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From the Townsend Letter
February / March 2017

A Case of Autonomic Dysregulation Syndrome
by Richard Kitaeff, MA, NMD, DipAc, LAc
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The Case
Eric is a 36-year-old male, married with one child. His primary complaint was one to three daily episodes of rapid or irregular heartbeat, sometimes accompanied by chest pain or shortness of breath, starting about 10 months prior to his initial consultation after an extended period of taking red yeast rice at a high dose (6000 mg daily) for self-treatment of a long-standing hyperlipidemia. Episodes could be triggered by neck movement or feelings of anxiety. The heart arrhythmia, in turn, could intensify feelings of anxiety. His history included a whiplash injury, leading to ongoing left-sided middle to upper back (scapular) and costal pain. He also experienced frequent gastroesophageal symptoms, including tightness in the throat, nausea, heartburn, abdominal pain, and bloating. Digestive symptoms seemed to be helped by taking Zypan (hydrochloric acid) with meals. His energy was usually low, his sleep was often disturbed, and he had seasonal allergy. He was also concerned about a history of low testosterone. Prior to seeing me, a cardiology examination had shown EKG to be normal, and he was given a provisional diagnosis of preventicular contractions.

On my initial examination, his pulse rate and temperature were normal, blood pressure was 130/90, chest sounds unremarkable, and salivary pH was 7.0. His tongue was red and slightly dry, and superficial second pulse positions on both wrists (representing stomach and gall bladder organ systems in the traditional Chinese medical system of diagnosis) were excessive.

On recent blood chemistry testing, BUN/Creatinine was slightly high, total cholesterol 286, LDL 174, and triglycerides 364. (A previous test for triglycerides showed a level of 712.) Recent findings for Vitamin D 25(OH) were 14.8 and 30.1.

HgbA1C was 5.5. Free testosterone at 6.4 and sex hormone binding globulin at 11.7 were both low. On ASI testing, DHEA was borderline low. Hair Mineral Testing showed moderately toxic levels of mercury, aluminum, and titanium; and there were notable deficiencies of magnesium, potassium, copper, sodium, manganese, chromium, boron, lithium, and molybdenum. IgG/IgE Food Allergy testing showed reactions to whey, egg white and yolk, shellfish, banana, pineapple, green bean, kidney bean, brewer's yeast, and mushroom. On the same test, the candida antibody was elevated, agreeing with a high score on the Candida Questionnaire.

While initiating a program of treatment, I referred Eric to another cardiologist for a repeat EKG and Holter monitor testing. The cardiologist confirmed the previous diagnosis of PVC's and tried to reassure him that they were benign to allay his anxiety. He considered Eric a candidate for beta blockers but respected his preference for a natural therapy approach.

ProTheraThe Syndrome
Considering the extent of symptoms and test data, the diagnosis of PVC does not seem adequate for this patient. The traditional Chinese medical syndrome, in this case, of a rebellious digestive fire rising up to disturb the heart rhythm and cause emotional unease, seems far more inclusive. The best Western equivalence to the Chinese syndrome would be sympathetic dominance. In the medical literature, autonomic dysregulation syndrome is mentioned in the context of "Rapid Onset Obesity with Hypothalamic Dysfunction, Hypoventilation and Autonomic Dysregulation Syndrome" or ROHAAD: "a rare childhood disease, affecting endocrine, respiratory and autonomic nervous systems, and including cardiopulmonary arrest and digestive dysmotility and may be accompanied by behavioral problems, personality changes and mood disorders."1 The autonomic nervous system is known to regulate bodily functions such as heart rate, digestion, and respiratory rate and is itself regulated by the hypothalamus, receiving input from the limbic system, including the amygdala (the "emotional brain"), and releasing neurotransmitters affecting mood as well as the previously mentioned physical functions. While ROHAAD may be "a rare childhood disease," one could postulate an autonomic dysregulation syndrome that fits the present case and in fact many cases typically presented to every health practitioner on a daily basis.

Eric's symptoms incorporate cardiac, digestive, endocrine, and emotional aspects of autonomic control. Shen and Zipes in Circulation Research write that "the autonomic nervous system plays an important role in the modulation of cardiac electrophysiology and arrhythmogenesis." Furthermore, "the identification of specific autonomic triggers in different arrhythmias has brought the idea of modulating autonomic activities for both preventing and treating these arrhythmias."2

Eric's digestive symptoms may be associated with gastroesophageal reflux disease (GERD), candidiasis, or atrophic gastritis, which is caused by H. pylori bacterium and is characterized by abdominal pain, nausea, and vomiting. His digestive symptoms are reduced by taking hydrochloric acid, and achlorhydria is often consistent with conditions such as gastroesophageal reflux, abdominal bloating, and discomfort. Some medical opinion notes the connection between atrial fibrillation and gastroesophageal reflux disease or "the cardiogastric interaction," due to the close anatomic proximity of the esophagus and the left atrium. Potential atrial arrhythmogenic mechanisms in patients with GERD could be gastric and could involve subsequent systemic inflammation or impaired autonomic stimulation. Treatment of GERD is therefore suggested as a way of avoiding atrial fibrillation.3

Numerous studies have utilized heart rate variability (HRV) and other measures of cardiac or respiratory function to demonstrate dysregulation of autonomic cardiac control by traumatic stress and anxiety.4 A systematic review and meta-analysis of autonomic nervous system dysfunction in psychiatric disorders concludes that "ANS dysfunction is a putative underlying mechanism for increased cardiovascular disease risk in individuals with psychiatric disorders."5 More generally, alteration of ANS reactivity has been found in depressed or anxious patients, dependent on the type of stressor.6

This patient was overweight with borderline high blood pressure, glucose, and HgBA1C and likely a strong hereditary hyperlipidemia, all suggesting metabolic syndrome. Again, there has been medical opinion that "activation of the sympathetic nervous system has an important role in metabolic syndrome" and "treatment strategies commonly recommended for patients with metabolic syndrome, such as diet and exercise to induce weight loss, are associated with sympathetic inhibition." Pharmacological and other approaches have also targeted the sympathetic nervous system.7 Low adrenal and sex hormone status also involve autonomic control. A study utilizing heart rate variability to measure the response to an infusion of angiotensin in healthy men concluded "an unfavorable shift in the cardiac autonomic tone in men with lower testosterone levels in response to a stressor."8

The thread that unites the various cardiac, digestive, emotional, and endocrine symptoms in this case appears to be the factor of autonomic nervous system control. Since this complex of symptoms is far from rare in most medical practice, one could adopt the Medical Symptoms Questionnaire (MSQ) as an initial screening for autonomic dysregulation syndrome. Its rating of symptoms in each category (including head, eyes, ears, nose, mouth/throat, skin, heart, lungs, digestive tract, joints/muscles, weight, energy/activity, mind, emotions) could arrive at a score (a total of 50 or greater) to make a preliminary assessment.

The Treatment
Treatment for this case involved several treatment modalities intended to regulate the autonomic nervous system. The primary modality used was acupuncture, since the mechanism through which acupuncture achieves its many treatment effects is widely recognized to be autonomic nervous system regulation. In fact, it could be termed the treatment of choice for the syndrome under consideration. Eric had a series of 10 weekly acupuncture treatments, followed by five treatments at two-week intervals as his symptoms improved. Over my four decades of acupuncture practice, following my original training in Asia, I have explained acupuncture to patients and professional colleagues not in terms of Yin and Yang or Qi, but as autonomic regulation, similar to tuning an instrument, resulting in the release of neurotransmitters and other body chemicals, as in the mediation of the well-known pain-relieving effect through the release of endorphins.
A study of electrically stimulated acupuncture "confirmed that acupuncture induced parasympathetic nerve stimulation, resulting in a decrease in the heart rate," suggesting possible modulation of the autonomic nervous system by acupuncture.9 A randomized controlled study in healthy volunteers concluded that sphenopalatine ganglion (SPG) acupuncture, one of several anatomical micro-systems utilized by acupuncturists, helped to improve nasal ventilation by increasing sympathetic nerve excitability.10 In the Journal of the Autonomic Nervous System, it was reported that sensory stimulation by acupuncture in healthy persons "is associated with changed activity in the sympathetic and parasympathetic nervous system."11
One of the most effective modalities to produce a strong relaxation response for this patient and others has been cranial electrical stimulation or cranial TENS, using a simple device that can be safely prescribed for home use. In this case, accompanying each acupuncture treatment, the device (either the Alpha-Stim or CES Ultra) consisted of clips attached to the earlobe delivering a barely perceptible micro-current. This method obviously takes advantage of the relationship found in auricular acupuncture (another of the acupuncture micro-systems) between the earlobe and the hypothalamus in the brainstem via the vagus nerve. Thus a strong parasympathetic response is elicited. Research has shown that cranial TENS or CES has produced significant reductions in autonomic measures of blood pressure, pulse rate, peripheral vasomotor activity, and anxiety.12
BEMER or pulsed electromagnetic field therapy (PEMF) also accompanied each acupuncture treatment. A popular therapy in Germany and other European countries, BEMER delivers a field surrounding the body that increases microcirculation through autonomic stimulation of vasomotor activity in precapillary vessels.13 Its effects have been beneficial for insomnia, pain, and a variety of other disorders, including osteoporosis and lymphoma. In addition, "pulsed EMF applied to the vagal trunks or noninvasively across the chest can significantly reverse atrial fibrillation inducibility."14
Eric's treatment program also included sessions of self-hypnosis or relaxation training, aided by galvanic skin response (GSR) biofeedback training. Biofeedback, using various instruments including GSR, is commonly used in medical settings for management of anxiety;15 and recently, heart rate variability biofeedback training has been shown to improve cardiac autonomic tone and to facilitate blood pressure adjustment for hypertensive individuals.16 When relaxation training was combined with GSR biofeedback, the combined approach optimized reduction of anxiety in a group of college students under stress.17 Since Eric's history of whiplash and thoracocostal pain appeared to be involved in his PVC episodes, he was also referred to a chiropractor in our clinic (a referral that was endorsed by the cardiologist) and seemed to derive considerable benefit from chiropractic adjustment.

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