Home » Misc » Narcolepsy early symptoms

Narcolepsy early symptoms


Narcolepsy - Symptoms and causes

Overview

Narcolepsy is a chronic sleep disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep. People with narcolepsy often find it difficult to stay awake for long periods of time, regardless of the circumstances. Narcolepsy can cause serious disruptions in your daily routine.

Sometimes, narcolepsy can be accompanied by a sudden loss of muscle tone (cataplexy), which can be triggered by strong emotion. Narcolepsy that occurs with cataplexy is called type 1 narcolepsy. Narcolepsy that occurs without cataplexy is known as type 2 narcolepsy.

Narcolepsy is a chronic condition for which there's no cure. However, medications and lifestyle changes can help you manage the symptoms. Support from others — family, friends, employers, teachers — can help you cope with narcolepsy.

Products & Services

  • Book: Mayo Clinic Family Health Book, 5th Edition
  • Newsletter: Mayo Clinic Health Letter — Digital Edition

Symptoms

The signs and symptoms of narcolepsy may worsen for the first few years and then continue for life. They include:

  • Excessive daytime sleepiness. People with narcolepsy fall asleep without warning, anywhere, anytime. For example, you may be working or talking with friends and suddenly you nod off, sleeping for a few minutes up to a half-hour. When you awaken, you feel refreshed, but eventually you get sleepy again.

    You may also experience decreased alertness and focus throughout the day. Excessive daytime sleepiness usually is the first symptom to appear and is often the most troublesome, making it difficult for you to concentrate and fully function.

  • Sudden loss of muscle tone. This condition, called cataplexy (KAT-uh-plek-see), can cause a number of physical changes, from slurred speech to complete weakness of most muscles, and may last up to a few minutes.

    Cataplexy is uncontrollable and is triggered by intense emotions, usually positive ones such as laughter or excitement, but sometimes fear, surprise or anger. For example, when you laugh, your head may droop uncontrollably or your knees may suddenly buckle.

    Some people with narcolepsy experience only one or two episodes of cataplexy a year, while others have numerous episodes daily. Not everyone with narcolepsy experiences cataplexy.

  • Sleep paralysis. People with narcolepsy often experience a temporary inability to move or speak while falling asleep or upon waking. These episodes are usually brief — lasting a few seconds or minutes — but can be frightening. You may be aware of the condition and have no difficulty recalling it afterward, even if you had no control over what was happening to you.

    This sleep paralysis mimics the type of temporary paralysis that normally occurs during a period of sleep called rapid eye movement (REM) sleep. This temporary immobility during REM sleep may prevent your body from acting out dream activity.

    Not everyone with sleep paralysis has narcolepsy, however. Many people without narcolepsy experience some episodes of sleep paralysis.

  • Changes in rapid eye movement (REM) sleep. REM sleep is typically when most dreaming happens. REM sleep can occur at any time of the day in people with narcolepsy. People with narcolepsy often transition quickly to REM sleep, usually within 15 minutes of falling asleep.
  • Hallucinations. These hallucinations are called hypnagogic hallucinations if they happen as you fall asleep and hypnopompic hallucinations if they occur upon waking. An example is feeling as if there is a stranger in your bedroom. These hallucinations may be particularly vivid and frightening because you may not be fully asleep when you begin dreaming and you experience your dreams as reality.

Other characteristics

People with narcolepsy may have other sleep disorders, such as obstructive sleep apnea — a condition in which breathing starts and stops throughout the night — restless legs syndrome and even insomnia.

Some people with narcolepsy experience automatic behavior during brief episodes of narcolepsy. For example, you may fall asleep while performing a task you normally perform, such as writing, typing or driving, and you continue to perform that task while asleep. When you awaken, you can't remember what you did, and you probably didn't do it well.

When to see a doctor

See your doctor if you experience excessive daytime sleepiness that disrupts your personal or professional life.

Request an Appointment at Mayo Clinic

From Mayo Clinic to your inbox

Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health.

To provide you with the most relevant and helpful information, and understand which information is beneficial, we may combine your email and website usage information with other information we have about you. If you are a Mayo Clinic patient, this could include protected health information. If we combine this information with your protected health information, we will treat all of that information as protected health information and will only use or disclose that information as set forth in our notice of privacy practices. You may opt-out of email communications at any time by clicking on the unsubscribe link in the e-mail.

Causes

The exact cause of narcolepsy is unknown. People with type 1 narcolepsy have low levels of the chemical hypocretin (hi-poe-KREE-tin). Hypocretin is an important neurochemical in your brain that helps regulate wakefulness and REM sleep.

Hypocretin levels are particularly low in those who experience cataplexy. Exactly what causes the loss of hypocretin-producing cells in the brain isn't known, but experts suspect it's due to an autoimmune reaction.

It's also likely that genetics play a role in the development of narcolepsy. But the risk of a parent passing this disorder to a child is very low — only about 1%.

Research also indicates a possible association with exposure to the swine flu (h2N1 flu) virus and a certain form of h2N1 vaccine that's currently administered in Europe, though it's not yet clear why.

Normal sleep pattern vs. narcolepsy

The normal process of falling asleep begins with a phase called non-rapid eye movement (NREM) sleep. During this phase, your brain waves slow considerably. After an hour or so of NREM sleep, your brain activity changes, and REM sleep begins. Most dreaming occurs during REM sleep.

In narcolepsy, however, you may suddenly enter into REM sleep without first experiencing NREM sleep, both at night and during the day. Some of the characteristics of narcolepsy — such as cataplexy, sleep paralysis and hallucinations — are similar to changes that occur in REM sleep, but occur during wakefulness or drowsiness.

Risk factors

There are only a few known risk factors for narcolepsy, including:

  • Age. Narcolepsy typically begins in people between 10 and 30 years old.
  • Family history. Your risk of narcolepsy is 20 to 40 times higher if you have a family member who has narcolepsy.

Complications

  • Public misunderstanding of the condition. Narcolepsy may cause serious problems for you professionally and personally. Others might see you as lazy or lethargic. Your performance may suffer at school or work.
  • Interference with intimate relationships. Intense feelings, such as anger or joy, can trigger signs of narcolepsy such as cataplexy, causing affected people to withdraw from emotional interactions.
  • Physical harm. Sleep attacks may result in physical harm to people with narcolepsy. You're at increased risk of a car accident if you have an attack while driving. Your risk of cuts and burns is greater if you fall asleep while preparing food.
  • Obesity. People with narcolepsy are more likely to be overweight. The weight gain may be related to a low metabolism.

By Mayo Clinic Staff

Related

Associated Procedures

Products & Services

The Symptoms and Early Signs of Narcolepsy

After a night of not enough sleep, most people will likely feel drowsy the next day. And if your surroundings are dark, quiet, and relaxing enough — or if your previous night of sleep was short enough — you may even nod off inadvertently.

But if a child or teen habitually falls asleep in school, or an adult finds themselves constantly dozing off at work, despite sleeping enough at night, a sleep disorder may be to blame. One such sleep problem is narcolepsy, a neurological disorder that triggers overwhelming and sudden episodes of sleep and sleepiness during the day, and potentially irregular sleep at night, too, according to the National Institute of Neurological Disorders and Stroke.

The chronic condition leaves the brain unable to regulate sleep and wake cycles, per MedlinePlus.

According to the Stanford Medicine Center for Narcolepsy, narcolepsy is the second most common cause of excessive daytime sleepiness diagnosed by sleep centers, right after obstructive sleep apnea.

Here are the symptoms that people with narcolepsy are most likely to experience — and how to tell the difference between the symptoms of narcolepsy and those of other sleep disorders.

Excessive Daytime Sleepiness (‘Sleep Attack’) Is a Hallmark Sign of Narcolepsy

One feature that does distinguish excessive daytime sleepiness due to narcolepsy is a “sleep attack,” when people fall asleep suddenly, unintentionally, and in a way that is out of their control, according to the National Heart, Lung, and Blood Institute.

Such episodes can occur multiple times throughout a day and last for varying amounts of time. People will usually wake up feeling refreshed but then have another sleep attack episode after a very short period of time.

In some cases, these sudden sleep episodes can happen right in the middle of engaging in an activity such as eating, talking, being in a meeting, or attending class.

People with narcolepsy experience sleep attacks because the brain is not able to properly regulate its sleep and wake cycles. People with the condition may go right into REM (rapid eye movement) sleep without first entering NREM sleep (non-rapid-eye-movement), and this can happen both during the night and in the daytime. The disruption of normal sleep-wake cycles leads to poor sleep at night, too, according to Harvard Medical School.

RELATED: What You Need to Know About the Different Stages of Sleep

While excessive daytime sleepiness (persistent sleepiness during waking hours regardless of how much sleep you get the night before) is a key early symptom of narcolepsy, many people who have extreme fatigue during the day may not initially suspect that they have the condition.

Several reasons may account for this:

  • People are used to feeling tired on a routine basis. “Daytime sleepiness could be a symptom of many things, even just not getting enough sleep,” says Shelley Hershner, MD, a clinical associate professor of neurology and the director of the Collegiate Sleep Clinic at the University of Michigan in Ann Arbor, who has worked on narcolepsy quality metrics for the American Academy of Sleep Medicine (AASM). Thus, the common symptoms many people with narcolepsy have that are related to inadequate sleep — mental fogginess, memory problems, trouble focusing or paying attention, or lack of energy — can look like the typical signs of the sleep deprivation that can come with having a packed schedule or being stressed, according to the Sleep Foundation.
  • Other symptoms usually show up later. Particularly in the early stages of the illness, more unique narcolepsy symptoms (such as cataplexy, which means experiencing sudden episodes of muscle weakness) often don’t appear until later, anywhere from weeks to years after someone gets the disorder. Or if they are present, they may be very subtle (a barely noticeable drooping of the eyelids, for example).
  • People aren’t as aware of narcolepsy. Even though narcolepsy isn’t extremely rare — it affects about 1 in 2,000 people, according to the MedlinePlus — it’s a condition that often flies under the radar and is frequently overshadowed by other more well-known sleep disorders, like insomnia and sleep apnea.
  • Extreme sleepiness during the day is often a symptom of other illnesses. Severe daytime drowsiness is a common symptom of sleep disorders such as obstructive sleep apnea and insomnia, and it could also be a sign of diabetes or an underactive thyroid, notes the Sleep Foundation.Obesity and depression can contribute to daytime drowsiness, too, according to the American Academy of Sleep Medicine.

Other Narcolepsy Symptoms Include Cataplexy, Sleep Paralysis, and Hallucinations

“Someone may present with cataplexy and then develop other symptoms,” says Eric Olson, MD, a professor of medicine and sleep medicine specialist at the Mayo Clinic and member of the board of directors of the American Academy of Sleep Medicine (AASM). While it’s common for people with narcolepsy to experience one or more of these symptoms, fewer than one-third experience all of them.

Cataplexy

Cataplexy is the sudden, temporary, and uncontrollable loss of muscle tone and control. It happens when an individual experiences a strong emotion, such as excitement, happiness, stress, surprise, anger, or fear. Cataplexy attacks may be mild, such as a slight drooping of the eyelids, or can involve losing muscle control in the hands, knees, or in some cases, the entire body.

Depending on what part of your body is affected, cataplexy may cause your head to nod, your hand to drop something, your speech to become slurred, or your facial muscles to go slack — or you may fall down or collapse as a result.

A cataplexy attack may last for a few seconds or a few minutes, and it may go away on its own (meaning the person regains control of their muscles). During episodes, people are typically awake and aware of what’s happening, even if they cannot control their affected muscles. (That’s why cataplexy is sometimes mistaken for a symptom of a seizure disorder.) Some people may experience only one or two cataplexy attacks in their entire lives, while others may have as many as several episodes a day.

Sleep Paralysis

When we enter the REM phase of sleep, we dream, and our bodies naturally paralyze the muscles so that we don’t act out our dreams and potentially injure ourselves while we sleep. But in people with narcolepsy, the paralysis happens at the wrong time, when they’re awake (which is cataplexy) or while they’re falling asleep or just waking up. This latter episode is termed “sleep paralysis.” The symptom can be brief, usually lasting only a few seconds or minutes, but it can make you feel helpless and be extremely frightening. “This sensation of being awake but not being able to move can be broken by someone touching you,” says Dr. Olson.

Hallucinations 

While this symptom isn't limited to people with narcolepsy, it is common in people with the condition, says Dr.  Hershner. These vivid dreams that feel very real are called hypnagogic if they occur while one is falling asleep, and hypnopompic if they are experienced while waking up.

When hallucinations occur with sleep paralysis (meaning you are awake but cannot move), they can be terrifying. People have reported seeing a demon sitting on their chest, a person in the room, or shadows looming nearby and not being able to move or cry out, says Hershner. In addition to these visual perceptions, people with narcolepsy may also feel like they can hear, smell, or even taste things that are not there.

Narcolepsy Symptoms Can Appear at Any Age

Many people with narcolepsy report having symptoms starting between ages 10 and 20, but it can develop as late as age 40 to 50.

The condition is most commonly diagnosed in late adolescence or early adulthood, when it becomes apparent that the fatigue and sleep problems are not healthy, says Emmanuel Mignot, MD, a professor of sleep medicine in the department of psychiatry and behavioral sciences at Stanford University and director of the Stanford Center for Narcolepsy in Palo Alto, California.

“They may collapse completely, sleep all the time, or gain 30 pounds in three months,” says Dr. Mignot. In older children, it can be really detrimental to self-esteem and school work.

It’s important to catch the condition in children and adults as early as possible. Kids who have narcolepsy tend to have trouble doing well in school because they often experience problems with attention and memory, and they may find themselves falling asleep at school or during extracurricular activities.

Adults who experience frequent sleep episodes during the day and do not realize that they have narcolepsy may believe that they are lazy or have poor self-esteem, and they may encounter social problems as well as problems at work or school. Some people may believe that their symptoms stem from a psychological disorder and may be afraid to discuss what they’re experiencing with a doctor, says Olson. “People think, 'Am I getting schizophrenia or am I delusional?'” says Olson. And some people may self-medicate with alcohol or medication to treat their symptoms, which can worsen the situation.

If you suspect that you or someone you love may have any of these symptoms, it’s a good idea to talk to your doctor about being evaluated for narcolepsy as soon as possible. Early diagnosis is a crucial first step to understanding and managing the disorder.

How to understand that you have narcolepsy and what to do about it

Share

0

What is narcolepsy

Narcolepsy is a neurological disorder Narcolepsy, National Sleep Foundation of sleep in which the brain cannot control sleep and wakefulness.

Very rare Narcolepsy, National Sleep Foundation - 1 in 2,000 to 3,000 people, equally common in men and women. Narcolepsy develops during adolescence, but can go unnoticed for a long time. Sometimes it progresses quickly, in a few weeks, and sometimes it takes years after the first signs before the symptoms become stable.

What are the symptoms of narcolepsy

The disease manifests differently in different people. Some signs are more pronounced and occur more often, others are weaker and very rare.

The main symptoms of Narcolepsy are:

  • Excessive daytime sleepiness. Usually the disease begins with this symptom. A person constantly wants to sleep, he cannot concentrate.
  • Sleep attacks. The patient falls asleep anywhere and anytime. He may work or talk, and then suddenly fall asleep for several minutes or even half an hour. Sometimes a person continues to do something, such as writing or eating. When he wakes up, he will feel alert and fresh, but then he will doze off again.
  • Poor night sleep. The patient often wakes up, he is tormented by realistic nightmares.
  • Loss of muscle tone (cataplexy). A person's muscles suddenly relax, causing the lower jaw to droop, knees to buckle, and the person to speak indistinctly. In severe cases, he cannot move at all. Cataplexy is usually triggered by some strong emotion, be it joy or anger, and lasts from a couple of seconds to several minutes. If the patient has this symptom, they speak of type 1 narcolepsy; if not, it is type 2.
  • Sleep paralysis. The person is unable to speak or move when falling asleep or waking up. This state lasts for a few seconds or minutes and causes fear or anxiety. This symptom sometimes occurs in healthy people.
  • Hallucinations. They usually appear when falling asleep or waking up. Most often, people think that there is a stranger in their bedroom.

See a neurologist if you notice any of these symptoms.

Where does narcolepsy come from

The exact cause of this illness is still unknown.

However, in people with type 1 narcolepsy, the brain produces little hypocretin (also known as orexin), a neurotransmitter that helps regulate sleep and wakefulness. Scientists suggest The Trouble with Tribbles: Do Antibodies Against TRIB2 Cause Narcolepsy? that the deficiency occurs due to an immune system attack on the brain cells that synthesize this substance. However, in type 2 narcolepsy, hypocretin levels do not decrease.

Researchers are considering other causes of the disease:

  • genetic predisposition Narcolepsy;
  • brain injury;
  • vaccine Risk of narcolepsy in children and young people receiving AS03 adjuvanted pandemic A/h2N1 2009 influenza vaccine: retrospective analysis of AS03 against swine flu.

However, all these theories require confirmation.

Why narcolepsy is so dangerous

Sometimes it leads to death: for example, if the patient falls asleep while driving. A person can cut or burn himself in the kitchen or while working with a saw and other tools.

Other difficulties arise. Intense emotions can cause cataplexy, and in order not to provoke it, a person stops contacting others.

In addition, people with narcolepsy are more likely to suffer from Depression, Weight Gain and Health Complications depression and obesity.

How to treat narcolepsy

Consult a neurologist to determine the severity of the disease and write out recommendations.

1. Take medication

Narcolepsy cannot be completely eliminated, but these drugs can be controlled Narcolepsy Fact Sheet symptoms.

  • Modafinil. It stimulates the nervous system, so it relieves daytime sleepiness. The drug practically does not cause dependence and gives a minimum of side effects, such as headache or nausea.
  • Amphetamine-like stimulants (methylphenidate, dexamphetamine). They are prescribed if modafinil is not working. They have more negative consequences, such as mental disorders, and they are more likely to cause addiction.
  • Antidepressants. They relieve symptoms such as cataplexy, hallucinations and sleep paralysis. These remedies are effective, but they have many side effects, such as impotence or obesity.
  • Sodium oxybate. It helps to get rid of muscle weakness, reduces daytime sleepiness and improves night sleep. It must be consumed strictly according to the schedule and in no case should be combined with alcohol.

2. Change your lifestyle

Doctors also recommend that you add healthy habits to your medication:

  • Take short (20-30 minutes) naps during the day. Distribute them evenly according to your schedule.
  • Go to bed and get up at the same time every day, even on weekends.
  • Avoid caffeine or alcohol 2-3 hours before bed.
  • Do not smoke, especially at night.
  • Exercise every day for 20 minutes, four to five hours before bed.
  • Do not eat fatty or meaty foods before going to bed.
  • Prepare your bedroom by ventilating and darkening it by turning off all lights and appliances.
  • Relax before bed, such as taking a bath.
  • Tell your doctor if you are taking medication. Some medications, such as anti-allergy medications, can cause drowsiness and need to be changed.

Read also 😴🛌💊

  • How daytime sleep affects metabolism0025
  • What to do if you constantly want to sleep
  • SLEEP: everything about how, how much and why to sleep

Center for Neurology and Sleep Medicine

Narcolepsy is a disease of the central nervous system resulting in a sleep disorder characterized by daytime bouts of irresistible drowsiness and sudden falling asleep during normal wakefulness, as well as bouts of cataplexy , that is, a sudden loss of muscle tone with clear consciousness, insomnia , disturbances of nocturnal sleep, appearances during falling asleep and waking up hallucinations . Sometimes there is short-term paralysis of the body right after waking up.

Causes

The exact causes of narcolepsy are not well understood. According to a number of experts, they are based on the lack of a biologically active substance of the brain, which re-regulates the processes of falling asleep and awakening. Factors that contribute to the development of this disease are often trauma to the skull, severe debilitating infections, severe overwork. Sometimes the disease is associated with the function of the endocrine glands, especially with a violation of the pituitary gland. In some cases, narcolepsy runs in families. Psychiatric and psychological problems are not the cause of narcolepsy.

Symptoms:

  • severe daytime sleepiness;
  • cataplexy - sudden loss of muscle strength;
  • hallucinations;
  • sleep paralysis;
  • nocturnal sleep disturbances;
  • automatic behavior;
  • blurred, double vision.

The first symptoms usually appear in a previously healthy person during adolescence or youth and persist for life. Symptoms of narcolepsy can appear all at once or develop gradually over many years:

  • Irresistible daytime sleepiness plus "forced" falling asleep at any time (reading a book, watching TV, talking, driving). Such drowsiness occurs in a person after a night's sleep. Patients often describe that they feel tired, apathetic, too lazy to do something, have no energy. It is possible to resist falling asleep only for a short time, but if a person has fallen asleep, then it is easy to wake him up. The number of such attacks per day can be very different, and each of them usually lasts about an hour or less. Upon awakening, a person may feel rested, but is able to fall asleep again after a few minutes and sleep all day. With such drowsiness, it is difficult for him to work, study, a person loses concentration, memory, motivation is lost, irritability increases.
  • Complete disturbance of nocturnal sleep (manifested mainly by very frequent awakenings, insomnia).
  • Hallucinations - unrealistic frightening in most cases visions or sensations of an often threatening nature when falling asleep and waking up.
  • Cataplexy, i.e. sudden loss of muscle tone, usually against the background of strong emotions such as laughter, rage or excitement, surprise. During attacks, which can last from a few seconds to half an hour, a person is unable to hold his head, feels weakness in his arms, knees, which often leads to a fall.
  • Sleep paralysis, i.e. a state in which, upon waking up, a person quite adequately assesses the environment, but at the same time he does not control his body at all, he is not able to move or speak.
  • Automatic behavior is the performance of normal actions by the patient without being aware of what he was doing. Sometimes a person may actually fall asleep and continue the activity, but not remember it after waking up. Automatic behavior can be a symptom of narcolepsy and is dangerous if the person performs potentially dangerous activities such as driving or cooking.

People with narcolepsy also often report symptoms such as double vision, inability to concentrate, memory loss and headaches. Children with this disease, as a rule, lag behind their peers in physical development and in school. Adults may not be able to perform daily duties at work.

If you have any of the above symptoms of narcolepsy and you think that these symptoms are affecting your ability to drive, attend school, perform normal daily activities, or if these symptoms affect your social activities and personal relationships, then then you need to contact specialists at the Center for Neurology and Sleep Medicine to confirm the diagnosis.

At the sleep center, a specialist will review your medical history and perform a complete physical examination. If the doctor suspects narcolepsy, you will be asked to undergo an examination. To confirm the diagnosis and determine the severity of the disease, two tests are usually performed: polysomnography with electroencephalogram (EEG) and multiple sleep latency test (MSLT test).

Treatment

The symptoms of narcolepsy can usually be controlled or alleviated so that those suffering from the disease are less likely to experience symptoms and can lead a reasonably normal life. If you are diagnosed with narcolepsy, then your treatment plan will include several components: medications, behavioral therapy, and the organization of certain activities in the patient's environment.

Medicines.

The type, number, and severity of symptoms determine which medications to use to treat narcolepsy. Only a doctor can prescribe those drugs that can effectively control excessive daytime sleepiness, cataplexy, hallucinations and sleep disturbances.

Behavioral therapy.

Treating narcolepsy will likely require not only the use of drugs, but also the organization of activities that will greatly improve your sense of well-being.

  • Keep a regular sleep and wake schedule. Go to bed and wake up at about the same time each day.
  • Regular short episodes of daytime sleep may be helpful.
  • Use caution when doing activities that may be dangerous, such as driving or cooking; try to plan your schedule so that you are vigilant at this time.
  • Carefully follow your doctor's advice about taking your medicines. Tell him right away about any changes or problems with your medications.

It is difficult to control narcolepsy if your family, friends and colleagues do not understand the essence of the disease. Daytime sleepiness can be mistaken for laziness, depression, or loss of ability. Signs of cataplexy or dreaming while awake may be mistaken for psychiatric problems. Understanding the symptoms of narcolepsy can relieve fear, shame, anger, and depression.

Therefore, if you suffer from narcolepsy, your doctor or you yourself should talk to your family members and reassure them that your behavior is not intentional or mentally abnormal. Family support is an important step in coping with illness.

Tell your employers about the illness. Providing certain conditions at work will allow you to remain a profitable employee. If narcolepsy is preventing you from doing your job, then consider other sources of income available. If your child has narcolepsy, make sure their teachers are aware of the condition. Small adjustments in the classroom can have a huge impact on your child's self-esteem and ability to get a good education.

Prognosis for narcolepsy

Narcolepsy is a disease that occurs over a long period of time. The symptoms of this disease can vary in severity throughout a person's life. Symptoms usually worsen over time or become stable. However, drowsiness can become a permanent condition that requires medication. In some cases, cataplexy and other symptoms may decrease or disappear over time.

Various factors influence a patient's symptoms, including: