Down syndrome

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Overview

Down syndrome is a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosome 21. This extra genetic material causes the developmental changes and physical features of Down syndrome.

Down syndrome varies in severity among individuals, causing lifelong intellectual disability and developmental delays. It’s the most common genetic chromosomal disorder and cause of learning disabilities in children. It also commonly causes other medical abnormalities, including heart and gastrointestinal disorders.

Better understanding of Down syndrome and early interventions can greatly increase the quality of life for children and adults with this disorder and help them live fulfilling lives.

Symptoms

Each person with Down syndrome is an individual — intellectual and developmental problems may be mild, moderate or severe. Some people are healthy while others have significant health problems such as serious heart defects.

Children and adults with Down syndrome have distinct facial features. Though not all people with Down syndrome have the same features, some of the more common features include:

  • Flattened face
  • Small head
  • Short neck
  • Protruding tongue
  • Upward slanting eye lids (palpebral fissures)
  • Unusually shaped or small ears
  • Poor muscle tone
  • Broad, short hands with a single crease in the palm
  • Relatively short fingers and small hands and feet
  • Excessive flexibility
  • Tiny white spots on the colored part (iris) of the eye called Brushfield’s spots
  • Short height

Infants with Down syndrome may be average size, but typically they grow slowly and remain shorter than other children the same age.

Intellectual disabilities

Most children with Down syndrome have mild to moderate cognitive impairment. Language is delayed, and both short and long-term memory is affected.

When to see a doctor

Children with Down syndrome usually are diagnosed before or at birth. However, if you have any questions regarding your pregnancy or your child’s growth and development, talk with your doctor.

Causes

Human cells normally contain 23 pairs of chromosomes. One chromosome in each pair comes from your father, the other from your mother.

Down syndrome results when abnormal cell division involving chromosome 21 occurs. These cell division abnormalities result in an extra partial or full chromosome 21. This extra genetic material is responsible for the characteristic features and developmental problems of Down syndrome. Any one of three genetic variations can cause Down syndrome:

  • Trisomy 21. About 95 percent of the time, Down syndrome is caused by trisomy 21 — the person has three copies of chromosome 21, instead of the usual two copies, in all cells. This is caused by abnormal cell division during the development of the sperm cell or the egg cell.
  • Mosaic Down syndrome. In this rare form of Down syndrome, a person has only some cells with an extra copy of chromosome 21. This mosaic of normal and abnormal cells is caused by abnormal cell division after fertilization.
  • Translocation Down syndrome. Down syndrome can also occur when a portion of chromosome 21 becomes attached (translocated) onto another chromosome, before or at conception. These children have the usual two copies of chromosome 21, but they also have additional genetic material from chromosome 21 attached to another chromosome.

There are no known behavioral or environmental factors that cause Down syndrome.

Is it inherited?

Most of the time, Down syndrome isn’t inherited. It’s caused by a mistake in cell division during early development of the fetus.

Translocation Down syndrome can be passed from parent to child. However, only about 3 to 4 percent of children with Down syndrome have translocation and only some of them inherited it from one of their parents.

When balanced translocations are inherited, the mother or father has some rearranged genetic material from chromosome 21 on another chromosome, but no extra genetic material. This means he or she has no signs or symptoms of Down syndrome, but can pass an unbalanced translocation on to children, causing Down syndrome in the children.

Risk factors

Some parents have a greater risk of having a baby with Down syndrome. Risk factors include:

  • Advancing maternal age. A woman’s chances of giving birth to a child with Down syndrome increase with age because older eggs have a greater risk of improper chromosome division. A woman’s risk of conceiving a child with Down syndrome increases after 35 years of age. However, most children with Down syndrome are born to women under age 35 because younger women have far more babies.
  • Being carriers of the genetic translocation for Down syndrome. Both men and women can pass the genetic translocation for Down syndrome on to their children.
  • Having had one child with Down syndrome. Parents who have one child with Down syndrome and parents who have a translocation themselves are at an increased risk of having another child with Down syndrome. A genetic counselor can help parents assess the risk of having a second child with Down syndrome.

Complications

People with Down syndrome can have a variety of complications, some of which become more prominent as they get older. These complications can include:

  • Heart defects. About half the children with Down syndrome are born with some type of congenital heart defect. These heart problems can be life-threatening and may require surgery in early infancy.
  • Gastrointestinal (GI) defects. GI abnormalities occur in some children with Down syndrome and may include abnormalities of the intestines, esophagus, trachea and anus. The risk of developing digestive problems, such as GI blockage, heartburn (gastroesophageal reflux) or celiac disease, may be increased.
  • Immune disorders. Because of abnormalities in their immune systems, people with Down syndrome are at increased risk of developing autoimmune disorders, some forms of cancer, and infectious diseases, such as pneumonia.
  • Sleep apnea. Because of soft tissue and skeletal changes that lead to the obstruction of their airways, children and adults with Down syndrome are at greater risk of obstructive sleep apnea.
  • Obesity. People with Down syndrome have a greater tendency to be obese compared with the general population.
  • Spinal problems. Some people with Down syndrome may have a misalignment of the top two vertebrae in the neck (atlantoaxial instability). This condition puts them at risk of serious injury to the spinal cord from overextension of the neck.
  • Leukemia. Young children with Down syndrome have an increased risk of leukemia.
  • Dementia. People with Down syndrome have a greatly increased risk of dementia — signs and symptoms may begin around age 50. Having Down syndrome also increases the risk of developing Alzheimer’s disease.
  • Other problems. Down syndrome may also be associated with other health conditions, including endocrine problems, dental problems, seizures, ear infections, and hearing and vision problems.

For people with Down syndrome, getting routine medical care and treating issues when needed can help with maintaining a healthy lifestyle.

Life expectancy

Life spans have increased dramatically for people with Down syndrome. Today, someone with Down syndrome can expect to live more than 60 years, depending on the severity of health problems.

Prevention

There’s no way to prevent Down syndrome. If you’re at high risk of having a child with Down syndrome or you already have one child with Down syndrome, you may want to consult a genetic counselor before becoming pregnant.

A genetic counselor can help you understand your chances of having a child with Down syndrome. He or she can also explain the prenatal tests that are available and help explain the pros and cons of testing.

Bulimia nervosa prt 2

Diagnosis

If your primary care provider suspects you have bulimia, he or she will typically:

  • Talk to you about your eating habits, weight-loss methods and physical symptoms
  • Do a physical exam
  • Request blood and urine tests
  • Request a test that can identify problems with your heart (electrocardiogram)
  • Perform a psychological evaluation, including a discussion of your attitude toward your body and weight
  • Use the criteria for bulimia listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

Your primary care provider may also request additional tests to help pinpoint a diagnosis, rule out medical causes for weight changes and check for any related complications.

Treatment

When you have bulimia, you may need several types of treatment, although combining psychotherapy with antidepressants may be the most effective for overcoming the disorder.

Treatment generally involves a team approach that includes you, your family, your primary care provider, a mental health professional and a dietitian experienced in treating eating disorders. You may have a case manager to coordinate your care.

Here’s a look at bulimia treatment options and considerations.

Psychotherapy

Psychotherapy, also known as talk therapy or psychological counseling, involves discussing your bulimia and related issues with a mental health professional. Evidence indicates that these types of psychotherapy help improve symptoms of bulimia:

  • Cognitive behavioral therapy to help you normalize your eating patterns and identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones
  • Family-based treatment to help parents intervene to stop their teenager’s unhealthy eating behaviors, to help the teen regain control over his or her eating, and to help the family deal with problems that bulimia can have on the teen’s development and the family
  • Interpersonal psychotherapy, which addresses difficulties in your close relationships, helping to improve your communication and problem-solving skills

Ask your mental health professional which psychotherapy he or she will use and what evidence exists that shows it’s beneficial in treating bulimia.

Medications

Antidepressants may help reduce the symptoms of bulimia when used along with psychotherapy. The only antidepressant specifically approved by the Food and Drug Administration to treat bulimia is fluoxetine (Prozac), a type of selective serotonin reuptake inhibitor (SSRI), which may help even if you’re not depressed.

Nutrition education

Dietitians can design an eating plan to help you achieve healthy eating habits to avoid hunger and cravings and to provide good nutrition. Eating regularly and not restricting your food intake is important in overcoming bulimia.

Hospitalization

Bulimia can usually be treated outside of the hospital. But if symptoms are severe, with serious health complications, you may need treatment in a hospital. Some eating disorder programs may offer day treatment rather than inpatient hospitalization.

Treatment challenges in bulimia

Although most people with bulimia do recover, some find that symptoms don’t go away entirely. Periods of bingeing and purging may come and go through the years, depending on your life circumstances, such as recurrence during times of high stress.

If you find yourself back in the binge-purge cycle, follow-up sessions with your primary care provider, dietitian and/or mental health professional may Dechelp you weather the crisis before your eating disorder spirals out of control again. Learning positive ways to cope, creating healthy relationships and managing stress can help prevent a relapse.

If you’ve had an eating disorder in the past and you notice your symptoms returning, seek help from your medical team immediately.

Lifestyle and home remedies

In addition to professional treatment, follow these self-care tips:

  • Stick to your treatment plan. Don’t skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
  • Learn about bulimia. Education about your condition can empower you and motivate you to stick to your treatment plan.
  • Get the right nutrition. If you aren’t eating well or you’re frequently purging, it’s likely your body isn’t getting all of the nutrients it needs. Talk to your primary care provider or dietitian about appropriate vitamin and mineral supplements. However, getting most of your vitamins and minerals from food is typically recommended.
  • Stay in touch. Don’t isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart and that nurturing, caring relationships are healthy for you.
  • Be kind to yourself. Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.
  • Be cautious with exercise. Talk to your primary care provider about what kind of physical activity, if any, is appropriate for you, especially if you exercise excessively to burn off post-binge calories.

Alternative medicine

Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with eating disorders. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications.

Weight-loss and other dietary supplements don’t need approval by the Food and Drug Administration (FDA) to go on the market. And natural doesn’t always mean safe. If you choose to use dietary supplements or herbs, discuss the potential risks with your primary care provider.

Coping and support

You may find it difficult to cope with bulimia when you’re hit with mixed messages by the media, culture, coaches, family, and maybe your own friends or peers. So how do you cope with a disease that can be deadly when you’re also getting messages that being thin is a sign of success?

  • Remind yourself what a healthy weight is for your body.
  • Resist the urge to diet or skip meals, which can trigger binge eating.
  • Don’t visit websites that advocate or glorify eating disorders.
  • Identify troublesome situations that trigger thoughts or behaviors that may contribute to your bulimia, and develop a plan to deal with them.
  • Have a plan in place to cope with the emotional distress of setbacks.
  • Look for positive role models who can help boost your self-esteem.
  • Find pleasurable activities and hobbies that can help distract you from thoughts about bingeing and purging.
  • Build up your self-esteem by forgiving yourself, focusing on the positive, and giving yourself credit and encouragement.

Get support

If you have bulimia, you and your family may find support groups helpful for encouragement, hope and advice on coping. Group members can truly understand what you’re going through because they’ve been there. Ask your doctor if he or she knows of a group in your area.

Coping advice for parents

If you’re the parent of someone with bulimia, you may blame yourself for your child’s eating disorder. But eating disorders have many causes, and parenting style is not considered a cause. It’s best to focus on how you can help your child now.

Here are some suggestions:

  • Ask your child what you can do to help. For example, ask if your teenager would like you to plan family activities after meals to reduce the temptation to purge.
  • Listen. Allow your child to express feelings.
  • Schedule regular family mealtimes. Eating at routine times is important to help reduce binge eating.
  • Let your teenager know any concerns you have. But do this without placing blame.

Remember that eating disorders affect the whole family, and you need to take care of yourself, too. If you feel that you aren’t coping well with your teen’s bulimia, you might benefit from professional counseling. Or ask your child’s primary care provider about support groups for parents of children with eating disorders.

Preparing for your appointment

Here’s some information to help you get ready for your appointment, and what to expect from your health care team. Ask a family member or friend to go with you, if possible, to help you remember key points and give a fuller picture of the situation.

What you can do

Before your appointment, make a list of:

  • Your symptoms, even those that may seem unrelated to the reason for your appointment
  • Key personal information, including any major stresses or recent life changes
  • All medications, vitamins, herbal products, over-the-counter medications or other supplements you’re taking, and their dosages
  • Questions to ask your doctor, so you can make the most of your time together

Some questions to ask your primary care provider or mental health professional include:

  • What kinds of tests do I need? Do these tests require any special preparation?
  • What treatments are available, and which do you recommend?
  • Is there a generic alternative to the medicine you’re prescribing for me?
  • How will treatment affect my weight?
  • Are there any brochures or other printed material I can have? What websites do you recommend?

Don’t hesitate to ask other questions during your appointment.

What to expect from your doctor

Your primary care provider or mental health professional will likely ask you a number of questions. He or she may ask:

  • How long have you been worried about your weight?
  • Do you think about food often?
  • Do you ever eat in secret?
  • Have you ever vomited because you were uncomfortably full?
  • Have you ever taken medications for weight loss?
  • Do you exercise? If so, how often?
  • Have you found any other ways to lose weight?
  • Are you having any physical symptoms?
  • Have any of your family members ever had symptoms of an eating disorder, or have any been diagnosed with an eating disorder?

Your primary care provider or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your appointment time.

Brain Cancer and Brain Tumours

Understanding the brain

The main parts of the brain include:

The cerebrum. This is divided into the right side (right hemisphere) which controls the left side of the body, and the left hemisphere which controls the right side of the body. Each hemisphere is divided into various subsections, the main divisions being the frontal lobe, temporal lobe, parietal lobe and occipital lobe. The cerebrum is also where you think and store your memory.

The cerebellum. This lies behind and below the cerebrum. One of its main functions is to help control balance and co-ordination.

The brain stem. This helps to control basic bodily functions such as the heartbeat, breathing and blood pressure. Nerves from the cerebrum also pass through the brainstem to the spinal cord.

The meninges. These are thin layers of tissue which separate the skull from the brain. The outer layer next to the skull is called the dura. The next layer is called the arachnoid. Under the arachnoid tissue is the cerebrospinal fluid (CSF) which bathes the brain and spinal cord.

The pituitary gland. This releases various hormones into the bloodstream.

The main type of cell in the brain is called a neuron. There are millions of neurons in the brain. Neurons have long thin nerve fibres which enable them to send messages to other parts of the brain and down the spinal cord to all parts of the body. The brain also contains glial cells. These provide support, nourishment and protection for neurons. There are various types of glial cells, including astrocytes, oligodendrocytes and ependymal cells.

The original site where a tumour first develops is called a primary tumour. Cancerous (malignant) tumours may also spread to other parts of the body to form secondary tumours (metastases). These secondary tumours may then grow, invade and damage nearby tissues and spread again.

Primary malignant brain tumours

A primary malignant brain tumour is a cancer which arises from a cell within the brain. The cells of the tumour grow into and damage normal brain tissue. Also, like non-cancerous (benign) brain tumours, they can increase the pressure inside the skull. However, unlike most other types of malignant tumours, primary brain tumours rarely spread (metastasise) to other parts of the body.

There are various types of primary malignant brain tumour. The different types develop from different types of cell in the brain. As a general guide, each type is graded on a scale of 1-4. Grade 1 and grade 2 tumours are said to be low-grade; grade 3 and grade 4 are termed high-grade. The higher the grade, the more aggressive the tumour tends to be and the faster it tends to grow. The treatment options and outlook (prognosis) can vary depending on the type and grade of the tumour.

Secondary malignant brain tumours

A secondary malignant brain tumour means that a cancer which started in another part of the body has spread to the brain. Many types of cancer can spread to the brain. The most common types that do this are cancers of the breastlungbowelkidney and skin (melanoma).

See the separate leaflet called Cancer for more general information about cancer

There are many types of non-cancerous (benign) brain tumours and primary cancerous (malignant) brain tumours. Many are very rare. The following is a brief description of the most common types.

Meningioma

Meningiomas are usually benign. They grow from cells in the tissues that surround the brain (the meninges).

Medulloblastoma

These are high-grade malignant tumours that grow in the cerebellum. They are uncommon in adults but are one of the two most common brain tumours in children. The other is astrocytoma in the cerebellum.

Gliomas

These are malignant primary brain tumours that arise from glial cells. There are various types, depending on the cell of origin – for example:

  • Astrocytomas (originating from astrocyte cells.) There are various types of astrocytoma. They include:
    • Low-grade astrocytomas.
    • Anaplastic astrocytoma. This is a high-grade tumour.
    • Glioblastoma multiforme. This is a high-grade tumour which tends to grow quite quickly. It is the most common type of primary malignant brain tumour in adults.
  • Oligodendrogliomas (originating from oligodendrocytes). These can vary in their grade.
  • Ependymoma (originating from ependymal cells). These are rare but are usually low-grade.

Primitive neuroectodermal tumours (PNETs)

These are very similar to medulloblastomas and mainly occur in children.

Pituitary tumours

There are various types of tumour which arise from the different cells in the pituitary gland. They tend to be benign. However, the cells of the tumour may produce large quantities of hormones which can cause various symptoms. As they grow, they may also cause pressure symptoms. The nerves of sight (optic nerves) are near to the pituitary gland and so a growing pituitary gland tumour may press on an optic nerve and affect vision.

Acoustic neuroma

An acoustic neuroma (schwannoma) is a benign tumour which arises from Schwann cells which cover the nerve that goes to the ear. Symptoms can include deafness on the affected side and dizziness with a spinning sensation (vertigo).

Other

There are various other rare types of benign and primary malignant brain tumours.

The cause of most non-cancerous (benign) brain tumours and primary cancerous (malignant) brain tumours is not known.

Genetic factors may be a risk for some people – perhaps in about 1 in 20 cases. For example, people with the hereditary diseases called neurofibromatosis type 1, Turcot’s syndrome, Li-Fraumeni cancer syndrome, and tuberous sclerosis have a higher-than-average risk of developing a glioma. When people with these diseases develop a glioma, it tends to occur in childhood or early adult life. However, these cases are only a small proportion of all glioma tumours.

Note:

  • Most gliomas occur in older adults and inherited (genetic) factors are not thought to be involved.
  • Previous radiotherapy to the brain is thought to increase the risk of a brain tumour.
  • There is no strong evidence that using mobile phones increases the risk of brain tumours.
  • Secondary (metastatic) brain tumours arise from various cancers of the body. These have various causes. See the separate leaflets about these other cancers.

Non-cancerous (benign) brain tumours and cancerous (malignant) primary brain tumours are uncommon. Overall they occur in about 12 in 100,000 people each year.

The most common types in adults are benign meningioma and a glioma called glioblastoma multiforme. Some types are very rare.

Brain tumours can occur at any age. Some types (such as medulloblastoma) are more common in children and some are more common in adults. Generally, the tumours that tend to occur in adults become more common with increasing age.

Secondary (metastatic) brain tumours are more common than benign brain tumours and malignant primary brain tumours.

General symptoms

Early symptoms may include headaches and feeling sick. These are due to increased pressure within the skull (raised intracranial pressure). These symptoms may come and go at first and tend to be worse in the morning. Coughing, sneezing and stooping may make the headaches worse. Epileptic seizures (convulsions) sometimes occur. Increasing drowsiness may occur as the tumour enlarges.

Note: most people who have headaches or epilepsy do not have a brain tumour.

Symptoms due to the location in the brain

As a tumour grows it can damage the nearby brain tissue. The functions of the different parts of the body are controlled by different parts of the brain. Therefore, the symptoms vary from case to case, depending on which part of the brain is affected and on the size of the affected area. For example, one or more of the following may develop:

These symptoms tend to develop gradually.

A doctor will examine you if a brain tumour is suspected from the symptoms. This will include checking on the functions of the brain and nerves (movements, reflexes, vision, etc).

A magnetic resonance imaging (MRI) scan or computerised tomography (CT) scan of the head is the common test done to confirm or rule out the presence of a brain tumour. See the separate leaflets called MRI Scan and CT Scan for more details. If a tumour is identified, further more detailed scans and tests may be done. For example, a PET scan or a cerebral angiogram are sometimes done to obtain more information about the tumour.

small tissue sample (a biopsy) may be needed to be sure of the type of tumour. The sample is then examined under the microscope to look for abnormal cells. To obtain a biopsy from a brain tumour you need to have a small operation, usually done under anaesthetic. A small hole is bored in the skull to allow a fine needle through to obtain a small sample of tissue. By examining the cells obtained by the biopsy, the exact type of tumour can be identified. If it is cancerous (malignant), the tumour grade can be determined (see above).

Blood tests and other tests on other parts of the body may be done if the tumour is thought to be a secondary (metastatic) tumour. For example, it is quite common for a lung cancer to spread to the brain. Therefore, a chest X-ray may be done if this is suspected. Various hormone tests may be done if a pituitary gland tumour is suspected. 

The main treatments used for brain tumours are surgery, chemotherapy, radiotherapy and medication to control symptoms such as seizures. The treatment or combination of treatments advised in each case depends on various factors – for example:

  • The type of brain tumour.
  • The grade of the tumour if it is cancerous (malignant).
  • The exact site of the tumour.
  • Your general health.

Surgery

Surgery is often the main treatment for non-cancerous (benign) brain tumours and primary cancerous (malignant) tumours. The aim of surgery is to remove the tumour (or even some of the tumour) whilst doing as little damage as possible to the normal brain tissue. Your specialist will advise on whether surgery is a possible option.

Radiotherapy

Radiotherapy is a treatment which uses high-energy beams of radiation which are focused on cancerous tissue. This kills cancer cells or stops cancer cells from multiplying. See the separate leaflet called Radiotherapy for more details.

Radiotherapy is sometimes used instead of surgery when an operation is not possible for a malignant brain tumour. Sometimes it is used in addition to surgery if it is not possible to remove all the tumour with surgery or to kill cancerous cells which may be left behind following surgery.

Chemotherapy

Chemotherapy is a treatment which uses anti-cancer medicines to kill cancer cells, or to stop them from multiplying. See the separate leaflet called Chemotherapy for more details. It may be used in addition to other treatments such as surgery or radiotherapy; again, depending on various factors such as the type of tumour.

Medication to control symptoms

If you have seizures caused by the tumour then anticonvulsant medication will usually control the seizures. Painkillers may be needed to ease any headaches. Steroid medication is also commonly used to reduce inflammation around a brain tumour. This reduces the pressure inside the skull, which helps to ease headaches and other pressure symptoms.

You should have a full discussion with a specialist who knows your case. They will be able to give the pros and cons, likely success rate, possible side-effects and other details about the possible treatment options for your type of brain tumour.

You should also discuss with your specialist the aims of treatment. For example:

  • In some cases, treatment aims for a cure. If a benign tumour can be removed by surgery then a cure is likely. The chance of a cure for malignant tumours varies, depending on the type of tumour, grade and other factors such as the location in the brain. Note: when dealing with malignant tumours, doctors tend to use the word remission rather than the word cured. Remission means there is no evidence of cancer following treatment. If you are in remission, you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.
  • In some cases, treatment aims to control the cancer. If a cure is not realistic, with treatment it may be possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
  • In some cases, treatment aims to ease symptoms (palliative treatment). For example, if a cancer is advanced then you may require painkillers or other treatments to help keep you free of pain or other symptoms. Some treatments may be used to reduce the size of a cancer, which may ease symptoms such as pain.

It is difficult to give an overall outlook (prognosis). Every case is different. For example, if you have a non-cancerous (benign) meningioma which is in a suitable place for surgery, the outlook is excellent.

For primary cancerous (malignant) brain tumours, the outlook will vary, depending on the type, grade and location in the brain.

The outlook is often poor if you have a secondary (metastatic) malignant brain tumour.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. The specialist who knows your case can give more accurate information about your particular outlook and how well your type and stage of cancer is likely to respond to treatment. 

Mask anxiety, face coverings and mental health

Photo by Anna Shvets on Pexels.com

Explains why masks can cause difficult feelings, and gives practical tips on how to cope. Includes information on exemptions for mental health reasons.

What is the law about masks?

The UK and Welsh Governments are making it compulsory for people to wear masks or face coverings in certain places, like on public transport. But the exact places and dates are slightly different in England and Wales. 

Why masks can cause difficult feelings

We all want to help stop the spread of coronavirus. And we know it isn’t easy. It means making big changes in our lives, like following social distancing guidelines, and now wearing masks.

But masks are not straightforward for everyone. Some of us may find covering our face very hard, or even impossible to cope with. And for those of us with existing mental health problems, masks may pose extra challenges.

For example:

  • Covering your mouth and nose might affect the air you breathe, which might make you feel anxious or panicky. This can then cause other symptoms as well, like feeling dizzy or sick, which you might associate with the mask.
  • You might feel trapped or claustrophobic.
  • Covering your face changes the way you look, which may cause negative feelings around your identity or body image.
  • Having certain materials touching your skin might feel very hard to cope with (sensory overload).
  • If you wear glasses, they might get steamed up so you can’t see clearly. This might add to feelings of being claustrophobic
  • Masks are a visual reminder of the virus, so seeing masks might make you feel on edge or unable to relax. It might seem like danger is everywhere.
  • Seeing people covering their faces might make you feel uneasy or scared of others. They might seem threatening, sinister, or dehumanised.
  • On the other hand, you might feel very anxious or upset around people who are not wearing masks in public. (Although many people are exempt from wearing them, and you won’t always know their reasons.)
  • If you are exempt from wearing a mask, you still might feel very anxious about being judged, shamed or stigmatised in public. Or about the possibility of being asked to pay a fine. This may feel especially hard to cope with if the reason you can’t wear a mask is also to do with your mental health.

Do I have to wear a mask?

If you feel able to wear a mask or face covering, then you must.

But there are some exceptions. The Government says you do not have to wear a mask if you have a ‘reasonable excuse’ not to. 

The exact guidance on how this applies to mental health conditions is written differently for England and Wales. And it’s being updated quite often. But in practice the meaning is similar.

In both nations, reasonable excuses to do with mental health include:

  • If you’re not able to put on, wear or remove a face covering, because of a physical or mental illness or impairment, or disability.
  • If it’s essential to eat, drink or take medication.

In England, the guidance also specifies that a reasonable excuse would be:

  • If putting on, wearing or removing a face covering will cause you severe distress.

(There are other exemptions besides these. You can find the full list of exceptions in England on the UK Government website, and the full list of exceptions in Wales on the Welsh Government website.)

What counts as ‘mental impairment’ or ‘severe distress’?

There is no clear-cut definition of ‘mental impairment’ or ‘severe distress’ in the mask regulations. These terms may cover a lot of different experiences.

For example, you might feel severely distressed or impaired if wearing a mask triggers acute symptoms of a mental health condition, like:

But even if you don’t have an existing mental health diagnosis, you might still feel overwhelmingly anxious, distressed or unwell when wearing a mask.

It can be difficult to judge if you feel unwell ‘enough’ to be excused from wearing a mask. But remember: you are the expert on your own experience.

  • If you’re not sure, look for a way to make covering your face feel more bearable. Try some of our tips for coping with masks and face coverings, and see if they help. You might be able to lessen your symptoms, so you feel less unwell.
  • If you’ve tried everything and nothing helps, you might decide you do have a reasonable excuse for not wearing a mask. That’s ok.
  • It might change. For example, you might have better or worse days, times or places. So you might feel exempt sometimes, but not all the time. That’s ok too. Use your face covering as much as you are able.

How do I prove I have a reasonable excuse?

You don’t need to. There’s no legal document or proof that you need to carry on you.

If you’re challenged about not wearing a mask:

  • You could tell the person: “I’m exempt for health reasons”, or “I have a good reason that you can’t see. Please be kind”.
  • Or you could write down your reason to show people, on a piece of paper or on your phone.
  • Various organisations have created optional exemption cards and badges that you can display. You do not need to buy or apply for one, and you do not need to carry or show one. But you may find having something like this to hand makes you feel more comfortable. It’s your choice. (You can find exemption cards to print or download on the UK Government website).

The Welsh Government is advising you to carry evidence of your condition if possible in Wales, but you do not have to.

Unfortunately, you might find that not everyone understands, or is supportive. This can be really hard to cope with. But you’re not alone. It might help to think about extra self-care ideas, to help look after yourself.

Tips for coping with masks and face coverings

You might not ever feel totally comfortable with masks. But there are lots of things you could try to help make the experience easier for you.

Anxiety, panic and breathing issues

If wearing a mask makes you feel panicky or like it’s harder to breathe:

  • Get some fresh air outside before and after you wear your mask.
  • Do something to relax you before and after you wear a mask. For example, you might do a short breathing exercise. (We have some tips on relaxation exercises).
  • Choose a face covering that hangs down your neck, rather than fitting around your jaw. This type of covering is called a ‘neck gaiter’. It might feel more breezy.
  • Keep your body as cool as possible. For example, by wearing loose-fitting clothes or sitting by an open window on the bus.
  • Add a comforting scent to your face covering. This might be a few drops of lavender oil, your own perfume or aftershave, or a smell that reminds you of someone else.
  • Reduce the time you spend having to wear your mask. For example, by planning your shopping in advance to help you keep browsing time down in shops.

Physical discomfort

If wearing a particular material creates sensory overload:

  • Experiment with different fabric types. You could try making a face covering from an old t-shirt that doesn’t bother you to touch. You can search for mask-making tutorials online. The Government also has some information on how to make your own mask.
  • Experiment with different ways to secure your mask. Some fit round the ears, some tie behind your head. You could try attaching buttons to a hat or hairband, so the mask does’t irritate your skin.
  • Choose another type of face covering that doesn’t touch your face in the same way, like a neck gaiter.

If wearing a mask steams up your glasses and makes it hard to see:

  • Wash your glasses with soapy water, and polish them with a tissue. A thin layer of soapy film may make it harder for the lenses to steam up.
  • Sit your glasses on top of the fabric by raising the top of your mask up onto your nose.
  • Line your mask with a tissue so it absorbs some of the moisture.

Body and identity issues

If covering a part of your face makes you feel uncomfortable in your identity or body image:

  • Think of your mask as a fashion accessory. Search for a mask or face covering with a design or pattern that expresses who you are. You could use a scarf or bandana. Or try to find a selection of colours that you can match in with your outfits.
  • Choose a transparent mask or see-through face covering, so it doesn’t obscure your face.

Anxiety around other people wearing masks

If seeing other people in masks make you feel uneasy or afraid:

  • Shift your focus away from someone’s face when communicating with them. Try switching the way your body is facing so that you’re side-by-side with the person you’re talking to, and both looking in the same direction.
  • Try to pay extra attention to your non-human surroundings. This might be trees, traffic, shop window displays, or the sounds and smells you notice. It may not be possible to avoid looking at people entirely. But by balancing it with other things that feel more usual, you might feel more calm.
  • Take a distraction out with you. For example, listen to music or podcasts through headphones, or call to someone you enjoy chatting to.
  • If someone you have to see often (like a friend or housemate) wears a mask that you find very scary, you could try gently letting them know how you feel. They might be able to change it or cover it up in your presence, to help you.

Being supportive to others

There are many ways we can be supportive to people who might be struggling with masks.

  • Don’t judge people who are not wearing masks. Don’t assume that someone not wearing a mask is ‘just being selfish’. Many people are exempt from wearing masks, and it might not be immediately obvious why.
  • Acknowledge people. You could say a friendly ‘hello’ or ‘good morning’ as you pass them, or wave your hand.
  • Communicate in other ways. Try using your voice, eyes, hands and body language to compensate for what you aren’t able to show through smiles or other facial expressions.
  • If you see someone regularly who is uncomfortable with masks on other people, ask them what would help. For example, you might be able to get a transparent mask to wear with them.
  • If you work in a place where masks are compulsory, make sure you fully understand the exemption rules. If someone tells you they are exempt, accept their word for it.

Pick Me Up Thursday — Survivors Blog Here Mental Health Collaborative

Originally posted on Fightmsdaily: Offering Kindness Is Easy And It Is Necessary! Happy Friday Eve y’all! How has your week been so far? I hope your week is going well and you are feeling the best you possibly can! What a crazy week, as y’all know yesterday was my birthday and today is my 9…

Pick Me Up Thursday — Survivors Blog Here Mental Health Collaborative

Is Your Job giving you High Blood Pressure? See the way out! — Ponder Younder

The World’s Life expectancy in 80 years and you work from at least 18 years and retire at 67 years. This makes you spend most of your active life working. “I don’t like the nature of my job” “I don’t like my Boss’ attitude” “This job is fucking giving me stress” Well… your story is […]

Is Your Job giving you High Blood Pressure? See the way out! — Ponder Younder

Inspirational Wednesday! — Survivors Blog Here Mental Health Collaborative

Originally posted on Fightmsdaily: Inspire Those That Need It The Most, Always! Happy Wednesday y’all! We are officially halfway through the week and I hope the week is treating you well! Today is actually my birthday and unfortunately, both myself and my husband have to work. For years we always went to the beach for…

Inspirational Wednesday! — Survivors Blog Here Mental Health Collaborative

Spastic Cerebral Palsy

Spastic cerebral palsy is the most common form of the disorder, affecting around 70% to 80% of all people diagnosed. This form of cerebral palsy mainly affects the muscle groups, but may cause associated disorders as well. [1]

Spastic cerebral palsy occurs as a result of brain damage, usually before or during birth, or sometimes within the first years of a child’s life. It’s a disorder that affects coordination and control of motor function. This causes the child to be delayed in reaching normal developmental milestones, and that is when it becomes more evident. [2]

Muscles need enough tone in them to maintain correct posture, to enable standing and walking, and to maintain speed and flexibility. Motor nerve fibers, via the spinal cord, interact with the muscles to help control how they move.

For someone with spastic cerebral palsy, brain damage affects muscle control, coordination, and movement, mainly in the arms and legs. In turn, this influences the way the spinal cord and nerves react, which then causes the muscles to become tense, and spastic. [3]

Children born with spastic cerebral palsy do not usually have limb deformities at birth, but over time these may develop, due to muscle tenseness and stretching limitations.

Spastic cerebral palsy may be classified as quadriplegic, diplegic, or hemiplegic, according to how and where it affects the body.

Spastic Cerebral Palsy Symptoms

Spastic cerebral palsy, also known as hypertonic cerebral palsy, is characterized by hypertonia, meaning increased muscle tone, and leads to stiff, and sometimes painful limbs. [4]

Symptoms may include:

  • Involuntary limb movements
  • Continuous muscle spasms and contractions
  • Abnormal walking, marked by knees crossing in a scissor-like movement
  • Joint contractures
  • Limited stretching abilities
  • Flexion at the elbows, wrists, and fingers
  • Poor coordination and control of muscle movements

These symptoms can make it difficult for those with spastic cerebral palsy to walk, get dressed, brush their teeth, use the bathroom, and take a shower without assistance. The limitations on activities of daily living (ADLs) will depend on how severe the disorder is. Children with mild cases of spastic CP may not need any help but may still have mild difficulties with ADLs.

If both legs are affected, children may also have problems transferring from one position to the next, standing and sitting upright, walking, and running.

Children with spastic cerebral palsy may also develop other nervous system-related symptoms, which may include:

  • Speech difficulties
  • Hearing problems
  • Vision abnormalities
  • Cognitive, learning and behavioral disabilities [5]
  • Seizures

Related problems may include:

  • Drooling
  • Difficulties with chewing and swallowing
  • Hoarse voice or speech problems
  • Breathing irregularities
  • Failure to thrive or poor weight gain
  • Gastric reflux
  • Constipation and bladder incontinence
  • Spinal and joint deformities

Treatment Options for Spastic Cerebral Palsy

Although there’s no cure for any form of cerebral palsy, there are a number of treatment options available to help control the symptoms, including:

  • Physical therapy, as well as language, occupational, and behavioral therapies
  • Medications to control symptoms, such as muscle spasms or seizures
  • Baclofen pump (to help control muscle spasticity)
  • Spine or spinal cord surgery (to repair scoliosis or reduce spasticity)
  • Muscle-release and tendon-lengthening surgery
  • Devices to aid in communication
  • Orthotics, braces or other devices to help with positioning, standing or muscle control
  • Constraint-induced therapy (CIT)

Keep in mind that treatment options will depend on the age of the child, how severe the symptoms are, and any associated disorders. Most parents will work with a team of medical experts to implement the best treatments for the child, including therapists, surgeons, dietitians, and neurologists. [6]

Spastic Cerebral Palsy Prognosis

Again, there is no cure for spastic cerebral palsy, but with the proper treatment, children can grow up and thrive as adults. It’s essential, however, to start a treatment plan as early as possible for the child to have the best outcomes, not only as an adult but as he or she grows along the path through childhood and into adolescence.