I shared a post recently about a couple of big events that I have put my AuDHD hypermobile sensibilities through this year and how I did, or didn’t, cope with them and why one of them was much more successful than the other. Only a few weeks after that last big event put me through my paces, I had yet another big event to get through this week and, perhaps prompted by how deeply I had been thinking into the topic lately, trying once and for all to sift out the key factors that either “make” or “break” an event in my case, I also found myself pondering why I can “seem” to be coping at the time of the event and yet still have to pay such a disproportionately high price, in terms of both health crash and sensory overwhelm, long after the event.

I’ve known about post exertion malaise (PEM) for a long time (in fact I wrote a great deal on this topic last summer when I was stuck in one of the longest phases of this that I had ever experienced) but then I think the experience of PEM is much more nuanced for a person that is also neurodivergent and hypermobile, along with all the sensory sensitivities and autonomic nervous system quirks that come along with that, as compared to someone with chronic fatigue from some other origin such as a more neurotypical version of burnout or long covid. There is something going on deep in the domain of that glitchy nervous system that fuels the way that “I’m fine” turns suddenly and dramatically into “I’m really not fine at all”, a see-saw that makes it so very hard for us to be taken seriously or believed by other people because of the stark contrast between how we seem to be coping one minute before we crash the next.

Because, as ever, whilst I was in the midst of this big event, this week, which was my daughter’s masters graduation ceremony, for which (in the interests of coping better with my chronic pain and fatigue) we had booked two nights away in a hotel to make a three day trip of it, I did..as ever…seem to be doing pretty well at the time. Photos show me upright and smiling and I managed to be there for all the components of a pretty jam-packed schedule so what was the problem, as far as outside appearances were concerned?

Indeed, whenever I checked in with myself or others checked in with me to see how I was doing, I seemed to be generally OK and able to keep on going forwards into the next demanding phase, the main event-day being nothing but a long series of demands from early breakfast at the hotel (their timings required me to be up and eating before I am usual out of bed or finished with my pilates mat) until we finally fell into bed that night. After that earlier-than-usual breakfast, time soon rolled on to where it was time to get ready and order a taxi, then on into a busy drinks reception and exhibition for over an hour, rolling on into an hour and 40 minute long awards ceremony (which was actually over 2 hours long including the queue to get in and out) rolling on into outdoors photo opportunities in a park and hanging around for another taxi back to the hotel then (within the hour) yet another to take us out for an evening meal in extremely crowded, noisy and sensorily overstimulating restaurant and finally another taxi back to the hotel just in time for bed.

Yet at each stage of the day I was apparently doing remarkably well. I sat down whenever I could, I had my accommodations waiting for me in the venue where I was sat behind two people in wheelchairs on the flat, I kept drinking my electrolytes as carried all day in a 1.5 litre bottle by my husband, I used the disabled loos, I walked with my stick, I folded it out to perch on when the photos were dragging on, I was ushered to a step to sit down on as we waited for yet another taxi, in fact we made that extra effort to taxi back to the hotel for a small respite before dinner even though we only got half an hour on the bed before needing to taxi out to the restaurant for another long spell of social activity and a stroll to meet another taxi. I even boldly used my (slightly noisy…or was I being paranoid) neck fan and bedtime-level earplugs throughout the ceremony itself, abstaining from joining in with the near continuous clapping (a truly horrible sound to my ears, even with ear plugs wedged firmly in, and a social convention that is terribly jarring for my nervous system) though I unfortunately forgot to take either sensory aid to the restaurant in the evening because, by then, I was far too tired for effective executive functioning. So I mostly did “all the things” to help me to cope as best I could and I felt pretty much intact at the time, seeming perfectly fine to anyone evaluating how I was doing from a purely visual perspective, so you would therefore think that I was pretty much coping…but, of course, that surmise is completely wrong because the biggest payback aways comes along (in spadeloads) after the big event!

The thing is, with a hypermobile “system” the autonomic system is more than a little big glitchy and (I suspect) this gets to be more the case as we age. Parasympathetic functions that are “meant” to take place automatically don’t and somehow those to do with providing blood flow and energy go particularly awry. So when big events come along, our systems are often accustomed to leaning hard into the sympathetic nervous system to “keep us going”…thus adrenalin bumps up really strongly to boost blood pressure and circulation to needy muscles and to increase heart rate to provide energy under stress and then cortisol spikes to mobilise glucose and modulate inflammation in a vain attempt to keep us functioning.

Studies have actually shown this increase of adrenaline in hypermobile people when upright, even if there are no obvious signs that they are adrenalised so nobody would even guess that this is going on, from outward appearances. In my case, I can often tell my adrenaline is up because, during the big event itself, I might even feel like I have access to more resources than I usually have, which can come as such a pleasant change that it would be easy to gaslight myself into thinking that “all” that is wrong with me is that I clearly need more stimulation on an ongoing daily basis to keep myself going. In fact there have certainly been times in my life when I did keep myself excessively busy, jumping from one big event to another, because of the ADHD energy boost I would get from the constant supply of adrenaline fuelling my system, hating the feeling of the more lean times when it was as though my fuel sources suddenly dried up (my ADHD daughter lives like this now, much as I did at her age, “needing” to keep busy all the time in order to feel energised and avoid the unpleasant phases of flatness) but then the time eventually comes (and it seems to typically hit during your mid 30s) when this so-called energy hack is no longer viable and only ever leads to repeated burn outs as you constantly borrow from Peter to give to Paul. I passed that threshold over twenty years ago now and so these fake-energy splurges now only ever lead to increased fatigue and ever longer recovery and symptom phases afterwards, no matter how “well” I seemed to be coping at the time of the big event during which all the extra adrenaline my body was drumming up was no doubt keeping me going.

This considerable gap between “what seems” and the harsh reality I have to cope with behind the scenes, with repercussions that often last for days or weeks afterwards, has proven to be one of the hardest things to live with of the past twenty or so years because it leads to frequent misunderstandings and people not taking me seriously, therefore still not accommodating my genuine needs, meeting me half way or understanding the after effects that invariably come along to knock me over later. It can be incredibly hard to persuade them that these exaggerated after effects have anything to do with the big event they recently saw me take part in so successfully (I don’t count my immediate family in this as they know, from the inside, how hard I am hit) and it can be all too easy for them to blame it all on some sort of depressed state of mind or hypochondria. It makes it incredibly difficult to explain to people what I can and cannot manage to do because they have supposedly seen me coping with doing things which, in actual fact, I didn’t really cope with at all…except, they only see the front-facing version of me, putting on the smiling face, seldom indicating the numerous struggles going on as the demands of a big event take their inevitable toll and hit me even harder in the aftermath.

Another factor adding to this effect is that if MCAS (mast cell activation syndrome) is also present, as it so often is when a person is hypermobile, then vibration, noise, heat, travel, crowds and other sensory stimuli, alcohol, inflammatory foods and so on can all potentially trigger an exaggerated mast cell release leading to increased histamine, prostaglandins and cytokines circulating in your system, the effects of which are generally experienced a little further down the line because of a delay factor. Inflammation, increased vasodilation (leading to worsened POTS) and fatigue are often the results but these so often manifest a day or two after the trigger event rather than at the same time. In fact, to this day, I often have no idea what effect an increased amount of stimulation and other unusual exposures are really going to have on me, or the heavy consequences I will later reap, until this manifests over the course of the days or weeks afterwards. If I’m lucky, I might be pleasantly surprised and find that my flare-up only lasts, like a bad hangover, for a day or two but, ever more frequently, the aftermath involves a prolonged phase of increased inflammatory responses including severely disrupted gastrointestinal processes, chaotic autonomic function that may include heart arrythmia or palpitations, increased hot flushes and nighttime blood pressure spikes (leading to disrupted sleep), increased inability to regulate temperature, blood pooling episodes and dizziness, feeling weak on my feet and crashed out with brain fog during the daytime, increased body aches, pain and malaise including things like flared-up interstitial cystitis, headaches or neuralgia, deepest fatigue and then, inevitably given the circumstances, complete social withdrawal as I go off to lick my wounds and try to recover.

Of course, all of this comes along to floor me long after all the photos of me coping admirably with the event have been taken and put to one side as a “record” of how things turned out and with a vengeance that makes anyone else’s platitudes that “we all feel a bit tired after a few days away” feel like a painful thorn in the side. Lack of relatability is such a common consequence of living with hypermobility that I have long had to deal with it, though I can’t honestly say that it has ever got any easier to swallow!

PEM is something common not only to hEDS but to ME/CFS and long covid (and I consider myself to have had all three overlapping at different times: having one seems to make you much more prone to having another), reason being that, in all of these cases, mast cells seem to be much more readily activated with far less stimulation required to reach that threshold. Once released, we then seem to suffer from impaired ability to clear them out of our system, leading to a prolonged flare-up, then our dysregulated immune signalling can further lead to a prolonging of the immune activation turning into a sort of ongoing catch twenty-two if we aren’t very careful to avoid the unnecessary triggers that perpetuate the cycle. Going back to the adrenaline and cortisol spikes that we seem to have to lean into to push through a big event, these basically amount to living on borrowed energy which then leaves us depleted for long periods afterwards. Our inevitable “crash” is our system rebooting and thus a highly necessary phase in refinding our equilibrium. If we are also neurodivergent then there can also be a very big component of sensory and emotional shutdown after so much overstimulation as such big events usually involve and this too is a necessary requirement in order to self-regulate ourselves back into a more stable state after just a few days of lower sensory exposures or social demands…hopefully.

The combined effect is to really need the (what some people may consider to be exaggerated) withdrawal from other people and sources of undesirable stimulation to achieve systemic rest and recovery after such a big event. There can be no arguing with this phase and it really has to be factored into the event itself because there is simply no way of just pushing through or skipping past it. If we force ourselves to keep on going longer than we are capable of, we that are wired this way generally live to rue the consequences so self-advocating for whatever we need…perhaps complete withdrawal, rest and respite for as long as it takes to get back to baseline…is as necessary and expectable a part of the big event as the event itself. Whilst this phase is active, my sensory sensitivities are likely to be extremely exaggerated, my pain, inflammatory and other symptoms much higher, dizziness and POTS pretty activated, my executive functions compromised, brain fog very likely and even my serotonin noticeably lowered for a few days leading to emotional sensitivity on top of everything else, which can all make it quite the precarious time so safer by far to withdraw.

Of course, its not all about sweeping up the effects in the aftermath and there are things that can be planned for or prioritised during the event itself…so, its important to work out what these might be in our own particular case and to make a note of them so that we can get much better at surviving big events “relatively” unscathed. These things likely won’t prevent the crash altogether but they might help reduce the crash and this can help to avoid getting caught up in an extra long crash or what is sometimes called “rolling PEM” (a phenomenon I have written about before) where the effects of one highly triggering event roll on into how badly you then cope with the next one and the next one until you are suddenly caught up in a full-blown chronic fatigue or symptom flare-up phase, which can be incredibly difficult to get out of.

So whilst I was at this particular big event, this week, I found myself jotting down a list (addressed to myself but perhaps containing useful prompts for others) of all the things that I have found helpful for coping myself and I will share them below:

Big event survival tips:

• Rest often, even when I don’t feel like I need it and whenever/wherever I find an opportunity

• Keep to approximately the same rhythms as I have at home, with similar wake, exercise, meal, rest and sleep times as far as feasible.

• Do daily hypermobility-friendly movement practice (The Zebra Club) wherever I am and at the same time of day – all it takes is my phone and a yoga mat and this can make for quite a different kind of day with far better pain avoidance/management (as well as providing the comfort of a familiar routine).

• Avoid inflammatory foods and other known triggers, take extra boosts of quercetin and whatever else helps with mast cell release, alkalise with bicarbonate between meals, take extra NAC to mop up cytokines.

• Especially avoid alcohol and sugar temptations!

• Try, as far as possible, to keep to similar foods to normal. Bring stabilising staples from home (such as preferred muesli and milk substitute, herbal teas that soothe etc) and especially eat a grounding and familiar breakfast (most important meal of the day), one that isn’t too much to digest such as the temptation of a hotel “fry up”, trying to stick to the rule of small regular meals rather than big heavy ones. Remember that slow gut motility issues may be even more sluggish when I have been on my feet or braced, holding tension, for longer and that, when blood is diverted to the stomach to process a heavier than normal meal, this also trigger POTS more readily.

• Carry appropriate snacks eg. salty protein.

• Hydrate at all times and carry those electrolytes with you everywhere you go, no exceptions.

• Use whatever vagal stimulator currently works…for instance, my neck fan doubles up for both temperature regulation as well as gentle vagus nerve stimulation, helping me to stay upright and avoid dizzy spikes. Also a TENS machine doubles up as both coat hanger pain relief or mid back pain relief when more upright and as vagal “stim”, worn discretely under my clothes all day, helping to keep blood flow working and orthostatic symptoms at bay. The less hard the body has to work to circulate blood or regulate the nervous system the less reliant it will be on adrenaline to keep upright or keep on going and therefore the less exhausted it will feel afterwards.

• Wear whatever compression clothing I can bear (and, if I’m struggling due to hot weather, at least something snug but comfortable around the lower torso, even a torso belt, can help).

• Keep an extra eye on those measurable devices (in my case, Visible strap, Garmin watch, Hilo device) during events: how many higher stress minutes have I accumulated today, am I getting any genuine rest period or does my watch indicate that my system isn’t really calming down even when I take a so-called rest or when asleep (this is a sure sign my adrenaline and cortisol are “up”) and, if so, use breathing techniques and mindfulness tools, longer leg elevation periods and calming supplements such as l-theanine or CBD as emergency measures. How many body battery points am I ending and starting my days with (aim for finishing the day with no less than 20 points left to get through the night with sufficient resources for deep rest and repair)? Notice what the specific energy drains are during the day and avoid or minimise them. How well am I coping with being upright, look out for signs of POTS and hydrate or sit down more than ever when this is active because pushing through this is the biggest fatigue source of all. Is my blood pressure spiking overnight, can I wind down any better than this, even in the alien bed/room, to achieve more consistent sleep? Use whatever it takes, eg audibles, to soothe myself back to sleep promptly if I keep waking up.

• Keep a particular eye on sleep quality as a gauge for the day ahead and, when body battery is still low after a night’s sleep, make those daytime naps and rest periods happen whenever there is the slightest opportunity, even for just ten minutes lucid shut-eye here and there. Don’t be too proud to close your eyes during the boring bit of a performance or ceremony!

• Use sensory soothers and modulators: wear comfortable fabrics close to skin, take stim objects everywhere with me, pick most comfortable shoes, wear a soft scarf around the neck even on a hot day, don’t forget hat and sunglasses (and to use them whenever things get too bright, even indoors), use loop earplugs as necessary, take familiar pillows/cushions and blanket to replace hotel bedding, dress in removable layers, pack soothing scents and anything else that brings familiarity and comfort wherever I go, carry hygienic sprays and wet wipes to achieve cleanliness in places that cause contact anxiety.

• Surround myself with comfort sensations such as own sleep blanket and familiar aromas and avoid triggering textures and smells. Use familiar comforting perfume to mask any dubious aromas in the room where I am staying and disengage any hotel-provided room scents which likely contain MCAS triggers, open windows for fresh air (however the window in our room would only open about an inch as it was on the ground level). Cover face in any aroma-triggering zones (eg. at the hotel this week, the corridor outside our room had no windows and smelt like the inside of a vacuum cleaner bag, which I found extremely nauseating and triggering so I would hold my breath or walk with my scarf over my nose until we got to our room).

• Acknowledge to myself that sensory triggers can have broad and deeply affecting consequences so avoid them as best I can but also allow them to be valid. I really do have a very high degree of sensitivity that is more akin to the sensibilities of an animal, such as a dog with its acute sense of smell, than the average human and the only reason other people don’t always make such a thing of sensory triggers isn’t because I am wrong or fussy but because they simply don’t even notice them. If you have ever read Gulliver’s Travels you will have some idea how it can be for someone with high-functioning olfactory senses! The world is therefore not very often made to my exacting standards so, when triggers occur, I need to allow the emotions that arise to be expressed and heard and not denied, made wrong or allowed to get bottled up inside of me where they would do most harm. Sensory issues can give rise to emotions as strong as rage, especially when I feel deeply frustrated, helpless or even angry that they had to occur in the first place (e.g. because other people presumably have lower cleanliness standards than I do), so I cannot simply tell myself to “get over this” as a neurotypical person might say to me. The freedom to express my legitimate emotions out loud, in whatever most appropriate way and timing possible, is important to prevent escalation of the overwhelm I am feeling. (For instance, the hotel room we stayed in was in a really poor decorative and cleanliness state, with strong musty aromas that spoke of aged overworn carpets in dire need of replacing etc, in spite of this being a “premier” room in a not inexpensive hotel. There were also trays of room service debris outside our door when we arrived, and the corridor was often strewn with empty bottles and uncollected trays. I had to both acknowledge and process my disappointment and discontent, and also how much all this was triggering my senses, out loud to my husband (who patiently listened as much as I needed him to but far better this than a hostile confrontation with front staff that would have no immediate solution to offer as regards our “tired” room) to prevent these feelings from getting the better of me (did you know venting to someone who willingly listens releases cortisol and slows the heart). I also resolved to send my feedback to the hotel and write my honest review after the trip. Rage is an interesting emotion that speaks of a kind of fear stemming from a sense of powerlessness, i.e. “feeling like there is nothing that can be done about something deeply bothering us” so offering to myself ways that I can “do something” active, like vent my frustrations out loud or feed my opinions back in a proactive way, allows for a kind of release to occur before the intense emotions become internalised or toxic to my health).

• Self-advocate and set boundaries with those who pressure me to do more than I know I am capable of…they don’t necessarily relate and they’re not the ones paying for it, in triplicate, for weeks afterwards, nor do they have any real idea how much, nor in how many ways, I struggle both during and especially after the event so the responsibility to self-advocate and set boundaries lies with me. Standing up for what I need to happen or not happen (deciding for myself the bits I can and can’t do or which can be modified slightly or “not a chance” I can manage this) is a crucial part of mitigating any after effects. I can never hope to cope with big events whilst I still allow myself to go with the flow of other people’s expectations and idea of normal behaviour since these are simply not designed to accommodate my actual capacity. Its down to me to set my own limits and make these come into being.

• “Things happen” so I need to have my emotional regulation tactics handy for unexpected upsets and turns of event, especially if I want to avoid meltdowns or shutdowns at exactly the wrong moment. (For instance, at the hotel this week, I was enjoying some brief quiet time outside after breakfast right before leaving for the graduation when I witnessed a fisherman on the lake catch a baby coot on his rod and then the ensuing scene where the bird was in obvious distress hanging from the line and the parent coot in equal distress charging across the water wings outstretched at the fisherman threatening its young. The fisherman, who was too far away for me to get to and on a sort of island with private access (I tried but failed to get there to find out what was happening close up) apparently made some sort of clumsy effort to release the panicking bird from his rod, or perhaps he just cut the wire it was attached to leaving it attached, before calmly reloading his rod and continuing to fish as if nothing had happened. I still have no idea what the outcome was for the bird since I couldn’t see in any detail and the distress noises from the parent bird continued on for quite some time. I had the “video” of this highly distressing scene of human carelessness and wanton harm towards nature running through my head on loop for hours afterwards…and can still see it vividly in my head…but knew that I had to use all of my self-soothing techniques and logic – things like “I don’t know for sure that the bird was badly hurt” – to talk myself down from my distress or the compunction to hyperfocus upon it, which could have utterly floored me with a trauma response even before my busy day began if I’d let it. Believe me, this took quite some doing!)

• Related to this topic, emotional processing is often pretty delayed in my case (as is often so with neurodivergence) so an apparent lack of reaction at the time of the occurance or “seeming to carry on as if nothing has happened” is not ever a case of my not feeling any emotions but of postponing them until later when there is more time or a safer space in which to process them. In fact, emotional responses are very often much stronger in neurodivergent than typical people expect since we often think and feel into everything especially deeply, pondering into all the possible scenarios, repercussions and outcomes of life’s twists and turns. A big event is generally littered with multiple emotional triggers so I need to be aware that my own null response to some of them “at the time” of the big event does not mean that I am unaffected but that they may all catch up with me later on in one almighty autistic emotion bomb after the event. (For instance, at this event, there were many nuanced emotional layers occurring all at once, with other people’s excitement and anxiety amongst them for me to readily soak up as I do. My own included having a more social time than usual plus the heightened emotions of spending a rare few days with my daughter and her boyfriend both of whom we have seen so little whilst she was under deadline pressure all year, the happy but intense experience of seeing her graduate finally and knowing that she is now a fully-fledged adult entering the world of work, therefore the realisation that my parenting job of twenty years whilst she has been in education is now over (a prolonged period because she chose a particularly long academic route) is only just hitting me. It’s a lot to have to take in and process all at once and bound to catch up with me as soon as I have the time and space to process).

• Don’t ever forget how deeply and profoundly I need solitude and space in order to self-regulate. First of all, its unlikely I will get much or any of this whilst the big event itself is underway and (like holding my breath for a deep plunge underwater) I have to brace myself for this and be prepared to sustain myself without two of my most crucial resources for as long as it lasts. Equally, when I get back home, I will need space and solitude even more than ever for as long as it takes to recover from all the sensory and emotional overstimulation so shutdown is very likely and should be accepted and expected, not guilted (by me or others) and with no apology or explanations required. The more I self-advocate for this and claim it, the more usual and unprovocative it will seem to those who have to live with me when I withdraw into myself and avoid even eye contact for these highly necessary periods of sensory respite.

• Immersion in water is a powerful and, usually, fairly accessible self- regulation tool, achievable by, for instance, making sure that there is always a bathtub in the hotel room whenever I am attending a big event. Knowing I have access to this at the end of the day or before I have to face the world again can make all the difference to the experience. Having access to a pool “should” also provide a similar facility if it can be accessed at quieter times of day but is thwarted, in my case, by the fact that I am utterly intolerant of chlorine which meant that I wasn’t able to take advantage of this at the hotel this week but I did have a bathtub. However, this sensory need for ready access to water to self-regulate can backfire when things go unexpectedly wrong (all the worse when you are poised to get into the bathtub to wash away all the unpleasant sensory dross of the day but then this doesn’t happen for some reason…), in which case one of the first things that can help me get back on the road to recovery, the minute I get home, is to take myself off for a long soak in a mineral infused bath, even if I think I am too tired to be bothered; believe me, it always pays off. (This is something I did last night as soon as I arrived home as my hope of soaking away the aches, pains and sensory overstimulation of the day of the big event itself, or the morning afterwards when I was as stiff as if I had taken part in a triathlon, was confounded by our room having such dire water pressure that I couldn’t manage to draw a bath in the short time available to me before breakfast ended; another sensory let-down of the hotel that I was forced to process out loud to my long suffering husband in order to let go of the high frustration it gave rise to!)

• The minute I get back home, for goodness sake, don’t start strategising the next big event in the diary (a temptation that always seems to arise because the urge to survive the next one is unusually strong straight after I’ve got past one big hurdle…) As the aftermath is yet to happen, I haven’t safely got past this event yet so I really need to allow my nervous some respite from the endless survival strategising, at least for a few days ahead or a week or so. If not careful, life turns into nothing but a long series of big events to “get through” and that is absolutely no way to live life, either for me or my nervous system!

• Allow whatever way things unfold or any strong emotions that arise during an event to be “OK” without judgement or shame. My way of getting through an event might not be typical and will generally involve a lot of extra strategy and accommodations but it is just as valid as the next person’s and, the more I own this, the less disappointed I am with myself or my circumstances (rather than how it was when I endlessly compared myself with other people for years and years). The world does not, in any large way, accommodate people with neurodivergent sensory responses to the environment or their not insubstantial neurological or physical differences, especially if hypermobile, therefore big events are seldom pitched to accommodate us, as a minority factor in the room. The very best I can do is have my own list of helpful methods and tools at hand to get me through these big events my way whenever they happen, with a view to minimising the worst kinds of after effects sufficiently enough for me to be able to hold on to the happy highlights (of which there were many this celebratory week) instead of all the low points.

• If I then continue to manage the aftermath to the best of my ability (which always involves a scheduled “withdrawal day” to help me refind my equilibrium…though I am using the writing of this piece as self-regulation I have utterly withdrawn from all social interactions, not even able to make eye contact today, in order to be in my sensory “cave” and I am yet still experiencing a whole lot of heightened sensory symptoms for sure) then I hope to be left with far more than just a set of smiling photographs that feel like they belie harsh reality because the undeniably hard parts of the event or its aftermath won’t have completely overshadowed the mostly positive way things actually played out overall. I can then feel validated in all the positive self-supportive steps that I was able to take along the way.

Disclaimer: This blog, it’s content and any material linked to it are presented for autobiographical, general interest and anecdotal purposes only. They are not intended to serve as medical advice, diagnosis, treatment or prescribing. Opinions are my own based on personal experience. Please seek medical advice from a professional if you are experiencing any mental or physical symptoms that concern you.