A personal history of passing out.

A cardinal symptom of panic disorder is the sudden, inexplicable sense of an imminent loss of control. Panicky persons become afraid that if they do not leave wherever they happen to be when they suffer an attack and return to a place where they feel safe, those feelings will worsen until they cause the stricken individuals to fall apart or do something that is dangerous, such as driving off a road -- or embarrassing, such as throwing up, soiling themselves or fainting. When I developed the condition in college, I thought I was going to scream out something vulgar in a classroom setting or in the library. Also, I thought I might faint. It turns out the fear of fainting is very common—and not readily understood. After all, fainting occurs not infrequently in different settings (not when someone is panicky) and nothing very awful happens as a result. Still, panicky individuals often say to me, “What if I faint while I’m driving?” or “What if I faint in the middle of the dance floor?”  “What if…” is a common refrain of anxious men and women. “Well, then…” is what they need to contemplate in case the terrible, worst-case scenarios they imagine were actually to come to pass. For that reason, I thought it might be interesting to those of you who have such fears to consider my actual experiences with fainting and near-fainting.

First of all, people do not faint in the middle of a panic attack. During an attack, their pulse and blood pressure rises. Those individuals who have a blood and injury phobia do, indeed, faint. Their blood pressure falls, but what they experience is not a panic attack. A few such phobics have both a panic disorder and a blood phobia and can experience both feelings, but they have no trouble telling one feeling from the other. In any case, I never fainted during a panic attack.

Probably, my first experience with near-fainting occurred when I was an adolescent. I frequently suffered what I now know to be was “postural hypotension.” If I stood up suddenly, my vision would go all black (“blacking-out”) and I would get wobbly. I never actually fainted, but I did feel some hard-to-describe sensations that I discovered later on are associated with fainting. Postural hypotension is very common in thin, growing kids because their blood pressure is labile. Girls, who are likely to be somewhat anemic because they menstruate, are somewhat more vulnerable than boys.

By the way, these ordinary experiences led to some of my early medical misadventures. When my mother brought me from one doctor to another, I was told, first, that I had hypothyroidism (not so) and then, later on, that I had hypoglycemia. I was told to eat a chocolate bar whenever I started to black out. This is not a proper treatment for reactive hypoglycemia, which I did not have anyway. (I did like the chocolate, though.) Postural hypotension is not always entirely benign. A nephew of mine got up suddenly from a toilet seat one day after moving his bowels and fell over, cutting his forehead so that he needed stiches. Moving one’s bowels, I should point out, is a modified Valsalva maneuver and causes a sudden rise then fall in blood pressure.

In college, around the same time I was having panic attacks, I did actually pass out once under different circumstances. I was in the infirmary with a G.I. condition that caused me to have diarrhea and persistent vomiting. I lay in bed most of the day and then decided I needed to go to the bathroom again. When I got to the hallway, I passed out. It happened quickly, but not so quickly that I hurt myself falling to the floor. Within a few seconds I found myself sweating and feeling suddenly much better, and much cooler. These are some of the feelings a person may feel recovering from fainting. I was not frightened. I got up slowly and went over to the bathroom. I was not incapacitated. I knew very well that what I had experienced was quite different from the sudden anxious feelings I was having regularly in my classes. There were two reasons why I passed out: I was dehydrated from my illness and I had been lying, unmoving, in bed for a considerable time. Both predispose to fainting. When I actually got up, my blood pressure dropped suddenly.

On a second memorable occasion I was sitting in a crowded college amphitheater looking down at my professor who had just started a film portraying a young, attractive, but obviously psychotic, woman who was undergoing a pre-frontal lobotomy. The movie showed a surgeon sawing through the woman’s head with an ordinary handsaw. I could feel myself starting to pass out, but since I was squashed between other students, there was no room. I had time to stand up and climb over to the steps adjacent to the seats, where I lay down. I was the only student of the 300 in the room who had started to faint. I heard someone behind me say, “and he’s pre-med too.” I want to point out to those of you who are always afraid of embarrassing yourself that not one of all those students remarked to me after the class about what happened. This was not because they were sensitive to my feelings and were not inclined to tease me. It is because they completely forgot what had happened only 20 or 30 minutes before. And so it is with most of the embarrassments phobics can imagine. No one notices, or if they do, no one cares. So, certain kinds of emotional upsets can cause fainting, very much as a blood-phobic would be inclined to faint. Under extreme circumstances, anyone can become a blood and injury-phobic. By the way, blood and injury phobias are treated the same way as other phobias, by a slow exposure, so that the vulnerable person learns a different reaction to these circumstances.

I had a similar experience in medical school when I went to the morgue to watch a post-mortem examination. When the pathologist started pulling the face down off the corpse, I had to leave the room. Around the same time I was one of three medical students who were learning how to take a blood pressure by practicing on each other. My partners blew up the cuff on my arm and promptly got distracted by an argument with each other, leaving the cuff inflated. I was quickly in a lot of pain, which was enough to make me feel faint. It was only my finally freeing myself from the sphygmomanometer that allowed me to recover without actually fainting. Pain can cause a sudden drop in blood pressure, in extreme cases, sometimes causing, or contributing to, a loss of consciousness and shock.

As an interne I had an uncomfortable experience which struck me as amusing at the time. My brother’s wife had given birth to a son, who was scheduled according to Jewish law for a ritual circumcision, a briss. My whole family, of which I was the only doctor, gathered in a room separated from the surgical suite by a one-way mirror. Everybody was drinking schnapps and having a good time. I watched while my new nephew was brought into the adjacent room tied down to a plank of wood. The doctor performing the procedure unwrapped the child’s penis, which stuck up in the air. The man came at him then with a knife that I remember being the size of a cleaver—and I started to pass out. Everyone else in the family was doing fine. I had time to leave the room and go into a hallway where I put together some folding chairs to lie down on so I would not have to lie on the floor. Another near-fainting.

Two weeks later, I, myself, was doing circumcisions as part of my medical duties—without any inclination to faint. This anecdote illustrates two more facts: someone who has to do something (as opposed to standing by and watching) is not likely to faint. The first person on the scene of a bloody accident who has to stop someone from bleeding and then call the police will not pass out. But the individual who stops later on to watch the treatment of someone bleeding on the road may very well pass out.

The second moral to take from this story is that anyone can embarrass himself from time to time, and no one remembers. Certainly, no one thinks less of a person for passing out. I remember giving blood in medical school and starting to faint halfway through the procedure. They had to start infusing my own blood back into me. I had not previously realized it was possible to pass out while lying down.

Certain surgical procedures on particular areas of the body may cause fainting. These include operations on the eyes, the fingers and the genitals. There is an emotional component to these procedures which may contribute to the lowering of blood pressure. Later in life, I had a minor operation on my palm and could not stand up until I had rested sitting down for five or ten minutes.

In mid-life, I regularly jogged, even in very hot weather, and then took a bath. I would have to crawl out of the bathtub to avoid fainting. People are prone to fainting after exercising vigorously. That is why marathoners have to walk around slowly at the end of the race. If they sit down, they will be unable to stand up again without fainting. Also, hot showers and baths predispose to a drop in blood pressure since the heat causes the peripheral blood vessels to dilate and allows pooling of blood.

So, there are many causes of a drop of blood pressure which can cause near-fainting or actual fainting. I did not mention drugs, but there are many that affect blood pressure indirectly, such as the anti-depressant drugs, or directly, such as those drugs that are given purposely in hypertensive patients to lower blood pressure. Here are some other factors which together, or by themselves, can cause fainting: drugs, dehydration, emotional shock, heat, exercise, sunburn, gastro-intestinal illness, anemia and a variety of other diseases, including cardiac diseases. Something pressing on a sensitive area of the neck can cause fainting. Simply standing too long in one place can cause fainting.

None of these conditions implies anything bad about the person who has fainted. Anyone can faint under just the wrong circumstances.

Also note that fainting itself is rarely dangerous and does not usually occur so suddenly that the person is immediately incapacitated. Even after fainting, the affected individual—unless seriously sick from some other cause—can recover, get up and go about his/her business. True fainting deserves a medical work-up; but fainting, per se is no big deal. (c) Fredric Neuman Author of "Rising Above Fear." Follow Dr. Neuman's blog at fredricneumanmd.com/blog/ or ask advice at fredricneumanmd.com/blog/ask-dr-neuman-advice column.

Fighting Fear

Confronting phobias and other fears
Fredric Neuman M.D.

Fredric Neuman, M.D., is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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