Trembling in the hands

You were unpleasantly surprised and upset by the fact that in a certain situation or for no apparent reason there is a shiver in your hands, do not rush to panic and immediately run to the neurologist.

Approximately 6% of the world's population encounters a similar situation. But to brush aside the problem is also not worth it, because the causes of this pathology can be both pathological in nature, and invested in the symptomatology of "normal" tremor. 

Causes of trembling in the hands

So what are the causes of trembling in your hands? How much this symptomatology is dangerous, and whether it is possible to get rid of it independently, without recourse to specialists? All in order. 

I think many at least once, but I had to experience this unpleasant feeling, while a person is lost, it becomes difficult to concentrate. So what is the reason that causes the hands to shake?

This process of small reciprocating movements of parts of the human body, and in this case of the upper limbs, in medicine is termed " tremor."

• This physiological reaction of the body can relate to the manifestations of normal tremor. This pathological deviation is manifested by a slight twitching in the limbs, which can be caused by an external stimulus:
  • Psychological excitation of the human nervous system in a stressful situation (excitement, overexcitation, depression, hysteria ) is explained by the fact that during emotional excitation in the human body a hormonal burst occurs, in which the level of hormones in the plasma increases sharply, which is the catalyst for tremor of the upper limbs .
  • Physical stress: overstrain in the gym, professional activity is associated with increased loads on the hands. And if it's easier - the upper limbs tremble with fatigue.
• Causes of trembling in the hands can be associated with some serious pathology. By the nature of the trembling and concomitant symptomatology, a qualified specialist can reasonably expect a disease that causes an uncomfortable state. It can be:
  • Deep depression that requires medical intervention.
  • Nervous disorders of various genesis.
  • Parkinsonian tremor - trembling in the hands is observed constantly and differs asymmetry. With this disease, the right limb is subjected to greater shaking than the left arm, but at the moment of concentration, when it is necessary to perform a certain action, hands shake cease.  
  • Atrophic phenomena affecting the cerebellum.
  • There is also a so-called essential tremor that affects people of advanced age, cases of transmission of this symptom by heredity are ascertained. The manifestation of an essential tremor is akin to parkinsonism, with the only difference being that the trembling of the right and left limbs occurs symmetrically. The trembling of the hands in this case is slightly noticeable.
• Provoke a similar symptom can alcohol. One has only to recall the chronic alcoholic who abuses strong drinks, with constantly shaking hands. Often, this manifestation is associated with a morning hangover. After taking the next dose of alcoholic tremor passes.
• A similar symptomatology is observed in the abuse of narcotic drugs - this is how withdrawal manifests itself.
• The cause of pathological manifestations may be the taking of prescribed medications. If you have this symptomatology for taking medication, you must always inform your doctor about it. In this situation, the doctor must change the drug for another drug of a similar effect.
• Myoclonus is the so-called rhythmic tremor. Functional shaking of the upper limbs is manifested in conjunction with high-amplitude movements of the whole body and hands. This tandem is observed in case of increased motor activity and disappears at the time of muscle relaxation. This pathology is peculiar:
  • Multiple sclerosis.
  • Pathological changes affecting the trunk of the brain.
  • In the case of Wilson's disease.
  • With other vascular diseases.
• Asterixis - non-rhythmical asymmetric twitching with tonic tension of the muscles of the extremities, as well as the trunk and neck, inability to maintain a fixed posture. Often, this disease is also called a "fluttering" movement. Such symptomatology is observed, for example, in hepatic encephalopathy.
• The cause of this symptom may be chronic fatigue, especially tremor, is clearly visible in the case of the urging of the body using energy drinks.
• Trembling in the hands can become a consequence of changes in the quantitative component of glucose in the blood plasma. In parallel with this, a person may be affected by general apathy and physical weakness. In this case, it is enough to eat a little sweet and pathology, often, it is docked (but this concerns changes that are not related to diabetes mellitus). To measure the blood sugar level, you can use a special mobile device with a glucometer, which you can buy today in any pharmacy.
• Spine diseases can also provoke this pathology, for example, osteochondrosis.
• Numerous diets and prolonged starvation.

To understand the reason and dot all the "i", it is necessary to seek the help of a neurologist, especially if the patient watches a tremble in his hands for a long time and even at rest.

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Trembling in the hands as a symptom   

The tremor of the upper limbs is an unpleasant sensation, which may be all - only a consequence of physical or emotional overstrain, and enough rest will be enough to make such a symptomatology disappear. But, at times, abnormal symptoms continue to be observed and amid tranquility and tranquility, then tremors of the hands can become one of the first bells in the manifestation of more dangerous diseases. In this situation, one can consider a trembling in the hands as a symptom of one of the multiple diseases that, in its development, can affect the receptors of the central nervous system, leading to tremor.

Let's try to consider the most common pathological causes of the manifestation of trembling in the hands.

• Poisoning, which arose against a background of various provoking factors. This can be food poisoning, chemical damage, poisoning with medicines and so on. Intoxication of the body is capable of provoking a nerve-paralytic shock. Toxins adversely affect individual parts of the brain, leading to various disruptions in motor activity. In this situation, a small tremor in the hands is usually accompanied by nausea, sweating, pain in the head, pale skin, vomiting, a tremor of the lower extremities may be added, a loss of spatial orientation.
• Essential or hereditary tremor. Predominantly a slight tremor is amplified if you want to strain your hands or in case of trying to keep their canopy. At the same time, familiality is seen when the patient's parents have the same gene defect. Usually this symptom affects other areas of the body.
• Parkinson's disease - for today it is an incurable pathology, mainly affecting old people. It is enough simple excitement that the motor amplitude amplifies. Large tremor, which can be discerned even in a state of rest. A distinctive feature - tremor has an asymmetric character.
• Pathological changes affecting the "control center", located in the cerebellum of the brain. The cause of this pathology may be a craniocerebral injury or multiple sclerosis. The patient quickly gets tired, can not touch the tip of the nose with his eyes closed.
• Wilson's disease - a large, sweeping, rhythmic tremor is most visible with the slightest need to make a move. In a state of rest, tremor is almost invisible.
• The cause of this symptom may be hyperthyroidism - pathological malfunctions in the thyroid gland, which began excessive hormone production. This failure "beats" on the work and other internal organs.
• Encephalitis, caused by an encephalitic mite, is one of the pathologies capable of manifesting a tremor in the upper limbs. Can be accompanied by spasms in the muscles, pain symptoms, loss of sensitivity.
• Unstable emotional state.

Trembling in the legs and hands

Reciprocating, oscillating movements, characterized by rhythm or arrhythmia - all this is associated with a rapid alternation of involuntary tension and relaxation of the muscular tissue of the whole body or its individual parts. Most often you can see a shiver in the legs and hands, in some cases, adds tremor of the head, jaw, whole body as a whole.

Predominantly, this symptomatology is established when a variety of factors occur. Become a catalyst for trembling in the legs and arms can be as much emotional excitement, panic fear, and chronic body fatigue. Provoke a tremor of the upper and lower extremities can also a large number of stimulant drinks drunk, spurting a surge in the release of blood into the blood of an increased number of adrenaline hormones: strong tea, coffee or alcoholic beverages. Especially their effect increases against the background of general fatigue or poor nutrition.

Often the tremor of the upper and lower extremities can be observed in older people. In this situation, it is, most likely, not a specific disease. "Essential" jitter (the frequency of which is calculated from 6 to 10 motor pulsations in one second) has nothing to do with the disease and is observed in a small number of people, and they have inherited it - there is a so-called family predisposition.

Observe the trembling of the hands and feet and can be with Parkinson's disease, which does not pass and at rest. The speed of involuntary movements in a relaxed state fluctuates around four to five movements per second. This symptomatology can be observed in other pathologies that damage the brain stem. Provocative tremor in the legs and arms can become hyperthyroidism - a disease of the endocrine system, associated with increased production of thyroid hormones. Similar symptoms show the patient's body affected by hepatic encephalopathy, which develops with a cancerous lesion that affects the liver and negatively affects the work of certain parts of the brain.

A similar symptomatology can be observed in patients who took courses with drugs related to antidepressants, tranquilizers, amphetamines or psychotropic medications. That is, chemical compounds that directly affect the psycho-neuralgic sphere of man.

Shaking in hands and body

 In the pathological lesion of the cerebellar zone of the brain, there is a tremor in the hands and body. Cerebellar tremor people can get due to head injury, the cause of this manifestation may be progressive multiple sclerosis, as well as this may be a consequence of serious poisoning. 

With this pathology, the intensity and amplitude of tremor increases with the growth of the patient's motor activity and decreases in case of rest.

The tremulous form is also characteristic of Parkinson's disease (a composite pathology of slowly progressing chronic neurological diseases, united by similar symptoms and etiology). With parkinsonism there is a constant medium - amplitude tremor and / or trembling in the upper and lower extremities, as well as the tongue, lower jaw and head, large amplitude. In parallel, there is increased muscle tone.

Such a symptomatology can be observed in the case of severe poisoning, when harmful toxins affect the nervous system, leading to its functional malfunction. To bring to this manifestation are capable and some potent medicamentous preparations. In this case, if there is even a slight tremor, it is necessary to tell your doctor who prescribes this therapy. Most quickly, he corrects the treatment, replacing the provoking drug with another analog.

Often, a shiver in the hands and body can be observed with alcoholism, in a neglected stage. Especially characteristic symptomatology is manifested in the morning as a hangover syndrome. There are enough regular portions of alcohol and the physical condition of the alcoholic is somewhat stabilized (this is akin to breaking off the addict).

Weakness and trembling in the hands

Very unpleasant sensation, when "everything falls from the hands" not in the figurative, but in the direct sense of the word. And when they get weak and trembling in their hands, the situation becomes even more unpleasant. One of the reasons for this combination may be a change in the level of glucose in the blood plasma. If this change is not related to diabetes, it is sufficient to drink a cup of warm sweet tea or eat something sweet. Usually this is enough to correct the situation.

This situation in the language of doctors sounds like hypoglycemia, which is caused by a deterioration in the quality of processing and utilization of sugar by the cellular structure of the central nervous system. Many people have known since childhood that glucose is a food product of brain cells and the main source of energy. Deficiency of this product in the human body invariably leads to various pathological changes (hypoxia), which subsequently pushes to aggravation of disruptions in the work of carbon and protein metabolism occurring in the cells of the central nervous system.

Hypoglycemia acts as a catalyst that stimulates the activity of the sympathoadrenal system. This development of pathology provokes an increase in the level of adrenaline and norepinephrine (catecholamines) in the blood of the victim, which is manifested by characteristic vegetative symptoms. Such a defeat of the brain and contributes to the appearance in the patient of drowsiness, weakness and trembling in the hands, rapid heart rate, increased sweating.

The prolonged carbon deficiency leading to cerebral hypoxia provokes not only functional disturbances in the normal operation of individual parts of the brain, but also leads to morphological, sometimes irreversible changes. The cells of the brain gradually begin to give way to necrosis, the edema of individual parts of the brain is diagnosed.

The cause of this symptom can also become changes in the hormonal background of a person. Failures in the work of the thyroid gland, starting to produce more hormone, and we get characteristic symptoms.

Trembling of the fingers

For some people, the trembling of the fingers is a consequence of the work activity, such as various construction professions, installers (for example, people working with a puncher), blacksmiths, stenographers, musicians and many other kinds of activities. All this is due to the increased workload that the upper limbs of the working person are exposed to. Over time, tremor becomes a chronic symptom and is an occupational disease.

Many people begin to tremble during the excitement. This manifestation of excitement is called a hysterical tremor. Such a symptomatology should alert, since it is caused by disturbances in the work of the nervous system. In this situation, it is necessary to check if the tremor is observed continuously for a couple of weeks - this is a direct road to consultation and examination to a neurologist.

A shiver in his hands

A small tremor in the hands sometimes appears in quite healthy people. This can be the body's reaction to excessive physical exertion (the upper limbs begin to faint simply from fatigue). A similar reaction can be observed with increased emotional excitement, resulting from stress, depressive state, or violent anxiety.

If the tremor does not last a long time - this is an indicator of vegetative CNS disorder.

To appear a small tremor in the hands is capable and against the background of therapeutic therapy. Side effect of some pharmacological drugs is precisely tremor. It is necessary to tell about the appearance of such a symptomatology to a doctor who will replace the drug with a drug of a similar effect and, if necessary, correct the treatment.

To provoke a small tremor in the hands is also capable of poisoning. In the case of intoxication, toxins adversely affect the operation of individual parts of the brain, which leads to a similar symptomatology.

Trembling and dizziness

A person often does not even think about what makes him feel comfortable in the environment around him, freely maneuver between obstacles. This gift was given to us by nature in the form of receptors, which help us to determine the position of the body in relation to other objects of the situation. They are localized in the tube space of the inner ear. It is from here that the signal is transmitted to the brain, where it is processed. 

In case of appearance of pathological changes affecting these receptors, or blocking the transmitted signal, a person begins to feel the rotation of objects and the ground, before his eyes everything floats. Trembling and dizziness can cause fatigue, general dehydration, prolonged starvation, lack of sleep. Characteristic symptomatology is a manifestation of low hemoglobin in a patient, as well as in the case of hypoglycemia. In both cases, the consultation of the attending physician and the careful implementation of his recommendations can not be avoided.

Often accompanying symptoms of dizziness are constantly accompanying noise in the ears, tachycardia, there may be attacks of vomiting.

Trembling in the hands of excitement

Excitement - this feeling is inherent in every person. A lot of people feel uncomfortable on the big stage before the gathered crowd, remember the feelings of the student, who "suddenly" was called to the board. Excitement is a normal physiological state - the body's response to such nervous excitement. You can correct this situation by switching your attention to another object. Perfectly in this case, and walk in the fresh air, auto-training or a mild sedative (for example, warm tea with melissa or mint).

When a person is nervous, you can see a shiver in your hands when you are agitated - this symptomatology of the manifestation of excitement should alert. A healthy organism does not show itself that way. In such a situation it is better to have a consultation with a neuropathologist, such a characteristic hysteria may reveal a deeper functional disorder of the nervous system, one of which, for example, may be hypoglycemia. 

Shaking in the hands and nausea

Quite often, the hands begin to tremble from emotional overexcitation or physical stress. But the cause of tremor can be and pathological changes occurring in the patient's body and affecting the receptors and nerve endings of the central nervous system.   

The effect of toxins and the neuro-paralytic shock, which leads to varying degrees of intoxication, affects the functioning of the brain. This is a provocative factor that causes a violation of the coordination of movement in humans. One of such manifestations is trembling in the hands and nausea, accompanying them may be loss of spatial orientation, dizziness, pallor of the skin, headache.

A similar symptomatology can be given by some other diseases of the central nervous system.

Trembling in the chest and arms

The sensation of internal tremor, tremor of the upper limbs - all these are the symptoms by which the human body shows the pathological changes that affected the central nervous system. Neuroses - this name hides multiple diseases of the psyche caused by physical or psychological trauma, manifested by instability of mood. One of the symptoms of most neuroses is a tremor in the chest and hands.

Depending on the severity of the disease and the area of damage, this process can be either potentially reversible or regressive. Quite often the cause of a neurosis is a sudden severe psychological trauma (for example, a natural disaster or the death of a loved one) - for the most part people with a weak psyche are exposed to it. More often to the nerves leads to a slight psychological pressure, but a long time.

Therefore, getting a psychosis is more risky for people with a low psychophysical organization. If you do not succeed in changing something in yourself and your life, it is worthwhile to ask a qualified specialist for help.

Tremor in the left hand

The cause of hand tremor may be endocrine factors: excessive production of the fermented product by the thyroid gland. If the tremor in the left arm is observed for two weeks, and it is not associated with physical exertion on the upper limbs, a survey under the supervision of a neuropathologist is necessary. Only a qualified specialist can correctly determine the cause of pathological manifestations and prescribe a treatment or maintenance therapy. After all, this problem will not work out on its own - it must be treated.

Elevated tremor of the left arm may be a consequence of Parkinson's disease - an unpleasant, dangerous and completely unexplored disease, most of it is observed in elderly people. Sometimes the cause of this disease can be an obvious or latent stroke, atherosclerotic processes that occur in the vessels of the brain. Today, it is impossible to recover from this disease, but it is quite possible to suspend its destructiveness. The main thing is not to delay with a hike to the doctor after finding the first signs of a tremor.

Shaking in the right hand

It's no secret that people living on Earth are divided into those with the predominant left brain hemisphere - these are righties, and, conversely, with the dominant right hemisphere - the left-hander. According to the statistics of right-handers, there is much more, that is, the main physical load falls on the leading, right, arm. Hence the trembling in the right hand - this reason does not lie in the field of pathologies and refers to the norm. Worse, when the hand receives such a load continuously and for a long time, for example, due to professional activity. This may be the profession of a violinist, painter, a builder working with a puncher or a jackhammer.

Long-term exposure to increased loads can translate tremor into a chronic manifestation and become an occupational disease.

A tremor in the right hand can be a characteristic of Parkinsonian tremor, which, by virtue of its asymmetry, is capable of mainly hitting the right (or left) arm. In any case, medical assistance is indispensable here. Tremor in Parkinson's disease is observed constantly, even at rest. At the same time, its intensity significantly decreases or disappears completely if the patient makes an attempt to make any movement.

A strong tremor in the hands

The demonstrating characteristic of some diseases affecting the CNS receptors is a strong tremor in the hands. Such symptomatology, for example, differs Wilson's disease - a hereditary disease, in which chronic intoxication of the body with copper is observed due to disruption of its transportation and accumulation. This pathology is transmitted by an autosomal recessive type. This type indicates that both parents of the patient are the owners of the abnormal gene.

To observe a strong tremor in the hands it is possible in the case of some lesions of the brainstem, as well as with diffuse atherosclerosis - a disease of the cerebral vessels, which subsequently leads to the development of cardiovascular diseases, myocardial infarction and coronary heart disease. This pathology is more susceptible to men than the fair sex.

With these lesions, there is a rhythmic, sweeping tremor and its strength increases during the movement. In a state of rest, the tremor of the hands is somewhat reduced, but it is quite difficult to completely relax the muscles.

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Constant trembling in the hands       

If the tremor of the upper extremities is observed constantly, then it can be unequivocally said that this is not included in the conditions of the norm. This state of affairs refers to the field of pathologies. In this situation, one can advise one - to observe the state of their hands for a couple of weeks. If the constant trembling in the hands remains unchanged, the solution should be one - immediate application for consultation and for examination to a specialist. It is necessary to understand, the earlier the cause of tremor of the upper extremities is established, the better the prospects for the future (until the pathological process has gone too far and the violations have become so global that they are not amenable to any regression).

Trembling in the hands of a child

It is very unpleasant to see when tremors of limbs are observed in children. In this case, we are not talking about babies and newborn babies. If parents observe a child's trembling in their hands, the first thing to do is to talk confidentially with the baby. Try to find out from him, maybe a child is very upset or frightened. It is possible that a tremor is a result of the nervous experiences of a little man. For example, you can often see a trembling in the hands of teenagers before a responsible exam, an important competition. The cause of tremors in a child can be quite large school loads.

In the period of puberty, the trembling of the upper limbs can be caused by hormones. At this time, the body of a teenager is being rebuilt, amplified from production. In this case, a stressful situation or a weakly developed muscular system of the body and can lead to tremor. During this period, many children begin to grow rapidly. Usually, the growth of bone tissues does not have time for the internal organs and systems of the body, they are late with development, and the muscular skeleton does not have time to build up. It is this imbalance that causes the baby to tremble.

In this situation, it is necessary to revise the diet of the child, he should spend more time in the open air and in mobile games. It is not superfluous to write down a child in one of the sports sections, the main thing is not to allow the overfatigue of the baby and his physical and emotional exhaustion.

It is more difficult to find the cause of tremor in newborn babies and infants when a small man is not yet able to explain what is troubling him. In this situation, it is necessary to clearly distinguish the localization of tremor. If, during crying, the chin, lower and upper limbs begin to choke, then there is nothing terrible in this - this is a manifestation of the norm. After all, the little man has not yet formed a nervous system with its receptors. Worse if the baby periodically or constantly has a shivering of the head, then it is necessary to sound an alarm and immediately contact the specialists to determine the cause of the anomaly. Such a symptom may be a signal of a serious disease requiring thorough examination and painstaking treatment.

Treating trembling in the hands

Before transgressing to therapy, it is necessary to determine the cause of this pathology. If this is an overstrain, it is enough to have a simple rest. Otherwise, the treatment of tremor in the hands is prescribed by the doctor depending on the diagnosed pathology, while in some cases one can hope for a full recovery, in others - the doctor is ready to offer only maintenance therapy.

With a number of diseases it is appropriate to take sedatives in the form of phyto tea, valerian drops. If the disorder affects the brain and nervous system, they will help to support and restore such drugs as pantocalcin, atarax, afobazole, elcar, finlepsin, rexetin, lecithin, grandoxin, lucetam 400.

Finlepsin is prescribed inside. The adult starting daily dosage is represented by one or two tablets (0.2-0.4 g), gradually the amount of the drug administered increases until the necessary therapeutic effect is obtained and can be 0.8-1.2 g per day, broken down into one to three doses . The maximum allowable daily dose varies between 1.6 and 2 g.

For children, the dosage of the drug depends on the age group where the patient falls:

• the starting dose for children from one year to five is 0.1-0.2 g per day, the next day the amount increases by 0.1 g. And so until the therapeutic effect is achieved. Supportive dose of 0.2 - 0.4 g / day, divided into one or two doses.
• child 6-10 years old: starting - 0.2 g per day, then similar to the previous one. Supportive dose 0.4 - 0.6 g / day, divided into two or three doses.
• children 11 - 15 years: the starting dose - 0.1 - 0.3 per day, then the amount is increased by 0.1 g. And so until the therapeutic effect is achieved. A maintenance dose of 0.6 - 1.0 g / day, divided into two to three doses.

It is not recommended to take the drug in case the patient has an increased sensitivity to carbamazepine and other components of the drug, with leukopenia and anemia, porphyria.

Atarax is used to relieve anxiety, psychomotor agitation. The drug is administered orally. The dosage of the drug depends on the age of the patient:

Breasts from year to six are administered 1 -2.5 mg, calculated per kilogram of the baby's weight and divided into several approaches.

Babies older than six years - 1 - 2 mg per kilogram of the patient's weight per day (in several receptions).

Adult patients are prescribed from 25 to 100 mg per day and is divided into three approaches. For example, with the administered daily dose of 50 mg: in the morning - 12.5 mg, at lunch - 12.5 mg, before going to bed - 12.5 mg. In case of medical necessity, the daily amount of atarax can be increased to 300 mg.

For people of advanced age or people with dysfunction of the liver and kidneys, the starting dosage should be half that. In this case, one-time administration should not be more than 200 mg, and daily - 300 mg.

Contra-indications of the drug include hypersensitivity to its components, a tendency to epileptic seizures, a period of pregnancy and lactation.

Pantocalcin is administered orally, half an hour after a meal. A single dose of the drug for adult patients is from 0.5 to 1 g, taken three times throughout the day. For children and adolescents, the drug is administered from 0.25 to 0.5 g, taken three times a day. Duration of the treatment course from a month to four (very rarely up to six months). In case of therapeutic need, treatment can be repeated after three to six months.

The drug is categorically contraindicated in case of hypersensitivity of the patient's body to the components of the medication, with acute renal failure and the first trimester of pregnancy.

How to remove the trembling in your hands?

You can also try yourself on your own, but this must necessarily be agreed with your doctor (if the pathology is associated not only with short-term physical and emotional stress). So how to remove the trembling in your hands? Can I do this at home? If the cause of the tremor is not a deep lesion of the NA, you can suggest some recommendations.

• Organism after exercise requires a full rest.
• The food should be healthy and balanced.
• It is necessary to monitor your weight. Overeating is unacceptable.
• Interleaving loads with small interruptions. Walks in the open air. Lack of oxygen significantly "beats" on the work of the brain.
• The use of special restorative exercises for the hands with the use of dumbbells. One of them is to stand, stretching out your arms with weight. Hold until you have enough strength. Do every day.
• Training brushes and phalanges: this is suitable for an expander. 20 -30 "vice" will be enough. To overload too it is not necessary. For the flexibility of your fingers, you can learn how to roll two or three balls in the palm of your hand with the same hand.
• A good strengthening exercise will be the lessons of playing the guitar or piano.
• Do not do without exercises on concentration of attention and movement. This can be, for example, the well-known game "house of cards".
• If there is a tremor of a hysterical nature, you need to take a few deep breaths, try to calm down, switching your attention to something neutral. It does not hurt to drink a soothing tea or a mild sedative.

If you start to notice that you have a shiver in your hands, try to analyze the situation and find the cause of the unpleasant manifestation. It may be enough to give your body a rest. But if the tremor is not associated with physical exertion, then it is not worthwhile to delay the trip to a specialist, because such an organism can speak of a serious internal disease. And here you can not do without the help of a doctor.