Blood Glucose/Blood Sugar Tests

Glucose, a simple sugar is the major source of energy for all cells. The three most frequently
prescribed blood sugar tests to determine the glucose level in the blood are

 FBS - Fasting blood sugar

 PPBS- Post prandial blood sugar

 GTT- Glucose tolerance test

F B S -The blood test has to be performed after twelve hours of fasting. That means the person
must refrain from eating approximately 12 hours prior to this blood test.
PPBS - Prior to this test, the person fasts overnight and then consumes a carbohydrate
meal. Approximately between 11/2 to 2 hours after eating, a blood sample from vein is
drawn for testing.
G T T - The test is performed after consuming a concentrated amount of glucose dissolved in
water.
The above mentioned tests are to monitor, confirm or rule out the Diabetes.

The state of increased blood sugar level (above 140mg/dl) is known as Hyperglycemia and
the decreased blood sugar level is Hypoglycemia (Below 70mg/dl).

The normal range of blood sugar is

 RBS - 70-130mg/dl

 FBS - 70-115mg/dl

 PPBS-70-140mg/dl

R B S - Random blood Sugar test, is also common to monitor blood glucose levels. In this
case, the blood sample can be taken at any time irrespective of the consumption of food.

Best and Worst Foods for Diabetes

When you've got diabetes, your food choices matter a lot. Some are better than others.
To help you choose, here are lists of best and worst foods for:

 Breads, grains, and other starches

 Vegetables
 Fruits
 Meat, meat substitutes, and other protein
 Dairy
 Fats, oils, and sweets

Foods that are in the "worst" group can be occasional treats. But in general, it will be easier to
manage your diabetes if you choose most of your foods from the “best” lists.
Slideshow: Best and Worst Meals for Diabetes-Savvy Dining
 Diabetes a d Breads, Grains, and Other Starches
Your body needs carbs. But you want to choose wisely. Use this list as a guide.
Best Choices

 Whole-grain flours, such as whole wheat flour

 Whole grains, such as brown rice
 Cereals containing whole-grain ingredients and little added sugar
 Whole-grain bread
 Baked potato or baked steak fries
 Whole-grain flour or corn tortillas

Worst Choices

 White flour
 Processed grains, such as white rice
 Cereals with little whole grain and lots of sugar
 White bread
 French fries
 Fried white-flour tortillas

Diabetes mellitus

Diabetes mellitus (DM) or simply diabetes, is a group of metabolic diseases in which a person
has high blood sugar.[2] This high blood sugar produces the symptoms of frequent
urination, increased thirst, and increased hunger. Untreated, diabetes can cause many
complications. Acute complications include diabetic ketoacidosis and nonketotic hyperosmolar
coma. Serious long-term complications include heart disease, kidney failure, and damage to the
eyes.

Diabetes is due to either the pancreas not producing enough insulin, or because cells of the
body do not respond properly to the insulin that is produced.[3] There are three main types of
diabetes mellitus:[4]

 Type 1 DM results from the body's failure to produce insulin. This form was previously
referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes".[4]
 Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin
properly, sometimes also with an absolute insulin deficiency. This form was previously
referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adult-onset diabetes".
 Gestational diabetes, is the third main form and occurs when pregnant women without a
previous diagnosis of diabetes develop a high blood glucose level.
Prevention and treatment often involve a healthy diet, physical exercise, not using tobacco, and
being a normal body weight.[4] Blood pressure control and proper foot care are also important for
people with the disease.[4] Type 1 diabetes must be managed with insulin injections.[4] Type 2
diabetes may be treated with medications with or without insulin.[4]Insulin and some oral
medications can cause low blood sugar, which can be dangerous. A pancreas transplant is
occasionally considered for people with type 1 diabetes who have severe complications of their
disease, including end stage renal disease requiring kidney transplantation.[5] They have had
limited success Gastric bypass surgery has been successful in many with severe obesity and
type 2 DM. Gestational diabetes usually resolves after the birth of the baby.

Signs and symptoms

Overview of the most significant symptoms of diabetes

The classic symptoms of untreated diabetes are weight loss, polyuria (frequent
urination), polydipsia (increased thirst), and polyphagia (increased hunger).[9] Symptoms may
develop rapidly (weeks or months) in type 1 diabetes, while they usually develop much more
slowly and may be subtle or absent in type 2 diabetes.
Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads
to changes in its shape, resulting in vision changes. Blurred vision is a common complaint
leading to a diabetes diagnosis. A number of skin rashes that can occur in diabetes are
collectively known as diabetic dermadromes.
 Diabetic emergencies

People (usually with type 1 diabetes) may also experience episodes of diabetic ketoacidosis, a
type of metabolic problems characterized by nausea, vomiting and abdominal pain, the smell
of acetone on the breath, deep breathing known as Kussmaul breathing, and in severe cases a
decreased level of consciousness.[10]
A rare but equally severe possibility is hyperosmolar nonketotic state, which is more common in
type 2 diabetes and is mainly the result of dehydration.

 Causes

 Comparison of type 1 and 2 diabetes[6]

 Type 2 diabetes
 Feature  Type 1 diabetes

 Gradual
 Onset  Sudden

 Mostly in adults
 Age at onset  Mostly in children

 Often obese
 Body size  Thin or normal[16]

 Rare
 Ketoacidosis  Common

 Absent
 Autoantibodies  Usually present

 Normal, decreased
 Endogenous insulin  Low or absent or increased

 Concordance  90%
 50%
in identical twins
 ~90%
 Prevalence  ~10%

 Diabetes mellitus is classified into four broad categories: type 1, type 2, gestational diabetes,
and "other specific types".[3] The "other specific types" are a collection of a few dozen individual
causes.[3] The term "diabetes", without qualification, usually refers to diabetes mellitus.
 Type 1
 Main article: Diabetes mellitus type 1
 Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets
of Langerhans in the pancreas, leading to insulin deficiency. This type can be further classified
as immune-mediated or idiopathic. The majority of type 1 diabetes is of the immune-mediated
nature, in which a T-cell-mediated autoimmune attack leads to the loss of beta cells and thus
insulin.[17] It causes approximately 10% of diabetes mellitus cases in North America and Europe.
 Most affected people are otherwise healthy and of a healthy weight when onset occurs.
Sensitivity and responsiveness to insulin are usually normal, especially in the early stages.
Type 1 diabetes can affect children or adults, but was traditionally termed "juvenile diabetes"
because a majority of these diabetes cases were in children.
 "Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term that was
traditionally used to describe the dramatic and recurrent swings in glucoselevels, often occurring
for no apparent reason in insulin-dependent diabetes. This term, however, has no biologic basis
and should not be used.[18] Still, type 1 diabetes can be accompanied by irregular and
unpredictable hyperglycemia, frequently with ketosis, and sometimes with
serious hypoglycemia. Other complications include an impaired counterregulatory response to
hypoglycemia, infection, gastroparesis (which leads to erratic absorption of dietary
carbohydrates), and endocrinopathies (e.g., Addison's disease).[18] These phenomena are
believed to occur no more frequently than in 1% to 2% of persons with type 1 diabetes.[19]
 Type 1 diabetes is partly inherited, with multiple genes, including certain HLA genotypes, known
to influence the risk of diabetes. In genetically susceptible people, the onset of diabetes can be
triggered by one or more environmental factors, such as a viral infection or diet. There is some
evidence that suggests an association between type 1 diabetes and Coxsackie B4 virus. Unlike
type 2 diabetes, the onset of type 1 diabetes is unrelated to lifestyle.
 Type 2
 Main article: Diabetes mellitus type 2
 Type 2 diabetes mellitus is characterized by insulin resistance, which may be combined with
relatively reduced insulin secretion.[3] The defective responsiveness of body tissues to insulin is
believed to involve the insulin receptor. However, the specific defects are not known. Diabetes
mellitus cases due to a known defect are classified separately. Type 2 diabetes is the most
common type.
 In the early stage of type 2, the predominant abnormality is reduced insulin sensitivity. At this
stage, hyperglycemia can be reversed by a variety of measures andmedications that improve
insulin sensitivity or reduce glucose production by the liver.
 Type 2 diabetes is due primarily to lifestyle factors and genetics.[20] A number of lifestyle factors
are known to be important to the development of type 2 diabetes, including obesity (defined by
a body mass index of greater than thirty), lack of physical activity, poor diet, stress,
and urbanization.[6] Excess body fat is associated with 30% of cases in those of Chinese and
Japanese descent, 60-80% of cases in those of European and African descent, and 100% of
Pima Indians and Pacific Islanders.[3] Those who are not obese often have a high waist–hip
ratio.[3]
 Dietary factors also influence the risk of developing type 2 diabetes. Consumption of sugar-
sweetened drinks in excess is associated with an increased risk.[21][22]The type of fats in the diet
is also important, with saturated fats and trans fatty acids increasing the risk
and polyunsaturated and monounsaturated fat decreasing the risk.[20] Eating lots of white
rice appears to also play a role in increasing risk.[23] A lack of exercise is believed to cause 7%
of cases.[24]
 Gestational diabetes
 Main article: Gestational diabetes
 Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a
combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2–
5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is fully
treatable, but requires careful medical supervision throughout the pregnancy. About 20–50% of
affected women develop type 2 diabetes later in life.
 Though it may be transient, untreated gestational diabetes can damage the health of the fetus
or mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac and
central nervous system anomalies, and skeletal muscle malformations. Increased fetal insulin
 may inhibit fetal surfactant production and causerespiratory distress
syndrome. Hyperbilirubinemia may result from red blood cell destruction. In severe cases,
perinatal death may occur, most commonly as a result of poor placental perfusion due to
vascular impairment. Labor induction may be indicated with decreased placental function.
A Caesarean section may be performed if there is marked fetal distress or an increased risk of
injury associated with macrosomia, such as shoulder dystocia.
 Other types
 Prediabetes indicates a condition that occurs when a person's blood glucose levels are higher
than normal but not high enough for a diagnosis of type 2 DM. Many people destined to develop
type 2 DM spend many years in a state of prediabetes.
 Latent autoimmune diabetes of adults (LADA) is a condition in which type 1 DM develops in
adults. Adults with LADA are frequently initially misdiagnosed as having type 2 DM, based on
age rather than etiology.
 Some cases of diabetes are caused by the body's tissue receptors not responding to insulin
(even when insulin levels are normal, which is what separates it from type 2 diabetes); this form
is very uncommon. Genetic mutations (autosomal or mitochondrial) can lead to defects in beta
cell function. Abnormal insulin action may also have been genetically determined in some
cases. Any disease that causes extensive damage to the pancreas may lead to diabetes (for
example, chronic pancreatitis and cystic fibrosis). Diseases associated with excessive secretion
of insulin-antagonistic hormones can cause diabetes (which is typically resolved once the
hormone excess is removed). Many drugs impair insulin secretion and some toxins damage
pancreatic beta cells. The ICD-10 (1992) diagnostic entity,malnutrition-related diabetes
mellitus (MRDM or MMDM, ICD-10 code E12), was deprecated by the World Health
Organization when the current taxonomy was introduced in 1999.[25]
 Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of
insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses
of glucocorticoids, and several forms of monogenic diabetes.
 The following is a comprehensive list of other causes of diabetes:[26]

 Genetic defects of β-cell function  Endocrinopathies

 Maturity onset diabetes of the young  Growth hormone excess (acrom
 Mitochondrial DNA mutations  Cushing syndrome
 Genetic defects in insulin processing or insulin action  Hyperthyroidism
 Defects in proinsulin conversion  Pheochromocytoma
 Insulin gene mutations  Glucagonoma
 Insulin receptor mutations  Infections
 Exocrine pancreatic defects  Cytomegalovirus infection
 Chronic pancreatitis  Coxsackievirus B
 Pancreatectomy  Drugs
 Pancreatic neoplasia  Glucocorticoids
 Cystic fibrosis  Thyroid hormone
 Hemochromatosis  β-adrenergic agonists
 Fibrocalculous pancreatopathy  Statins[27]

 Pathophysiology
 The fluctuation of blood sugar (red) and the sugar-lowering hormoneinsulin (blue) in humans
during the course of a day with three meals - one of the effects of a sugar-rich vs astarch-rich
meal is highlighted.
 Mechanism of insulin release in normal pancreatic beta cells - insulin production is more or less
constant within the beta cells. Its release is triggered by food, chiefly food containing absorbable
glucose.
 Insulin is the principal hormone that regulates uptake of glucose from the blood into most cells
(primarily muscle and fat cells, but not central nervous system cells). Therefore, deficiency of
insulin or the insensitivity of its receptors plays a central role in all forms of diabetes mellitus.
 Humans are capable of digesting some carbohydrates, in particular those most common in food;
starch, and some disaccharides such as sucrose, are converted within a few hours to simpler
forms, most notably the monosaccharide glucose, the principal carbohydrate energy source
used by the body. The rest are passed on for processing by gut flora largely in the colon. Insulin
is released into the blood by beta cells (β-cells), found in the islets of Langerhans in the
pancreas, in response to rising levels of blood glucose, typically after eating. Insulin is used by
about two-thirds of the body's cells to absorb glucose from the blood for use as fuel, for
conversion to other needed molecules, or for storage.
 Insulin is also the principal control signal for conversion of glucose to glycogen for internal
storage in liver and muscle cells. Lowered glucose levels result both in the reduced release of
insulin from the β-cells and in the reverse conversion of glycogen to glucose when glucose
levels fall. This is mainly controlled by the hormone glucagon, which acts in the opposite
manner to insulin. Glucose thus forcibly produced from internal liver cell stores (as glycogen) re-
enters the bloodstream; muscle cells lack the necessary export mechanism. Normally, liver cells
do this when the level of insulin is low (which normally correlates with low levels of blood
glucose).
 Higher insulin levels increase some anabolic ("building up") processes, such as cell growth and
duplication, protein synthesis, and fat storage. Insulin (or its lack) is the principal signal in
converting many of the bidirectional processes of metabolism from a catabolic to an anabolic
direction, and vice versa. In particular, a low insulin level is the trigger for entering or leaving
ketosis (the fat-burning metabolic phase).
 If the amount of insulin available is insufficient, if cells respond poorly to the effects of insulin
(insulin insensitivity or resistance), or if the insulin itself is defective, then glucose will not have
its usual effect, so it will not be absorbed properly by those body cells that require it, nor will it
be stored appropriately in the liver and muscles. The net effect is persistent high levels of blood
glucose, poor protein synthesis, and other metabolic derangements, such as acidosis.
 When the glucose concentration in the blood is raised to about 9-10 mmol/L (except certain
conditions, such as pregnancy), beyond its renal threshold (i.e. when glucose level surpasses
the transport maximum of glucose reabsorption), reabsorptionof glucose in the proximal renal
tubuli is incomplete, and part of the glucose remains in the urine (glycosuria). This increases
the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in
increased urine production (polyuria) and increased fluid loss. Lost blood volume will be
replaced osmotically from water held in body cells and other body compartments,
causing dehydrationand increased thirst.
 Diagnosis
 See also: Glycated hemoglobin and Glucose tolerance test

 WHO diabetes diagnostic criteria[28][29] edit

 HbA1c
 Condition  2 hour glucose  Fasting glucose

 %
  mmol/l(mg/dl)  mmol/l(mg/dl)
  <6.0
 Normal  <7.8 (<140)  <6.1 (<110)

 6.0–6.4
 Impaired fasting glycaemia  <7.8 (<140)  ≥ 6.1(≥110) & <7.0(<126)

 6.0–6.4
 Impaired glucose tolerance  ≥7.8 (≥140)  <7.0 (<126)

 ≥6.5
 Diabetes mellitus  ≥11.1 (≥200)  ≥7.0 (≥126)

 Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by

demonstrating any one of the following:[25]
 Fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dl)
 Plasma glucose ≥ 11.1 mmol/l (200 mg/dL) two hours after a 75 g oral glucose load as in
a glucose tolerance test
 Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl)
 Glycated hemoglobin (Hb A1C) ≥ 6.5%.[30]
 A positive result, in the absence of unequivocal hyperglycemia, should be confirmed by a repeat
of any of the above methods on a different day. It is preferable to measure a fasting glucose
level because of the ease of measurement and the considerable time commitment of formal
glucose tolerance testing, which takes two hours to complete and offers no prognostic
advantage over the fasting test.[31]According to the current definition, two fasting glucose
measurements above 126 mg/dl (7.0 mmol/l) is considered diagnostic for diabetes mellitus.
 Per the World Health Organization people with fasting glucose levels from 6.1 to 6.9 mmol/l
(110 to 125 mg/dl) are considered to have impaired fasting glucose.[32]people with plasma
glucose at or above 7.8 mmol/L (140 mg/dL), but not over 11.1 mmol/L (200 mg/dL), two hours
after a 75 g oral glucose load are considered to have impaired glucose tolerance. Of these two
prediabetic states, the latter in particular is a major risk factor for progression to full-blown
diabetes mellitus, as well as cardiovascular disease.[33] The American Diabetes
Association since 2003 uses a slightly different range for impaired fasting glucose of 5.6 to
6.9 mmol/l (100 to 125 mg/dl).[34]
 Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular
disease and death from any cause.[35]
 The rare disease diabetes insipidus has similar symptoms to diabetes mellitus, but without
disturbances in the sugar metabolism (insipidus means "without taste" in Latin) and does not
involve the same disease mechanisms.
 Prevention
 There is no known preventive measure for type 1 diabetes.[4] Type 2 diabetes can often be
prevented by a person being a normal body weight and physical exercise.[4]
 Management
 Main article: Diabetes management
 Diabetes mellitus is a chronic disease, for which there is no known cure except in very specific
situations. Management concentrates on keeping blood sugar levels as close to normal
("euglycemia") as possible, without causing hypoglycemia. This can usually be accomplished
with diet, exercise, and use of appropriate medications (insulin in the case of type 1 diabetes;
oral medications, as well as possibly insulin, in type 2 diabetes).
 Learning about the disease and actively participating in the treatment is vital for people with
diabetes, since the complications of diabetes are far less common and less severe in people
who have well-managed blood sugar levels.[36][37] The goal of treatment is an HbA1C level of
 6.5%, but should not be lower than that, and may be set higher.[38] Attention is also paid to other
health problems that may accelerate the deleterious effects of diabetes. These
include smoking, elevated cholesterollevels, obesity, high blood pressure, and lack of
regular exercise.[38] Specialised footwear is widely used to reduce the risk of ulceration, or re-
ulceration, in at-risk diabetic feet. Evidence for the efficacy of this remains equivocal,
however.[39]
 Lifestyle
 See also: Diabetic diet
 People with diabetes can benefit from education about the disease and treatment,
good nutrition to achieve a normal body weight, and sensible exercise, with the goal of keeping
both short-term and long-term blood glucose levels within acceptable bounds. In addition, given
the associated higher risks of cardiovascular disease, lifestyle modifications are recommended
to control blood pressure.[40]
 Medications
 See also: Anti-diabetic medication
 Metformin is generally recommended as a first line treatment for type 2 diabetes, as there is
good evidence that it decreases mortality.[41] Routine use of aspirin, however, has not been
found to improve outcomes in uncomplicated diabetes.[42] Angiotensin converting enzyme
inhibitors (ACEIs) improve outcomes in those with DM while the similar medications angiotensin
receptor blockers (ARBs) do not.[43]
 Type 1 diabetes is typically treated with a combinations of regular and NPH insulin, or
synthetic insulin analogs. When insulin is used in type 2 diabetes, a long-acting formulation is
usually added initially, while continuing oral medications.[41] Doses of insulin are then increased
to effect

Vegetables and Diabetes

Many vegetables contain fiber and are naturally low in fat and sodium (unless they are canned).
Starchy vegetables, such as potatoes and corn, aren't included in this category. They are
considered part of the breads, grains, and other starches group.
Best Choices:

 Fresh vegetables, eaten raw or lightly steamed, roasted, or grilled

 Frozen vegetables, lightly steamed
 Fresh cucumbers
 Fresh shredded cabbage or coleslaw

Worst Choices:

 Canned vegetables with lots of added sodium

 Vegetables cooked with lots of added butter, cheese, or sauce
 Pickles (if you need to limit sodium; otherwise, pickles are a good choice)
 Sauerkraut, (same as pickles; limit only if you have high blood pressure)

Fruits and DiabetesFruits have carbohydrates, vitamins, minerals, and fiber. They are naturally
low in fat (except for avocados) and sodium. Fruits often have more carbs than are found in
vegetables.
 Best Choices:

 Frozen fruit or fruit canned in fruit juice

 Fresh fruit
 Sugar-free or low-sugar jam or preserves
 No-sugar-added applesauce
 100% fruit juice or low-carb juices

Worst Choices:

 Canned fruit with heavy sugar syrup

 Chewy fruit rolls
 Regular jam, jelly, and preserves (unless portion is kept small)
 Sweetened applesauce
 Fruit punch, fruit drinks, fruit juice drinks

Diabetes and Meat and Other Protein

This category includes beef, chicken, fish, pork, turkey, seafood, beans, cheese, eggs, nuts,
and tofu.
Best Choices:

 Baked, broiled, grilled, or stewed meats

 Lower-fat cuts of meat, such as top sirloin
 Turkey bacon
 Low-fat cheeses
 Skinless breast of chicken or turkey
 Baked, broiled, steamed, or grilled fish
 Tofu lightly sautéed, steamed, or cooked in soup
 Baked or stewed beans

Worst Choices:

 Fried meats
 Higher-fat cuts of meat, such as ribs
 Pork bacon
 Regular cheeses
 Poultry with skin
 Fried fish
 Fried tofu
 Beans prepared with lard

Complete Blood Count (CBC)

The complete blood count (CBC) is a laboratory test that identifies the number of red and white
blood cells per cubic millimeter of blood. It is also called as complete haemogram test. It is
one of the most routinely performed blood tests and provides valuable information about the
patient's state of health. The CBC measures and evaluates the cellular component of blood.

Normal range of the test values are given below:

Haemoglobin:
Men 14-18 g/dl
Women 12-16 g/dl (in pregnancy : >11 g/dl)
Children 11-16 g/dl
Newborns 14-24 g/dl

Total WBC Count ------- 4000-11000/ cu.mm

Differential Count:
Neutrophils 50-70%
Eosinophils 0-6%
Lymphocytes 20-40%
Monocytes 2-6%
Basophils 0-1%

ESR: 0-20 mm/hr

Platelet Count: 1.5-4.0 lakhs/cu.mm

RBC (Erythrocyte) Count: Men 4.5-6.5 million/cu.mm

Women 3.8-5.8 million/cu.mm

Mean Corpuscular Volume (MCV) 80-92 fl

Mean Corpuscular Hemoglobin (MCH) 27-32 pg

Mean Corpuscular Hemoglobin Concentration (MCHC) 32-36%

Haematocrit (PCV-Packed Cell Volume): 36-47%

Panic disorder with agoraphobia

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version
Panic disorder with agoraphobia is an anxiety disorder in which a person has attacks of intense
fear and anxiety. There is also a fear of being in places where it is hard to escape, or where
help might not be available.
Agoraphobia usually involves fear of crowds, bridges, or of being outside alone.

This article discusses panic disorder with agoraphobia. For information on panic disorder itself,
see also: Panic disorder

Causes
The exact causes of panic disorder and agoraphobia are unknown. Because panic attacks often
occur in areas or situations where they have happened in the past, panic may be a learned
behavior. Agoraphobia sometimes occurs when a person has had a panic attack and begins to
fear situations that might lead to another panic attack.

Anyone can develop a panic disorder, but it usually starts around age 25. Panic disorder is more
common in women than men.

Symptoms
Panic attacks involve short periods of intense anxiety symptoms, which peak within 10 minutes.
Panic attack symptoms can include:

 Chest pain or discomfort

 Choking
 Dizziness or faintness
 Fear of being out of control
 Fear of dying
 Fear of "going crazy"
 Hot flashes or chills
 Nausea or other stomach distress
 Numbness or tingling
 Racing heart
 Shortness of breath
 Sweating
 Trembling

With agoraphobia, you avoid places or situations because you do not feel safe in public places.
The fear is worse when the place is crowded.

Symptoms of agoraphobia include:

 Being afraid of spending time alone

 Being afraid of places where escape might be hard
 Being afraid of losing control in a public place
 Depending on others
 Feeling detached or separated from others
 Feeling helpless
 Feeling that the body is not real
  Feeling that the environment is not real
 Having an unusual temper or agitation
 Staying in the house for long periods of time

Exams and Tests

People who first experience panic sometimes fear they have a serious illness, or are even
dying. Often, people will go to an emergency room or other urgent care center because they
think they are having a heart attack.

A physical examination and psychological evaluation can help diagnose panic disorder. It is
important to rule out any medical disorders, such as problems involving the heart, hormones,
breathing, nervous system, and substance abuse. Which tests are done to rule out these
conditions depends on the symptoms.

Treatment
The goal of treatment is to help you feel and function better. The success of treatment usually
depends in part on how severe the agoraphobia is.

The standard treatment approach combines cognitive-behavioral therapy (CBT) with an

antidepressant medication.

 Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice of
antidepressant.
 Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another choice. Other
antidepressants and some anti-seizure drugs may be used for more severe cases.
 Other anti-anxiety medications may also be prescribed. For example, your health care
provider may recommend benzodiazepines when antidepressants don't help or before
they take effect.

CBT involves 10 to 20 visits with a mental health professional over a number of weeks. CBT
helps you change the thoughts that cause your condition. It may involve:

 Gaining understanding and control of distorted feelings or views of stressful events or

situations
 Learning to recognize and replace panic-causing thoughts
 Learning stress management and relaxation techniques
 Relaxing, then imagining the things that cause the anxiety, working from the least fearful
to the most fearful (called systematic desensitization and exposure therapy)

You may also be slowly exposed to the real-life situation that causes the fear to help you
overcome it.

A healthy lifestyle that includes exercise, enough rest, and good nutrition can also help be
helpful.
Outlook (Prognosis)
Most patients can get better with medications or behavioral therapy. However, without early and
effective help, the disorder may become more difficult to treat.

Possible Complications

 Some people may abuse alcohol or other drugs while trying to self-medicate.
 Some people may be unable to function at work or in social situations.
 Some people may feel isolated, lonely, depressed, or suicidal.

When to Contact a Medical Professional

Call for an appointment with your health care provider if you have symptoms of panic attacks or
agoraphobia.

Prevention
Early treatment of panic disorder can often prevent agoraphobia.

Alternative Names
Agoraphobia; Anxiety disorder- agoraphobia

What Is a Panic Disorder With Agoraphobia?

Panic Disorders

People who have a panic disorder (also known as anxiety attacks) suffer from sudden attacks of
intense and overwhelming fear that something awful is about to happen. Their bodies react as if
they’re in a life-threatening situation. These attacks come without warning and often strike when
the person is in a non-threatening situation.

According to the Anxiety and Depression Association of America (ADAA), about 6 million adults
have a panic disorder (ADAA, 2012). Anyone can develop the disorder. However, it is more
common in women than in men.

Symptoms typically first appear at about age 25.

Agoraphobia

Agoraphobia usually involves a fear of being caught in a place where “escape” would not be
easy. This includes malls, airplanes or trains, theaters, and similar areas.

You may begin to avoid the places and situations where you had a panic attack before, for fear
it might happen again. This fear can keep you from traveling freely or even leaving your home.

Agoraphobia affects about one in three people with panic disorder.

What Causes a Panic Attack with Agoraphobia?

Genetics
The specific cause of panic attacks is unknown. However, some evidence suggests that there
may be a genetic aspect involved. Some individuals diagnosed with the disorder do not have
other family members with the disorder, but many do. For example, if one identical twin has the
disorder, the other twin will also have it in 40 percent of cases.

Rivotril (clonazepam)

How does it work?

Rivotril tablets contain the active ingredient clonazepam, which a type of medicine called a
benzodiazepine. (Clonazepam is also available without a brand name, ie as
the generic medicine.) Clonazepam acts on nerve cells in the brain.

The brain and nerves are made up of many nerve cells that communicate with each other
through electrical signals. These signals must be carefully regulated for the brain and nerves to
function properly.

When abnormally rapid and repetitive electrical signals are released in the brain, it becomes
over-stimulated and normal function is disturbed. This results in fits or seizures.

Clonazepam works by acting on receptors in the brain called GABA receptors. This causes the
release of a neurotransmitter called GABA in the brain. GABA is involved in transmitting
messages between the nerve cells and acts as a natural 'nerve-calming' agent. It helps keep the
nerve activity in the brain in balance.

By increasing the release of GABA, clonazepam helps to calm the excessive electrical nerve
activity that is responsible for causing seizures

Clonazepam is used to help to reduce the frequency and severity of fits in people with epilepsy.

What is it used for?

 Rivotril tablets are used to treat various different forms of epilepsy, including absence
seizures (petit mal epilepsy), generalised tonic-clonic seizures (grand mal epilepsy),
partial seizures and myoclonic seizures.

How do I take it?

 Rivotril tablets can be taken either with or without food. The tablets should be swallowed
whole with a glass of water.

 Your doctor will start you off on the lowest dose of clonazepam tablets and then
gradually increase your dose over a period of two to four weeks until a suitable dose for
you is reached.

 To start off with you should take the prescribed daily dose in three divided doses. This
means taking the tablets three times a day with approximately the same time intervals
between each dose. If it is not possible to divide the daily dose into three equal doses
then you should take the largest dose at bedtime.
  Once your maintenance dose has been reached it will be possible for you to take
your total daily dose as a single dose at bedtime. Follow the instructions given by your
doctor or pharmacist.

 It is important to take your medication regularly, as directed by your doctor, because

missing doses can trigger seizures in some people. If you have trouble remembering to
take your medicine you should ask your pharmacist for advice. You may find a pill
reminder box helpful.

Warning!

 This medicine causes drowsiness and muscle weakness and impairs concentration and
alertness. These effects may continue into the following day and are made worse
by drinking alcohol. If you are affected you should avoid potentially hazardous tasks
such as driving or operating machinery. Avoid drinking alcohol while taking this
medicine.

 You should not suddenly stop taking this medicine unless your doctor tells you
otherwise, as this may result in your seizures returning or getting worse. Stopping a
benzodiazepine suddenly can also cause withdrawal symptoms such as insomnia or
anxiety, confusion, sweating, tremor, headache or irritability. If your doctor decides that
you should stop taking this medicine, this should be done gradually. Follow the
instructions given by your doctor.

 It is important to tell your doctor if you have recently suffered a loss or bereavement, for
example the death of a close friend or relative, before taking this medicine.
Benzodiazepines such as this one can affect the way you adjust psychologically to
events like this.

 Some antiepileptic medicines have been associated with a small increased risk of
suicidal thoughts and behaviour. It is not known if clonazepam also has this effect, but
for this reason, it is very important to seek medical advice if you, or someone else taking
this medicine, experience any changes in mood, distressing thoughts, or feelings about
suicide or self-harm at any point while taking this medicine. For more information speak
to your doctor or pharmacist.

Use with caution in

 Elderly people.

 Weak or debilitated people.

 Decreased liver function.

 Decreased kidney function.

 People with lung disease such as COPD.

 People with a long-term decrease in lung function (chronic pulmonary insufficiency).

 People with a history of alcoholism or drug abuse.

 People with a history of depression or suicidal behaviour.

  People with shaky or unsteady voluntary movements eg walking, resulting from
disorders in the brain or spinal cord (spinal or cerebellar ataxia).

 People with rare hereditary blood disorders called porphyrias.

Not to be used in

 Patients in a coma.

 People who are known to be abusing pharmaceuticals, drugs or alcohol.

 People with a condition involving abnormal muscle weakness (myasthenia gravis).

 People with severe breathing problems or a sudden worsening of any underlying lung
disease (acute pulmonary insufficiency).

 People with a syndrome where breathing stops for short spells during sleep (sleep
apnoea syndrome).

 People with severely decreased liver function.

 People who are allergic to any medicine in the benzodiazepine family, eg diazepam,
temazepam.

 Rare hereditary problems of galactose intolerance, the Lapp lactase deficiency, or

glucose-galactose malabsorption (Rivotril tablets contain lactose).

This medicine should not be used if you are allergic to any of its ingredients. Please inform your
doctor or pharmacist if you have previously experienced such an allergy.

If you feel you have experienced an allergic reaction, stop using this medicine and inform your
doctor or pharmacist immediately.

Pregnancy and breastfeeding

Certain medicines should not be used during pregnancy or breastfeeding. However, other
medicines may be safely used in pregnancy or breastfeeding providing the benefits to the
mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or
planning a pregnancy, before using any medicine.

 It is vital that women with epilepsy receive specialist advice before getting pregnant, so
they are well informed of potential risks and benefits of continuing antiepileptic
treatment. Pregnant women taking antiepileptic medicine have a higher risk of carrying a
baby with developmental problems and malformations. However, if a woman with
epilepsy stops treatment because she is pregnant, there is a risk of seizures that can
harm both mother and baby. This risk may be higher than that from continuing the
medication. It is important that all the risks and benefits of treatment are weighed up.
Seek medical advice from your doctor.

 This medicine should be avoided during pregnancy unless considered essential by your
doctor. This is particularly important during the third trimester of pregnancy and before or
during labour. If this medicine is used in late pregnancy or during labour it may cause
floppiness, low body temperature and breathing or feeding difficulties in the baby after
 birth. It may also result in withdrawal symptoms in the baby after the birth. Ask your
doctor for further information.

 If you get pregnant while taking this medicine it is vital to get advice from your doctor as
soon as possible. You should not suddenly stop taking this medicine because this may
cause your seizures to come back, as well as withdrawal symptoms (see warning
section above).

 This medicine passes into breast milk and could have harmful effects on a nursing
infant. If you need to take this medicine to control your epilepsy your doctor may suggest
that you bottlefeed rather than breastfeed. It is important to get medical advice from your
doctor.

Label warnings

 Do not stop taking this medication except on your doctor's advice.

 This medication may cause drowsiness. If affected do not drive or operate machinery.
Avoid alcoholic drink.

Side effects

Medicines and their possible side effects can affect individual people in different ways. The
following are some of the side effects that are known to be associated with this medicine. Just
because a side effect is stated here, it does not mean that all people using this medicine will
experience that or any side effect.

 Fatigue.

 Drowsiness and sleepiness.

 Confusion.

 Concentration difficulties.

 Decreased co-ordination.

 Delayed reactions.

 Muscle weakness.

 Restlessness.

 Dizziness.

 Shaky movements and unsteady walk (ataxia).

 Loss of memory following an epileptic seizure (anterograde amnesia).

 Changes in behaviour such as aggression, anxiety, agitation, nervousness.

 Nightmares or vivid dreams.

 Difficulty with speech.

  Involuntary eye movements (nystagmus).

 Double vision.

 Skin reactions such as rash, itching, changes in pigmentation.

 Hair loss (reversible if treatment is stopped).

 Sexual problems such as loss of sex drive or erectile dysfunction.

 Urinary incontinence.

 Heart failure.

 Slow, shallow breathing (respiratory depression).

 Increased saliva or phlegm production (in infants and young children only).

 Physical and psychological dependence on the medicine can occur with

benzodiazepines like this one, particularly if high doses are used for long periods of time.
Withdrawal symptoms are possible if the medicine is stopped abruptly - see the warning
section above.

The side effects listed above may not include all of the side effects reported by the medicine's
manufacturer.

For more information about any other possible risks associated with this medicine, please read
the information provided with the medicine or consult your doctor or pharmacist.

How can this medicine affect other medicines?

It is important to tell your doctor or pharmacist what medicines you are already taking, including
those bought without a prescription and herbal medicines, before you start treatment with this
medicine. Similarly, check with your doctor or pharmacist before taking any new medicines
while having treatment with this one, to make sure that the combination is safe.

There may be an increased risk of drowsiness and sedation if clonazepam is taken with any of
the following (which can also cause drowsiness). These should be avoided while you are taking
clonazepam:

 alcohol

 antipsychotics, eg chlorpromazine, clozapine

 barbiturates, eg phenobarbital

 other benzodiazepines, eg temazepam

 MAOI antidepressants, eg phenelzine

 sedating antihistamines, eg chlorphenamine

 sleeping tablets, eg zopiclone

 strong opioid painkillers, eg morphine, codeine, dihydrocodeine

  tricyclic antidepressants, eg amitriptyline.

The following medicines may prevent the breakdown of clonazepam in the body. As this could
increase the blood level of clonazepam and its sedative effects, as well as the risk of its side
effects, your doctor may need to prescribe you a lower than normal dose of clonazepam if you
are taking any of these medicines:

 cimetidine

 disulfiram

 fluvoxamine

 isoniazid

 protease inhibitors for HIV infection, such as ritonavir or fosamprenavir.

The following medicines may decrease the blood level of clonazepam. As this could make it less
effective, your doctor may need to prescribe you a larger than normal dose of clonazepam if you
are taking any of these medicines:

 carbamazepine

 phenobarbital

 phenytoin

 primidone

 rifampicin

 sodium valproate.

There may be an increased risk of side effects if this medicine is taken in combination
with lithium.

Other medicines containing the same active ingredient

Clonazepam tablets and oral solution are also available without a brand name, ie as
the generic medicine.