms are not too bad, and times when symptoms flare up and become worse (a setback). The long-term outlook is variable:
•Most people with CFS/ME will show some improvement over time, especially with treatment. Some people recover in less than two years, while others remain ill for many years. However, health and functioning rarely return completely to previous levels.
•Some people will continue to have symptoms or have relapses of their symptoms.
•In some cases, the condition is severe and/or persists for many years. Those who have been affected for several years seem less likely to recover.
•The outlook in children and young people is usually better.

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What are the symptoms of phobia?

If you come near to, or into contact with, the feared situation you become anxious or distressed. In addition you may also have one or more unpleasant physical symptoms. These can be, for example, a fast heart rate, palpitations, feeling sick, shaking (tremor), sweating, dry mouth, chest pain, a ‘knot in the stomach’, and fast breathing.

The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.

You may even become anxious by just thinking of the feared situation. You end up avoiding the feared situation as much as possible, which can restrict your life and cause suffering.

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There are different types of phobia

Social anxiety disorder

This is also known as social phobia and it is possibly the most common phobia. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or ‘performing’ in front of other people, especially strangers. You fear that you will act in an embarrassing or humiliating way, and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. See separate leaflet called Social Anxiety Disorder for more details.

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Agoraphobia

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Agoraphobia

This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations.

For example, you may have a fear of:
•Entering shops, crowds, and public places.
•Travelling in trains, buses, or planes.
•Being on a bridge or in a lift.
•Being in a cinema, restaurant, etc, where there is no easy exit.

But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become anxious and distressed, and have an intense desire to get out. Therefore, to avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time. See separate leaflet called Agoraphobia for more details.

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Other specific phobias

There are many other phobias of a specific thing or situation – for example:
•Fear of confined spaces or of being trapped (claustrophobia).
•Fear of certain animals.
•Fear of injections or needles.
•Fear of vomiting.
•Fear of being alone.
•Fear of choking.
•Fear of the dentist.
•Fear of flying.

However, there are many others, some quite rare.

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What is the treatment for phobias?

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) helps you to change certain ways that you think, feel and behave. It is a useful treatment for various mental health problems, including phobias.
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety, depression and phobias. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or attitudes which you have that can make you anxious. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful.
•Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your response to the feared object (anxiety and avoidance) is not helpful. The therapist helps you to change this. Various techniques are used, depending on the condition and circumstances. For example, for agoraphobia the therapist will usually help you to face up to feared situations, a little bit at a time. A first step may be to go for a very short walk from your home with the therapist who gives support and advice. Over time, a longer walk may be possible, and then a walk to the shops, then a trip on a bus, etc. The therapist may teach you how to control anxiety when you face up to the feared situations and places. For example, by using deep breathing exercises. This technique of behavioural therapy is called exposure therapy where you are exposed more and more to feared situations, and learn how to cope.
•Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours.

CBT is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part, and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious.

Note: unlike other forms of talking treatments (psychotherapy), CBT does not look into the events of the past. CBT aims to deal with your current thought processes and/or behaviours, and helps to change them where appropriate.

CBT usually works well to treat most phobias, but does not suit everyone. However, it may not be available on the NHS in all areas. See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.

Antidepressant medicines

These are commonly used to treat depression, but they also help to reduce the symptoms of phobias (particularly agoraphobia and social phobia), even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and anxiety is helped. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good and it is too early to tell if the medication is working.
•Antidepressants are not tranquillisers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons and they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety and phobic disorders. Examples of SSRIs are escitalopram and sertraline.
•Note: after first starting an antidepressant, in some people anxiety symptoms can become worse for a few days before they start to improve. Your doctor or practice nurse will want to keep a check on you in the first weeks of treatment to see how you manage.

A combination of CBT and an SSRI antidepressant may work better in some cases than either treatment alone.

Benzodiazepines

Benzodiazepines such as diazepam are sometimes called minor tranquilizers but they can have serious side effects. They often work well to ease symptoms of anxiety. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Therefore, they are not a useful long-term treatment of phobias. However, a short course, or even a single dose, may be useful for a phobia which occurs rarely. For example, if you have a fear of flying in a plane, a short course just before a flight may help.

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Schizoaffective disorder was first described in the 1930s. This psychiatric condition has features of both schizophrenia and mood disorders, eg depression. Questions have been raised about whether it truly exists as a disease entity, although the term is still in common use by psychiatrists.[1][2]

The cause is unknown. Various factors have been mooted, including genetic[3], nutritional, viral, prenatal and metabolic (involving neurotransmitter dysfunction).[4]

Epidemiology

Schizoaffective disorder is less common than schizophrenia – there are no figures on the incidence and prevalence in the United Kingdom.

Schizoaffective manic patients have been reported to comprise 3-5% of all patients admitted to typical psychiatric hospital units.

The condition commonly presents in early adulthood and women are more often affected.

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Diagnosis[5]
•Schizoaffective disorder occurs when, during the same illness, there is major depressive, manic or a mixed episode. This occurs along with the symptoms of schizophrenia.
•Delusions or hallucinations need to be present for at least two weeks when the mood symptoms are not present.
•Symptoms of mood disturbance are present for a significant length of the illness.
•The disturbance is not due to other causes, eg organic illness, substance misuse, medication (see ‘Differential diagnosis’, below).

The schizoaffective illness can be described as:
•Bipolar type – when a manic or a mixed episode occurs.
•Depressive type – the illness has mainly depressive episodes.

Presentation

This can be divided into major depressive episode, manic episode, mixed episode and schizophrenia.[5]

Major depressive episode
Five of the following symptoms should be present for at least two weeks. One symptom must be either depressed mood or loss of interest or pleasure: •Depressed mood.
•Decreased pleasure in activities.
•Weight loss or weight gain or appetite change.
•Insomnia or hypersomnia.
•Psychomotor agitation or retardation.
•Fatigue.
•Feelings of guilt or worthlessness.
•Decreased concentration.
•Recurrent thoughts of death or suicidal notions.

Manic episode
Persistently elevated or irritable mood for at least one week. Three of the following need to be present (or four if the patient has an irritable mood): •Inflated self-esteem or grandiosity.
•Reduced need for sleep.
•Pressure of speech.
•Flight of ideas and racing thoughts.
•Easily distracted.
•Increase in goal-directed activity with psychomotor agitation.
•Excessive involvement in high-risk activities, eg shopping sprees.

Mixed episode
Features of both manic episode and major depressive episode are present – but only for one week.
Schizophrenia symptoms
Two or more of the following are present during one month of the illness: •Delusions – if bizarre, then no other symptoms are required to make the diagnosis.
•Hallucinations – if in the form of a running commentary or two voices, then no other symptoms are necessary to make the diagnosis.
•Speech abnormalities, eg incoherent speech and/or speech derailment.
•Behavioural abnormalities, eg disorganised or catatonia.
•Negative symptoms, eg apathy or lack of emotions.

Differential diagnosis

It is important to ascertain that the disorder is not caused by any underlying process. Main groups of differentials include:
•Substance misuse, eg cannabis.
•Organic illness, eg hypothyroidism, delirium.
•Medication side-effects.
•For a depressive episode, it is necessary to ensure that it cannot be explained by recent life events, eg recent bereavement or loss of employment.
•Other psychiatric illness, eg dementia, delusional disorder.

Investigations

This will mainly be to rule out underlying causes and may include:
•Baseline bloods: FBC, renal and liver function, TFTs, HIV test.
•Urine or plasma toxicology.
•CXR to exclude pneumonia in the elderly.
•Other imaging if clinically indicated, eg patients with abnormal neurology may require CT or MRI scanning.

Associated problems

Patients affected by schizoaffective disorder can also have a number of other problems. These can include:
•Learning difficulties.
•Abnormal personality, eg antisocial or dependent.
•Psychosis.

Complications
•Poor social integration and function.
•Self-neglect.
•Difficulties with relationships.
•Substance misuse, eg alcohol.
•Suicidal behaviour.
•Homicidal thoughts.

Management[4]

Urgent hospital admission should be arranged for patients who are thought to be a threat to themselves or others, or who are too disabled to care for themselves.

Community services may be vital in keeping patients out of hospital or in managing the step-down into the community after hospital discharge. Specialist services which may be required include community psychiatric nursing and occupational therapy as well as more pragmatic support such as transport to and from hospital appointments, pharmacy delivery services and help in managing domestic and financial affairs.

There are few large trials that have specifically studied the drug treatment of schizoaffective disorder and there are no consensus guidelines. Treatment is based largely on the treatment of schizophrenia.[1] Antipsychotics are the mainstay of treatment, sometimes combined with psychological therapies.

Treatments can be divided as:
•Treatment of an acute exacerbation of schizoaffective disorder – antipsychotics are useful and it may be that atypical antipsychotics have some qualities superior to typical antipsychotics, eg risperidone or olanzapine.
•Long-term treatment of schizoaffective disorder – this involves the use of antipsychotics with psychological treatments. Antipsychotics improve patients with schizoaffective disorder, being more efficacious in those with bipolar type. Atypical antipsychotics may be more effective in schizoaffective disorders but more research is required here. Clozapine is sometimes used in resistant cases.
•Treatment of ongoing depressive symptoms in schizoaffective disorder – in this situation a trial of antidepressants is warranted and these may need to continue for longer periods of time. Sertraline or fluoxetine are often used. Occasionally, electroconvulsive therapy may be required.
•Mood stabilisers such as lithium may be useful in the bipolar type. Carbamazepine and valproic acid are other drugs in this category which have been used with some good results.

Psychological treatments involve – cognitive behavioural therapy, family interventions, counselling, art therapy and supportive psychotherapy. This is similar to the treatment of schizophrenia. The National Institute for Health and Clinical Excellence (NICE) in fact includes schizoaffective disorder as one of the ‘negative symptoms’ of schizophrenia and recommends psychological treatment accordingly.[6]

Prognosis

The bipolar type of schizoaffective disorder has a better prognosis than the depressive type, as the latter usually results in long-term mood disturbances.

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