QUESTION: I have a problem with sudden attacks of dizziness and then passing out. They started in my 20s but then disappeared for many years.
I am 32 years old, take no chronic meds and live a busy but healthy life.
I am not sleeping at night and am so stressed this will happen at work as I started a new job this year. I am looking after my grandmother and my mom who has been widowed for eight years, so my income means the world to me.
My mom says she had similar attacks but outgrew them.
ANSWER: I understand your anxiety around this issue, but the only way out is to deal with the problem and get some answers.
There are a few details one has to supply when dealing with fainting spells or drop attacks of an unknown origin, or when anyone complains of a brief loss of consciousness. Associations and a detailed analysis of symptoms will guide a clinician.
Obviously the medical conditions that lead to fainting are plentiful and the cause is not always apparent. However, the good news is that most common causes are treatable. Things like sugar levels, blood pressure issues and heart rhythm disturbances are at the top of the list.
Fainting (syncope) is caused by a temporary reduction in blood flow to the brain. There are different types of fainting, because blood flow to the brain can be interrupted for different reasons.
The nervous system is very important when assessing these attacks.
Neurally mediated syncope is usually caused by a temporary malfunction in the autonomic nervous system. This system is made up of the brain, nerves and spinal cord, and regulates a number of automatic bodily functions, including heart beat and maintenance of blood pressure.
External triggers
Vasovagal syncope occurs when an external experience triggers a malfunction in the autonomic nervous system – the effect is a drop in your blood pressure and a reduction in your heartbeat. Blood supply to the brain is then altered.
Causes:
* Sudden exposure to an unpleasant sight or experience.
* Standing for long periods of time.
* Spending a long time in hot or stuffy environments.
* A sudden intense episode of stress, emotional upset, fear or anxiety.
* A sudden feeling of pain.
Crucial questions:
* Are there warning signs?
* How often does it happen?
* How long is the loss of consciousness?
* Are the spells followed by drowsiness or disorientation?
* Is there incontinence of urine or faeces?
* Is there an associated place or activity linked to attacks?
* Is there an association with postural change?
* Is the time of day or association with meal times relevant?
* Are there any triggers, like emotions or medication?
* Are these episodes ever witnessed?
* Are there accompanying features of abnormal movements?
* Are there concurrent medical problems at the time of event?
The above list assists the clinician with differentiating a syncope (drop attack) from a seizure and often the early signs of epilepsy. There are, however, some simple conditions like vasovagal attacks that can cause these “blackout” symptoms.
Warning signs or smells often form part of the aura or prodrome of a seizure, particularly in complex partial epilepsy.
When do I need to see a doctor ?
If the frequency of these events is progressive and you find yourself at risk of having possible prolonged losses of consciousness, as well as being a risk to yourself and others.
Tests
A few basic tests like blood sugar and blood pressure as well as an ECG of the heart are essential.
The ECG helps exclude rhythm abnormalities – an irregular heart beat can precipitate syncope. One must also note that the arrhythmia can be missed by doing a single ECG while the patient is no longer symptomatic. The ECG is only a snapshot of the heart and in complex cases, a 24-hour holter study is advised (this is where a device is attached to the patient, monitoring rhythm and heart rate during activity and even while they sleep).
An EEG (electroencephalogram) of the brain is done when a seizure is considered. This represents an abnormal electrical impulse mapping process via scull electrodes attached to the scalp. Often the wave frequencies help in identifying specific epilepsy syndromes associated with certain locations in the brain.
What if they don’t find the cause?
Because so many medical conditions can give you “blackouts”, diagnosis is by exclusion. The more difficult cases are often seen by physicians, cardiologists and neurologists.
Issues ranging from thyroid abnormalities and hormonal imbalances all play a role. The most important thing is that you understand why your doctor does any test. It’s your right to ask if it has any benefit.
More often than not, the answers are found with careful scrutiny of the patient’s account of events. The treating doctor’s experience, patience and commitment to finding a cause are essential.
When a patient is exhausted and feels hopeless about poor progress, they must tell their doctor and ask for a second opinion or referral to a colleague. You will be surprised how often this approach actually helps everyone.
Some common triggers or behaviours associated with situational fainting:
* Coughing
* Sneezing
* Swallowing
* Laughing
* Passing stools
* Urinating
* Some physical activities, such as weightlifting
* Situational syncope may also occur after eating a meal or exercising.
* Dr Darren Green, a trusted figure in the field of media medicine, is a University of Stellenbosch graduate who adds innovative spark to health and wellness issues.
He features on 567CapeTalk, and is a regular guest on SABC3 and the Expresso show. Dr Green works as an emergency medical practitioner at a leading Cape Town hospital and completed four years of training as a registrar in the specialisation of neurology.
If you’ve got medical problems, contact the doctor at [email protected], 021 930 0655 or Twitter @drdarrengreen. Catch him in Cape Town on 567 CapeTalk, most Fridays at 1.30pm.
The advice in this column does not replace a consultation and clinical evaluation with a doctor.
Cape Argus