The main causes of liver damage are:
1. Sleeping too late and waking up too late are main cause.
2. Not urinating in the morning.
3. Too much eating.
4. Skipping breakfast.
5. Consuming too much medication.
6. Consuming too much preservatives, additives, food coloring, and artificial sweetener.
7. Consuming unhealthy cooking oil. As much as possible reduce cooking oil use when frying, which includes even the best cooking oils like olive oil. Do not consume fried foods when you are tired, except if the body is very fit.
8. Consuming raw (overly done) foods also add to the burden of liver.
Veggies should be eaten raw or cooked 3-5 parts. Fried veggies should be finished in one sitting, do not store.
We should prevent this without necessarily spending more. We just have to adopt a good daily lifestyle and eating habits. Maintaining good eating habits and time condition are very important for our bodies to absorb and get rid of unnecessary chemicals according to 'schedule.'
Saturday, January 31, 2009
The top five cancer-causing foods are:
The top five cancer-causing foods are:
1. Hot dogs
Because they are high in nitrates, the Cancer Prevention Coalition advises that children eat no more than 12 hot dogs a month. If you can't live without hot dogs, buy those made without sodium nitrate.
2. Processed meats and bacon
Also high in the same sodium nitrates found in hot dogs, bacon, and other processed meats raise the risk of heart disease. The saturated fat in bacon also contributes to cancer.
3. Doughnuts
Doughnuts are cancer-causing double trouble. First, they are made with white flour, sugar, and hydrogenated oils, then fried at high temperatures. Doughnuts, says Adams , may be the worst food you can possibly eat to raise your risk of cancer.
4. French fries
Like doughnuts, French fries are made with hydrogenated oils and then fried at high temperatures. They also contain cancer- causing acryl amides which occur during the frying process. They should be called cancer fries, not French fries, said Adams .
5. Chips, crackers, and cookies
All are usually made with white flour and sugar. Even the ones whose labels claim to be free of trans-fats generally contain small amounts of trans-fats.
BRAIN DAMAGING HABITS
1. No Breakfast
People who do not take breakfast are going to have a lower blood sugar level.
This leads to an insufficient supply of nutrients to the brain causing brain degeneration.
2. Overeating
It causes hardening of the brain arteries, leading to a decrease in mental power.
3. Smoking
It causes multiple brain shrinkage and may lead to Alzheimer disease.
4. High Sugar consumption
Too much sugar will interrupt the absorption of proteins and nutrients causing malnutrition and may interfere with brain development.
5. Air Pollution
The brain is the largest oxygen consumer in our body. Inhaling polluted air decreases the supply of oxygen to the brain, bringing about a decrease in brain efficiency.
6. Sleep Deprivation
Sleep allows our brain to rest. Long term deprivation from sleep will accelerate the death of brain cells.
7. Head covered while sleeping
Sleeping with the head covered increases the concentration of carbon dioxide and decrease concentration of oxygen that may lead to brain damaging effects.
8. Working your brain during illness
Working hard or studying with sickness may lead to a decrease in effectiveness of the brain as well as damage the brain.
9. Lacking in stimulating thoughts
Thinking is the best way to train our brain, lacking in brain stimulation thoughts may cause brain shrinkage.
10. Talking Rarely
Intellectual conversations will promote the efficiency of the brain
1. Hot dogs
Because they are high in nitrates, the Cancer Prevention Coalition advises that children eat no more than 12 hot dogs a month. If you can't live without hot dogs, buy those made without sodium nitrate.
2. Processed meats and bacon
Also high in the same sodium nitrates found in hot dogs, bacon, and other processed meats raise the risk of heart disease. The saturated fat in bacon also contributes to cancer.
3. Doughnuts
Doughnuts are cancer-causing double trouble. First, they are made with white flour, sugar, and hydrogenated oils, then fried at high temperatures. Doughnuts, says Adams , may be the worst food you can possibly eat to raise your risk of cancer.
4. French fries
Like doughnuts, French fries are made with hydrogenated oils and then fried at high temperatures. They also contain cancer- causing acryl amides which occur during the frying process. They should be called cancer fries, not French fries, said Adams .
5. Chips, crackers, and cookies
All are usually made with white flour and sugar. Even the ones whose labels claim to be free of trans-fats generally contain small amounts of trans-fats.
BRAIN DAMAGING HABITS
1. No Breakfast
People who do not take breakfast are going to have a lower blood sugar level.
This leads to an insufficient supply of nutrients to the brain causing brain degeneration.
2. Overeating
It causes hardening of the brain arteries, leading to a decrease in mental power.
3. Smoking
It causes multiple brain shrinkage and may lead to Alzheimer disease.
4. High Sugar consumption
Too much sugar will interrupt the absorption of proteins and nutrients causing malnutrition and may interfere with brain development.
5. Air Pollution
The brain is the largest oxygen consumer in our body. Inhaling polluted air decreases the supply of oxygen to the brain, bringing about a decrease in brain efficiency.
6. Sleep Deprivation
Sleep allows our brain to rest. Long term deprivation from sleep will accelerate the death of brain cells.
7. Head covered while sleeping
Sleeping with the head covered increases the concentration of carbon dioxide and decrease concentration of oxygen that may lead to brain damaging effects.
8. Working your brain during illness
Working hard or studying with sickness may lead to a decrease in effectiveness of the brain as well as damage the brain.
9. Lacking in stimulating thoughts
Thinking is the best way to train our brain, lacking in brain stimulation thoughts may cause brain shrinkage.
10. Talking Rarely
Intellectual conversations will promote the efficiency of the brain
Sunday, January 25, 2009
melanin
Also called pigment, melanin is a substance that gives the skin and hair its natural color. It also gives color to the iris of the eye, feathers, and scales. In humans, those with darker skin have higher amounts of melanin. By contrast, those with less pigment have lighter or more fair skin coloring.
A skin pigment (substance that gives the skin its color). Dark-skinned people have more melanin than light- skinned people. Melanin also acts as a sunscreen and protects the skin from ultraviolet light.
Melanin is produced by cells called melanocytes. It provides some protection again skin damage from the sun, and the melanocytes increase their production of melanin in response to sun exposure. Freckles, which occur in people of all races, are small, concentrated areas of increased melanin production.
Melanin, sometimes referred to as a chemical, is formed as part of the process of metabolizing an amino acid called tyrosine. In the skin, melanin is formed by cells called melanocytes. Certain medical conditions, such as albinism, are associated with the lack of melanin. Albinism is a condition marked by the abesnce of a normal amount of pigment in the body. Animals, humans, and even plants can have albinism.
Albinism exists in a number of variations. Depending on the type of albinism, the skin, hair, and eyes may all be affected. In fact, ocular albinism affects not only the color of the eyes, hair, and skin, but also results in poor vision. Additionally, some types of melanin deficiency are associated with increased mortality rates.
Melanin provides many benefits to human beings. One of the most recognized benefits involves ultraviolet rays of the sun. Melanin provides a natural protection against the harmful effects of these rays. However, it does not provide complete protection from the sun, and individuals with darker skin tones are still at risk from the sun's damaging rays.
Generally, those with darker skin tones and more melanin are able to tolerate exposure to the sun for hours without getting sunburn. By contrast, a person with lighter skin may get sunburn after spending only minutes in the midday sun. Skin cancer is directly related to exposure to the sun and the presence of less than optimal amounts of pigment. Sun exposure has even been linked with cataracts.
Melanin is the natural substance that gives color (pigment) to hair, skin, and the iris.
In humans, melanin is the primary determinant of human skin color and also found in hair, the pigmented tissue underlying the iris, the medulla and zona reticularis of the adrenal gland, the stria vascularis of the inner ear, and in pigment-bearing neurons within areas of the brain stem, such as the locus ceruleus and the substantia nigra.
Dermal melanin is produced by melanocytes, which are found in the stratum basale of the epidermis. Although human beings generally possess a similar concentration of melanocytes in their skin, the melanocytes in some individuals and ethnic groups more frequently or less frequently express the melanin-producing genes, thereby conferring a greater or lesser concentration of skin melanin. Some individual animals and humans have very little or no melanin in their bodies, a condition known as albinism.
Because melanin is an aggregate of smaller component molecules, there are a number of different types of melanin with differing proportions and bonding patterns of these component molecules. Both pheomelanin and eumelanin are found in human skin and hair, but eumelanin is the most abundant melanin in humans, as well as the form most likely to be deficient in albinism.
Eumelanin polymers have long been thought to comprise numerous cross-linked 5,6-dihydroxyindole (DHI) and 5,6-dihydroxyindole-2-carboxylic acid (DHICA) polymers; recent research into the electrical properties of eumelanin, however, has indicated that it may consist of more basic oligomers adhering to one another by some other mechanism. Thus, the precise nature of eumelanin's molecular structure is once again the object of study.[citation needed] Eumelanin is found in hair and skin, and colors hair grey, black, yellow, and brown. In humans, it is more abundant in peoples with dark skin. There are two different types of eumelanin, which are distinguished from each other by their pattern of polymer bonds. The two types are black eumelanin and brown eumelanin, with black melanin being darker than brown. Black eumelanin is in mostly non-Europeans and aged Europeans, while brown eumelanin is in mostly young Europeans. A small amount of black eumelanin in the absence of other pigments causes grey hair. A small amount of brown eumelanin in the absence of other pigments causes yellow (blond) color hair.
Pheomelanin is also found in hair and skin and is both in lighter skinned humans and darker skinned humans. In general women have more pheomelanin than men, and thus women's skin is generally redder than men's. Pheomelanin imparts a pink to red hue and, thus, is found in particularly large quantities in red hair. Pheomelanin is particularly concentrated in the lips, nipples, glans of the penis, and vagina.[4] Pheomelanin also may become carcinogenic when exposed to the ultraviolet rays of the sun. Chemically, pheomelanin differs from eumelanin in that its oligomer structure incorporates benzothiazine units which are produced instead of DHI and DHICA when the amino acid L-cysteine is present.
Neuromelanin is the dark pigment present in pigment bearing neurons of four deep brain nuclei: the substantia nigra (in Latin, literally "black substance") - Pars Compacta part, the locus ceruleus ("blue spot"), the dorsal motor nucleus of the vagus nerve (cranial nerve X), and the median raphe nucleus of the pons. Both the substantia nigra and locus ceruleus can be easily identified grossly at the time of autopsy due to their dark pigmentation. In humans, these nuclei are not pigmented at the time of birth, but develop pigmentation during maturation to adulthood. Although the functional nature of neuromelanin is unknown in the brain, it may be a byproduct of the synthesis of monoamine neurotransmitters for which the pigmented neurons are the only source. The loss of pigmented neurons from specific nuclei is seen in a variety of neurodegenerative diseases. In Parkinson's disease there is massive loss of dopamine producing pigmented neurons in the substantia nigra. A common finding in advanced Alzheimer's disease is almost complete loss of the norepinephrine producing pigmented neurons of the locus ceruleus. Neuromelanin has been detected in primates and in carnivores such as cats and dogs.
Melanin is also a mechanism for absorbing heat from the sun. This purposes is of particular importance to cold-blooded animals. Snakes, lizards, certain types of fish, and a wide range of other animals depend on their surroundings, including the rays of the sun, to establish and maintain their body temperatures.
Also important for sharpness of vision, melanin serves to minimalize the number of light beams that enter the eye. It also provides for the absorption of scattered light within the eye. In this way, pigmentation allows for more keen sight.
A skin pigment (substance that gives the skin its color). Dark-skinned people have more melanin than light- skinned people. Melanin also acts as a sunscreen and protects the skin from ultraviolet light.
Melanin is produced by cells called melanocytes. It provides some protection again skin damage from the sun, and the melanocytes increase their production of melanin in response to sun exposure. Freckles, which occur in people of all races, are small, concentrated areas of increased melanin production.
Melanin, sometimes referred to as a chemical, is formed as part of the process of metabolizing an amino acid called tyrosine. In the skin, melanin is formed by cells called melanocytes. Certain medical conditions, such as albinism, are associated with the lack of melanin. Albinism is a condition marked by the abesnce of a normal amount of pigment in the body. Animals, humans, and even plants can have albinism.
Albinism exists in a number of variations. Depending on the type of albinism, the skin, hair, and eyes may all be affected. In fact, ocular albinism affects not only the color of the eyes, hair, and skin, but also results in poor vision. Additionally, some types of melanin deficiency are associated with increased mortality rates.
Melanin provides many benefits to human beings. One of the most recognized benefits involves ultraviolet rays of the sun. Melanin provides a natural protection against the harmful effects of these rays. However, it does not provide complete protection from the sun, and individuals with darker skin tones are still at risk from the sun's damaging rays.
Generally, those with darker skin tones and more melanin are able to tolerate exposure to the sun for hours without getting sunburn. By contrast, a person with lighter skin may get sunburn after spending only minutes in the midday sun. Skin cancer is directly related to exposure to the sun and the presence of less than optimal amounts of pigment. Sun exposure has even been linked with cataracts.
Melanin is the natural substance that gives color (pigment) to hair, skin, and the iris.
In humans, melanin is the primary determinant of human skin color and also found in hair, the pigmented tissue underlying the iris, the medulla and zona reticularis of the adrenal gland, the stria vascularis of the inner ear, and in pigment-bearing neurons within areas of the brain stem, such as the locus ceruleus and the substantia nigra.
Dermal melanin is produced by melanocytes, which are found in the stratum basale of the epidermis. Although human beings generally possess a similar concentration of melanocytes in their skin, the melanocytes in some individuals and ethnic groups more frequently or less frequently express the melanin-producing genes, thereby conferring a greater or lesser concentration of skin melanin. Some individual animals and humans have very little or no melanin in their bodies, a condition known as albinism.
Because melanin is an aggregate of smaller component molecules, there are a number of different types of melanin with differing proportions and bonding patterns of these component molecules. Both pheomelanin and eumelanin are found in human skin and hair, but eumelanin is the most abundant melanin in humans, as well as the form most likely to be deficient in albinism.
Eumelanin polymers have long been thought to comprise numerous cross-linked 5,6-dihydroxyindole (DHI) and 5,6-dihydroxyindole-2-carboxylic acid (DHICA) polymers; recent research into the electrical properties of eumelanin, however, has indicated that it may consist of more basic oligomers adhering to one another by some other mechanism. Thus, the precise nature of eumelanin's molecular structure is once again the object of study.[citation needed] Eumelanin is found in hair and skin, and colors hair grey, black, yellow, and brown. In humans, it is more abundant in peoples with dark skin. There are two different types of eumelanin, which are distinguished from each other by their pattern of polymer bonds. The two types are black eumelanin and brown eumelanin, with black melanin being darker than brown. Black eumelanin is in mostly non-Europeans and aged Europeans, while brown eumelanin is in mostly young Europeans. A small amount of black eumelanin in the absence of other pigments causes grey hair. A small amount of brown eumelanin in the absence of other pigments causes yellow (blond) color hair.
Pheomelanin is also found in hair and skin and is both in lighter skinned humans and darker skinned humans. In general women have more pheomelanin than men, and thus women's skin is generally redder than men's. Pheomelanin imparts a pink to red hue and, thus, is found in particularly large quantities in red hair. Pheomelanin is particularly concentrated in the lips, nipples, glans of the penis, and vagina.[4] Pheomelanin also may become carcinogenic when exposed to the ultraviolet rays of the sun. Chemically, pheomelanin differs from eumelanin in that its oligomer structure incorporates benzothiazine units which are produced instead of DHI and DHICA when the amino acid L-cysteine is present.
Neuromelanin is the dark pigment present in pigment bearing neurons of four deep brain nuclei: the substantia nigra (in Latin, literally "black substance") - Pars Compacta part, the locus ceruleus ("blue spot"), the dorsal motor nucleus of the vagus nerve (cranial nerve X), and the median raphe nucleus of the pons. Both the substantia nigra and locus ceruleus can be easily identified grossly at the time of autopsy due to their dark pigmentation. In humans, these nuclei are not pigmented at the time of birth, but develop pigmentation during maturation to adulthood. Although the functional nature of neuromelanin is unknown in the brain, it may be a byproduct of the synthesis of monoamine neurotransmitters for which the pigmented neurons are the only source. The loss of pigmented neurons from specific nuclei is seen in a variety of neurodegenerative diseases. In Parkinson's disease there is massive loss of dopamine producing pigmented neurons in the substantia nigra. A common finding in advanced Alzheimer's disease is almost complete loss of the norepinephrine producing pigmented neurons of the locus ceruleus. Neuromelanin has been detected in primates and in carnivores such as cats and dogs.
Melanin is also a mechanism for absorbing heat from the sun. This purposes is of particular importance to cold-blooded animals. Snakes, lizards, certain types of fish, and a wide range of other animals depend on their surroundings, including the rays of the sun, to establish and maintain their body temperatures.
Also important for sharpness of vision, melanin serves to minimalize the number of light beams that enter the eye. It also provides for the absorption of scattered light within the eye. In this way, pigmentation allows for more keen sight.
Orthostatic Intolerance (OI)
Orthostatic intolerance (OI) is the development of symptoms while standing or sitting upright. It has been associated with chronic fatigue and immune dysfunction syndrome (CFIDS) in both adults and children.
The connection between OI and CFIDS was first introduced in 1995,8 by Rowe and associates at Johns Hopkins University, who identified neurally mediated hypotension (NMH) in CFIDS patients. Since 1995, scientists have learned much more about the broader problem of OI in CFIDS, of which NMH is just one form. It is now thought that many CFIDS patients (up to 97% in some studies) have some form of OI and it seems to be a particular problem in youth with CFIDS.
Types of OI
There are many types of OI, but two forms have been linked with CFIDS in research studies: NMH and postural orthostatic tachycardia syndrome (POTS).
NMH is a precipitous drop (at least 20-25 mm Hg) in systolic blood pressure when standing. The blood pressure drop is accompanied or preceded by an increase in symptoms.
POTS is a rapid increase in heart rate (pulse) of more than 30 beats per minute (bpm) from baseline, or to more than 120 bpm total, during the first 10 minutes of standing.1 It is also known as chronic orthostatic intolerance, or COI.
The blood pressure and heart rate changes in NMH and POTS are accompanied by orthostatic symptoms such as lightheadedness, dizziness, nausea, fatigue, tremors, breathing or swallowing difficulties, headache, visual disturbances, sweating and pallor. Many patients develop swollen, bluish legs, providing evidence of blood pooling in the lower part of the body.
Testing
Most doctors are familiar with orthostatic hypotension (OH), which can result in fainting (or syncope, pronounced "sin-coh-pee") very quickly after standing, and can be diagnosed with a simple in-office test of taking the blood pressure first while lying down and again upon standing.
Unlike those with OH, which occurs within the first three minutes of standing, CFIDS patients with NMH or POTS often have a delayed form 13,14 of orthostatic intolerance, meaning that heart rate and blood pressure changes don't develop for many minutes after standing, making the standard in-office test for acute orthostatic hypotension ineffective in diagnosis. A tilt table test in CFS is considered to be positive if a patient experiences orthostatic symptoms and blood pressure and/or heart rate changes, whether or not he or she faints. Patients typically undergo a head-up tilt table test (HUT) as an outpatient in a hospital or cardiology office to get a definitive diagnosis. Since the HUT reproduces the symptoms of NMH and POTS, patients often feel worse during and after the test. Some testers administer IV saline following the test to reduce the occurrence of prolonged symptoms.
Dr. David Streeten, a researcher who studied circulatory problems, and who collaborated with CFIDS clinician Dr. David S. Bell, favored the use of a prolonged standing test as more representative of a patient's daily symptoms and experiences than the HUT. Blood pressure and heart rate are measured every few minutes while patients lie quietly for 30 minutes and again as they stand quiet and motionless for 60 minutes, or until severe symptoms develop. It is very important that either this test or the HUT be done under close medical supervision, as serious complications, including brief periods of very slow heart rate, can occur during the test.
Pathophysiology
There are several hypothesized causes of NMH and POTS relevant to CFIDS; regardless of the cause, all lead to inadequate blood circulation that may reduce the amount of blood getting back to the heart and brain. Patients may have low blood volume throughout the body or their blood may pool excessively in the extremities or both.
When healthy people stand, gravity causes about 750 ml of blood to fall to the abdomen and legs, resulting in a decrease in blood flow to the brain. In patients with POTS, cerebral blood flow decreases more prominently while standing.21 In one study of adolescents, the amount of blood that pooled in the legs was highest in CFIDS patients and second highest in POTS patients, as determined by measuring the circumference of their calves while lying down and again while standing.
When the heart receives less blood from the limbs during standing, the brain releases chemicals and alters the pulse and blood pressure in an effort to get the blood flowing upwards again. When this chemical response is accentuated, as in NMH and POTS, patients can develop a rapid heart rate (tachycardia), low blood pressure (hypotension) and orthostatic symptoms (see "Types of OI" above). CFIDS patients can have either NMH or POTS, and some have both conditions.
Researchers have identified several physiological abnormalities in CFIDS patients that are consistent with autonomic nervous system problems such as NMH and POTS. In five studies, adults and adolescents with CFIDS had elevated heart rates at rest compared to healthy and sedentary controls although two studies found no difference.2,24Heart rate further increased when patients underwent a tilt test, a finding consistent with POTS.
In addition, three studies - one in adults and two in adolescents11, - found that heart rate variability is significantly reduced in CFS compared to controls. This means that instead of having a heart rate that changes appropriately when faced with orthostatic stress, many CFS patients have reduced modulation of their heart rate, suggesting impairment of the autonomic nervous system.11 In contrast, one study of adults with CFS found that heart rate variability is similar to that in controls.
Treatment
Effective treatment for NMH and POTS in CFIDS must be individualized. In general, treatment for POTS and NMH helps greatly to alleviate some symptoms, but rarely fully resolves the CFIDS.
The first line of treatment should be non-medical interventions, such as increasing fluids and salt, tilting the head of the bed up a few degrees, wearing compression garments (such as support hose, girdles or abdominal binders), and learning to avoid and cope with things that can make OI worse (such as standing in long lines, being in warm environments and eating large, heavy meals).
If these are not effective, doctors may introduce pharmaceutical treatments such as fludrocortisone (Florinef) to treat low blood volume, and vasoconstrictor medications, including methylphenidate (Ritalin), dextroamphetamine (Dexedrine) and midodrine (ProAmatine) to treat blood pooling, and sometimes drugs to block the release or effect of epinephrine and norepinephrine. Selective serotonin reuptake inhibitors (SSRIs) have been used with some success in patients with POTS, and one randomized trial has demonstrated the efficacy of paroxetine (Paxil) for those with recurrent syncope due to NMH.
Although randomized trials of treatment for POTS have not been performed, other randomized trials in those with recurrent syncope due to NMH have demonstrated efficacy for atenolol, midodrine and enalapril. It is unclear whether these medications will work in CFIDS. Intravenous saline can help reduce symptoms, especially following HUT or other acute exacerbations of symptoms. Common syncope treatments beta-blockers and clonidine may be less effective in POTS and may reflect different causes for POTS and simple fainting.
Conclusion
Further research is required to determine how orthostatic intolerance is involved in CFIDS. It is clear from past studies that OI is associated with CFIDS, but the degree and meaning of that association is still a focus of vigorous research.
The connection between OI and CFIDS was first introduced in 1995,8 by Rowe and associates at Johns Hopkins University, who identified neurally mediated hypotension (NMH) in CFIDS patients. Since 1995, scientists have learned much more about the broader problem of OI in CFIDS, of which NMH is just one form. It is now thought that many CFIDS patients (up to 97% in some studies) have some form of OI and it seems to be a particular problem in youth with CFIDS.
Types of OI
There are many types of OI, but two forms have been linked with CFIDS in research studies: NMH and postural orthostatic tachycardia syndrome (POTS).
NMH is a precipitous drop (at least 20-25 mm Hg) in systolic blood pressure when standing. The blood pressure drop is accompanied or preceded by an increase in symptoms.
POTS is a rapid increase in heart rate (pulse) of more than 30 beats per minute (bpm) from baseline, or to more than 120 bpm total, during the first 10 minutes of standing.1 It is also known as chronic orthostatic intolerance, or COI.
The blood pressure and heart rate changes in NMH and POTS are accompanied by orthostatic symptoms such as lightheadedness, dizziness, nausea, fatigue, tremors, breathing or swallowing difficulties, headache, visual disturbances, sweating and pallor. Many patients develop swollen, bluish legs, providing evidence of blood pooling in the lower part of the body.
Testing
Most doctors are familiar with orthostatic hypotension (OH), which can result in fainting (or syncope, pronounced "sin-coh-pee") very quickly after standing, and can be diagnosed with a simple in-office test of taking the blood pressure first while lying down and again upon standing.
Unlike those with OH, which occurs within the first three minutes of standing, CFIDS patients with NMH or POTS often have a delayed form 13,14 of orthostatic intolerance, meaning that heart rate and blood pressure changes don't develop for many minutes after standing, making the standard in-office test for acute orthostatic hypotension ineffective in diagnosis. A tilt table test in CFS is considered to be positive if a patient experiences orthostatic symptoms and blood pressure and/or heart rate changes, whether or not he or she faints. Patients typically undergo a head-up tilt table test (HUT) as an outpatient in a hospital or cardiology office to get a definitive diagnosis. Since the HUT reproduces the symptoms of NMH and POTS, patients often feel worse during and after the test. Some testers administer IV saline following the test to reduce the occurrence of prolonged symptoms.
Dr. David Streeten, a researcher who studied circulatory problems, and who collaborated with CFIDS clinician Dr. David S. Bell, favored the use of a prolonged standing test as more representative of a patient's daily symptoms and experiences than the HUT. Blood pressure and heart rate are measured every few minutes while patients lie quietly for 30 minutes and again as they stand quiet and motionless for 60 minutes, or until severe symptoms develop. It is very important that either this test or the HUT be done under close medical supervision, as serious complications, including brief periods of very slow heart rate, can occur during the test.
Pathophysiology
There are several hypothesized causes of NMH and POTS relevant to CFIDS; regardless of the cause, all lead to inadequate blood circulation that may reduce the amount of blood getting back to the heart and brain. Patients may have low blood volume throughout the body or their blood may pool excessively in the extremities or both.
When healthy people stand, gravity causes about 750 ml of blood to fall to the abdomen and legs, resulting in a decrease in blood flow to the brain. In patients with POTS, cerebral blood flow decreases more prominently while standing.21 In one study of adolescents, the amount of blood that pooled in the legs was highest in CFIDS patients and second highest in POTS patients, as determined by measuring the circumference of their calves while lying down and again while standing.
When the heart receives less blood from the limbs during standing, the brain releases chemicals and alters the pulse and blood pressure in an effort to get the blood flowing upwards again. When this chemical response is accentuated, as in NMH and POTS, patients can develop a rapid heart rate (tachycardia), low blood pressure (hypotension) and orthostatic symptoms (see "Types of OI" above). CFIDS patients can have either NMH or POTS, and some have both conditions.
Researchers have identified several physiological abnormalities in CFIDS patients that are consistent with autonomic nervous system problems such as NMH and POTS. In five studies, adults and adolescents with CFIDS had elevated heart rates at rest compared to healthy and sedentary controls although two studies found no difference.2,24Heart rate further increased when patients underwent a tilt test, a finding consistent with POTS.
In addition, three studies - one in adults and two in adolescents11, - found that heart rate variability is significantly reduced in CFS compared to controls. This means that instead of having a heart rate that changes appropriately when faced with orthostatic stress, many CFS patients have reduced modulation of their heart rate, suggesting impairment of the autonomic nervous system.11 In contrast, one study of adults with CFS found that heart rate variability is similar to that in controls.
Treatment
Effective treatment for NMH and POTS in CFIDS must be individualized. In general, treatment for POTS and NMH helps greatly to alleviate some symptoms, but rarely fully resolves the CFIDS.
The first line of treatment should be non-medical interventions, such as increasing fluids and salt, tilting the head of the bed up a few degrees, wearing compression garments (such as support hose, girdles or abdominal binders), and learning to avoid and cope with things that can make OI worse (such as standing in long lines, being in warm environments and eating large, heavy meals).
If these are not effective, doctors may introduce pharmaceutical treatments such as fludrocortisone (Florinef) to treat low blood volume, and vasoconstrictor medications, including methylphenidate (Ritalin), dextroamphetamine (Dexedrine) and midodrine (ProAmatine) to treat blood pooling, and sometimes drugs to block the release or effect of epinephrine and norepinephrine. Selective serotonin reuptake inhibitors (SSRIs) have been used with some success in patients with POTS, and one randomized trial has demonstrated the efficacy of paroxetine (Paxil) for those with recurrent syncope due to NMH.
Although randomized trials of treatment for POTS have not been performed, other randomized trials in those with recurrent syncope due to NMH have demonstrated efficacy for atenolol, midodrine and enalapril. It is unclear whether these medications will work in CFIDS. Intravenous saline can help reduce symptoms, especially following HUT or other acute exacerbations of symptoms. Common syncope treatments beta-blockers and clonidine may be less effective in POTS and may reflect different causes for POTS and simple fainting.
Conclusion
Further research is required to determine how orthostatic intolerance is involved in CFIDS. It is clear from past studies that OI is associated with CFIDS, but the degree and meaning of that association is still a focus of vigorous research.
Orthostatic Intolerance and CFS
There is much in life that we take for granted. One common, yet necessary, function is remaining upright – sitting and standing. We must remain upright when we drive a car. We must remain upright when we attend a class. We must remain upright to watch a movie, attend a wedding, or enjoy a church service. Most people don’t think twice about it, and many feel these activities are rest. Yet, orthostatic intolerance (the inability to sit and stand for periods of time) is, for many, the most disabling feature of chronic fatigue syndrome (CFS). It is a simple symptom, yet its presence can rob one of enjoying life’s opportunities and pleasures.
I remember when I first began to deal with CFS during my senior year of high school. I quickly noticed something was very different when I returned to classes. As soon as I took a seat, it was as if a timer was ticking, and I was on my way to a crash. My legs felt as if they were heavy and disconnected -suffocating. For simply remaining in my chair, I was paying a price.
Later, I would learn I was not alone. Orthostatic intolerance is one of the most prevalent symptoms of chronic fatigue syndrome (CFS). It is also one of the most disabling and devastating. One cannot secure a job without being able to remain seated for any given period of time. It is difficult to have a social life, attend functions, and participate in social activities. Life with orthostatic intolerance can seem overwhelming, in a way few understand.
How much it impedes life?
For most people, remaining seated is a restful act. However, for those with chronic fatigue syndrome (CFS), a restful chair is often far from restful. Their legs become heavy and exhausted. If they sit beyond a given period of time, they leave feeling completely exhausted.
Gerald Campbell took a biology degree and parlayed it into a promising career in the pharmaceutical industry before being derailed by CFS 12 years ago. Like many with chronic fatigue syndrome (CFS), he found standing in one place to be difficult. “On prolonged standing, my legs get tired and achy, and my energy level goes down... the pain and energy drain starts after several minutes” Like many with CFS, he finds, “…moving around feels better than standing still.”
Megan, an editor who has had CFS for 10 years, describes the feeling of orthostatic intolerance. “The most difficult is standing in one place (like in
a line for more than 5 minutes)… it's a real effort to maintain the standing position &my heart usually starts to race.”
Carole Anne Dumas, a former graphic artist, describes how the simple act of remaining upright can be very uncomfortable for those with CFS. “ I have blood pooling in hands and feet, blurred vision, heart racing, shortness of breath and a desperate need to sit or lie down when just trying to make up the bed, prepare a simple meal, or even walk to the mailbox. “
Many researchers feel that chronic fatigue syndrome (CFS) is primarily a cardiocirculatory or hematological disease; while other researchers believe the circulatory problems in CFS are secondary to another process, such as immune inflammation. At any rate, research has found a wide variety of abnormalities in both the cardiocirculatory functioning of CFS patients, as well as the makeup of the blood (see references below). PWC’s (people with CFS) also have lower cardiac stroke volumes. Many PWC’s also describe feeling thirsty. One person with CFS says, “I am tremendously thirsty and need to drink water pretty much all day, or at least have it handy.”
What Causes Orthostatic Intolerance and CFS?
Theories as to what causes orthostatic intolerance in CFS differ. Dr. Peter Rowe, a researcher from Johns Hopkins University, is one of the worlds leading experts on CFS and orthostatic intolerance. Many of Rowe’s patients come to his clinic carrying a water bottle with them, which he believes is part of the condition. He has published numerous studies on orthostatic intolerance and low circulating blood volume in CFS.
“Fully 66% of 171 study subjects with CFS who were screened with a 2-stage upright tilt table test developed neurally mediated hypotension, postural tachycardia syndrome, or both. The evidence for an association between CFS and orthostatic intolerance is strongest in adolescents (constituting Level 1 evidence). In the 9 controlled studies published thus far, 7 have identified a higher prevalence of orthostatic intolerance in CFS patients than in healthy controls. In those with substantial worsening of symptoms during quiet upright posture, orthostatic hypotension can be excluded with a 3 minute standing test. Prolonged orthostatic testing to exclude postural tachycardia syndrome or neurally mediated (vaso-vagal) hypotension may be appropriate in those whose symptoms are aggravated by several minutes of quiet upright posture. “
Theories as to the cause of orthostatic intolerance in chronic fatigue syndrome differ. Martin Lerner, an infectious disease specialist at Wayne State University, believes CFS is a cardiomyopathy, perhaps caused by immune dysfunction and active infection of the heart muscle .
Les Simpson, a biologist from New Zealand specializing in blood rheology (blood flow), believes that people with CFS may have capillaries that are too small for red blood cells to pass through. “I found that [CFS] blood filtered poorly - implying that they had a problem with blood flow, particularly at capillary level. In a paper published by New Jersey Medicine, I suggested that [CFS] people might have the anatomical feature of smaller than usual capillary diameters. Such a proposal would help to explain the great variety and variation in distribution of the symptoms reported…”
Red blood cells in CFS have been found to often be misshapen or flattened. This has been theorized to cause the blood to not flow well into the capillaries. Dr. Nancy Klimas at the University of Miami has published studies that the ability of the body to manufacture and restore red blood cells is impaired in those with CFS.
Other researchers feel that the circulatory impairment in chronic fatigue syndrome is caused by neurological impairment. Diabetes can, over the long term, lead to neurological damage. Yet, orthostatic intolerance in CFS is often far more severe than that seen in diabetes. Since many of the symptoms, such as vertigo are present when the patients are supine (lying down), many suggest that the nervous system’s role is secondary.
Conclusion
Whatever the cause, orthostatic intolerance is the most disabling symptom many with chronic fatigue syndrome face. Its very presence precludes them from many cherished activities. Even more troubling, it is difficult for others to understand the problem. After all, even the weakest members of society consider sitting in a chair restful, even relaxing.
Yet for those with CFS, the ability to remain upright is not taken for granted. Taking a seat is anything but restful.
I remember when I first began to deal with CFS during my senior year of high school. I quickly noticed something was very different when I returned to classes. As soon as I took a seat, it was as if a timer was ticking, and I was on my way to a crash. My legs felt as if they were heavy and disconnected -suffocating. For simply remaining in my chair, I was paying a price.
Later, I would learn I was not alone. Orthostatic intolerance is one of the most prevalent symptoms of chronic fatigue syndrome (CFS). It is also one of the most disabling and devastating. One cannot secure a job without being able to remain seated for any given period of time. It is difficult to have a social life, attend functions, and participate in social activities. Life with orthostatic intolerance can seem overwhelming, in a way few understand.
How much it impedes life?
For most people, remaining seated is a restful act. However, for those with chronic fatigue syndrome (CFS), a restful chair is often far from restful. Their legs become heavy and exhausted. If they sit beyond a given period of time, they leave feeling completely exhausted.
Gerald Campbell took a biology degree and parlayed it into a promising career in the pharmaceutical industry before being derailed by CFS 12 years ago. Like many with chronic fatigue syndrome (CFS), he found standing in one place to be difficult. “On prolonged standing, my legs get tired and achy, and my energy level goes down... the pain and energy drain starts after several minutes” Like many with CFS, he finds, “…moving around feels better than standing still.”
Megan, an editor who has had CFS for 10 years, describes the feeling of orthostatic intolerance. “The most difficult is standing in one place (like in
a line for more than 5 minutes)… it's a real effort to maintain the standing position &my heart usually starts to race.”
Carole Anne Dumas, a former graphic artist, describes how the simple act of remaining upright can be very uncomfortable for those with CFS. “ I have blood pooling in hands and feet, blurred vision, heart racing, shortness of breath and a desperate need to sit or lie down when just trying to make up the bed, prepare a simple meal, or even walk to the mailbox. “
Many researchers feel that chronic fatigue syndrome (CFS) is primarily a cardiocirculatory or hematological disease; while other researchers believe the circulatory problems in CFS are secondary to another process, such as immune inflammation. At any rate, research has found a wide variety of abnormalities in both the cardiocirculatory functioning of CFS patients, as well as the makeup of the blood (see references below). PWC’s (people with CFS) also have lower cardiac stroke volumes. Many PWC’s also describe feeling thirsty. One person with CFS says, “I am tremendously thirsty and need to drink water pretty much all day, or at least have it handy.”
What Causes Orthostatic Intolerance and CFS?
Theories as to what causes orthostatic intolerance in CFS differ. Dr. Peter Rowe, a researcher from Johns Hopkins University, is one of the worlds leading experts on CFS and orthostatic intolerance. Many of Rowe’s patients come to his clinic carrying a water bottle with them, which he believes is part of the condition. He has published numerous studies on orthostatic intolerance and low circulating blood volume in CFS.
“Fully 66% of 171 study subjects with CFS who were screened with a 2-stage upright tilt table test developed neurally mediated hypotension, postural tachycardia syndrome, or both. The evidence for an association between CFS and orthostatic intolerance is strongest in adolescents (constituting Level 1 evidence). In the 9 controlled studies published thus far, 7 have identified a higher prevalence of orthostatic intolerance in CFS patients than in healthy controls. In those with substantial worsening of symptoms during quiet upright posture, orthostatic hypotension can be excluded with a 3 minute standing test. Prolonged orthostatic testing to exclude postural tachycardia syndrome or neurally mediated (vaso-vagal) hypotension may be appropriate in those whose symptoms are aggravated by several minutes of quiet upright posture. “
Theories as to the cause of orthostatic intolerance in chronic fatigue syndrome differ. Martin Lerner, an infectious disease specialist at Wayne State University, believes CFS is a cardiomyopathy, perhaps caused by immune dysfunction and active infection of the heart muscle .
Les Simpson, a biologist from New Zealand specializing in blood rheology (blood flow), believes that people with CFS may have capillaries that are too small for red blood cells to pass through. “I found that [CFS] blood filtered poorly - implying that they had a problem with blood flow, particularly at capillary level. In a paper published by New Jersey Medicine, I suggested that [CFS] people might have the anatomical feature of smaller than usual capillary diameters. Such a proposal would help to explain the great variety and variation in distribution of the symptoms reported…”
Red blood cells in CFS have been found to often be misshapen or flattened. This has been theorized to cause the blood to not flow well into the capillaries. Dr. Nancy Klimas at the University of Miami has published studies that the ability of the body to manufacture and restore red blood cells is impaired in those with CFS.
Other researchers feel that the circulatory impairment in chronic fatigue syndrome is caused by neurological impairment. Diabetes can, over the long term, lead to neurological damage. Yet, orthostatic intolerance in CFS is often far more severe than that seen in diabetes. Since many of the symptoms, such as vertigo are present when the patients are supine (lying down), many suggest that the nervous system’s role is secondary.
Conclusion
Whatever the cause, orthostatic intolerance is the most disabling symptom many with chronic fatigue syndrome face. Its very presence precludes them from many cherished activities. Even more troubling, it is difficult for others to understand the problem. After all, even the weakest members of society consider sitting in a chair restful, even relaxing.
Yet for those with CFS, the ability to remain upright is not taken for granted. Taking a seat is anything but restful.
Postural Orthostatic Tachycardia Syndrome (POTS) / Orthostatic Intolerance Research
Postural Orthostatic Tachycardia Syndrome (POTS) / Orthostatic Intolerance Research
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POTS
Postural Orthostatic Tachycardia Syndrome (POTS) is the term used to describe a set of symptoms that impact over a million individuals throughout the country. POTS is not likely a single disorder, but rather a description of symptoms that likely have multiple underlying causes. In many ways this classification is more like an umbrella that covers a diverse group of individuals who tend to exhibit similar symptoms but with numerous underlying causal mechanisms. Since little is currently known about how these underlying mechanisms work, much of the therapy is aimed at treating symptoms, determining testing methods as well as establishing effective treatment plans.
As you review the medical literature, you will find a vast array of terminology that is used to describe the same basic condition. Postural Orthostatic Tachycardia Syndrome (POTS), Chronic Orthostatic Intolerance, Mitral Valve Prolapse Syndrome as well as Idiopathic Orthostatic Intolerance are all terms that are interchangeably used by physicians. The result for the patient can be multiple labels being used to describe the same condition - a dysfunction with your autonomic nervous system.
In the past few years, there have been a few rare findings identifying genetic mechanisms as the underlying cause of POTS for several families. Additionally, researchers have also described an autonomic autoimmune condition for a very small number of patients exhibiting POTS symptoms. These findings may point the way to future research discoveries.
As you view these journal articles keep in mind that research findings often may point to conflicting results. A single study's results may not be able to be duplicated, or may be contradicted by results from another study. Generalizations are very hard to make, and for the most part, a highly individualized therapy program has to be designed for each patient.
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POTS
Postural Orthostatic Tachycardia Syndrome (POTS) is the term used to describe a set of symptoms that impact over a million individuals throughout the country. POTS is not likely a single disorder, but rather a description of symptoms that likely have multiple underlying causes. In many ways this classification is more like an umbrella that covers a diverse group of individuals who tend to exhibit similar symptoms but with numerous underlying causal mechanisms. Since little is currently known about how these underlying mechanisms work, much of the therapy is aimed at treating symptoms, determining testing methods as well as establishing effective treatment plans.
As you review the medical literature, you will find a vast array of terminology that is used to describe the same basic condition. Postural Orthostatic Tachycardia Syndrome (POTS), Chronic Orthostatic Intolerance, Mitral Valve Prolapse Syndrome as well as Idiopathic Orthostatic Intolerance are all terms that are interchangeably used by physicians. The result for the patient can be multiple labels being used to describe the same condition - a dysfunction with your autonomic nervous system.
In the past few years, there have been a few rare findings identifying genetic mechanisms as the underlying cause of POTS for several families. Additionally, researchers have also described an autonomic autoimmune condition for a very small number of patients exhibiting POTS symptoms. These findings may point the way to future research discoveries.
As you view these journal articles keep in mind that research findings often may point to conflicting results. A single study's results may not be able to be duplicated, or may be contradicted by results from another study. Generalizations are very hard to make, and for the most part, a highly individualized therapy program has to be designed for each patient.
Orthostatic intolerance...
Orthostatic intolerance is an umbrella term for several conditions in which symptoms are made worse by upright posture. This document has been prepared for those who have requested further information about neurally mediated hypotension (NMH) and postural tachycardia syndrome (POTS), two common forms of chronic orthostatic intolerance. Hypotension is the medical term for low blood pressure (BP), and tachycardia is the medical term for an increased heart rate (HR).
What are NMH and POTS?
Neurally mediated hypotension refers to a drop in blood pressure that occurs after being upright. We define NMH by a drop in systolic BP of 25 mm Hg (compared to the BP measured when the person is lying flat) during standing or upright tilt table testing. Although NMH may be slightly more common in people with a low resting blood pressure, most people who develop NMH during standing have a normal resting blood pressure. NMH is an abnormality in the regulation of blood pressure during upright posture. It occurs when too little blood circulates back to the heart when people are upright, and triggers an abnormal reflex interaction between the heart and the brain. NMH is sometimes known by the following names: the fainting reflex, delayed orthostatic hypotension, neurocardiogenic syncope, vasodepressor syncope, vaso-vagal syncope. Syncope is the medical term for fainting.
Postural tachycardia syndrome refers to an exaggerated increase in heart rate with standing. A healthy individual usually has a slight increase in heart rate-by about 10-15 beats per minute--within the first 10 minutes of standing. POTS is considered present if the heart rate increases by 30 beats per minute, or if it reaches 120 beats per minute or higher over the first 10 minutes of standing. POTS is an abnormality in the regulation of heart rate, not necessarily in the resting heart itself. Some patients with POTS in the first 10 minutes of upright standing or tilt testing will go on to develop NMH if the test is continued; the two conditions often are found together, and they are not mutually exclusive diagnoses.
How does upright posture lead to these problems?
When a healthy individual stands up, gravity causes about 10-15% of his or her blood to settle in the abdomen or limbs. This pooling of blood means that less blood reaches the brain, the result of which can be a feeling of lightheadedness, seeing stars, darkening of vision, or even fainting. For most of us, this lightheaded feeling is infrequent when we stand up because the body turns on a series of rapid reflex responses. To make up for the lower amount of blood returning to the heart immediately after standing, the body releases norepinephrine and epinephrine (also known as adrenaline). These substances typically cause the heart to beat a little faster and with more force (a familiar feeling after we exercise or are frightened), and cause the blood vessels to tighten or constrict. The end result is more blood returning to the heart and brain. Most of the time, we are unaware of these reflex changes in blood flow when we stand up.
When people with either NMH or POTS are upright, they appear to pool a larger amount of blood in vessels below the heart. More blood settles in the limbs the longer the person remains upright. The body responds by releasing more norepinephrine or epinephrine, in an attempt to cause more constriction of the blood vessels. For a variety of reasons, not all of which are well understood, the blood vessels do not seem to respond normally to these substances (either they dilate too much or they do not constrict efficiently). Because the heart remains able to respond, we often see an increased heart rate.
In those with POTS, the main result of excessive pooling of blood during upright posture is an exaggerated rise in heart rate. In those with NMH, the main result is a reflex lowering of blood pressure. Some of this is caused by a "miscommunication" between the heart and the brain, both of which usually are structurally normal. Just when the heart needs to beat faster to pump blood to the brain and prevent fainting, the brain sends out the message that the heart rate should be slowed down, and the blood vessels should dilate further. These actions take even more blood away from the central part of the circulation where it is needed. At this time, it is not entirely clear why some people develop NMH and some develop POTS, although it may relate in part to the balance of epinephrine and norepinephrine release in the system.
Which symptoms can be caused by NMH or POTS?
Any time the brain is getting too little blood flow, the usual result is a lightheaded or spacey feeling. Recurrent lightheadedness is a common symptom of both NMH and POTS. If lightheadedness is severe, individuals may have dimming of their vision, may hear sounds as though they were far away, and may have nausea or vomiting. They may faint because not enough blood is getting to the brain. Fainting is helpful, in that it restores a person to the flat position, removing the effect of gravity on blood pooling in the limbs, and allowing more blood to return to the heart. Following the episodes of lightheadedness or fainting, most people feel tired for several hours (sometimes more than a day) and their thinking can be somewhat foggy. Some patients with NMH experience prolonged fatigue after a modest amount of physical activity, or after sustaining quiet activity like sitting at a desk. This fatigue after exertion or sustained activity can also last 24-72 hours, and can interfere with many daily activities.
While fainting has been considered a classic symptom of NMH, we have found that many persons who develop NMH during tilt table testing do not faint in day-to-day life. Chronic fatigue, muscle aches (or myalgias), headaches, and mental confusion can be prominent symptoms of NMH in these individuals. The mental confusion takes the form of difficulty concentrating, staying on task, paying attention, remembering, or finding the right words. Some describe being in a "mental fog." Some develop worse fatigue after mentally demanding activities, such as reading and concentrating. This may occur because the blood vessels of the limbs dilate rather than constrict in response to mental tasks, allowing more blood to pool.
In persons with POTS, a fast heart rate is a defining feature, and awareness of vigorous or skipped heart beats (palpitations) is common. In addition, patients can experience lightheadedness, intolerance of exercise, fatigue, visual blurring, weakness, imbalance, headaches, shakiness, clamminess, anxiety, shortness of breath, and the same type of mental fogginess that those with NMH describe.
It has now been established that there is a substantial overlap between syndromes of orthostatic intolerance on the one hand, and either chronic fatigue syndrome (CFS) or fibromyalgia (FM) on the other. It needs to be emphasized that not all those with NMH or POTS have CFS or FM, and not all with CFS or FM have NMH or POTS.
When do NMH and POTS lead to symptoms?
Symptoms of NMH and POTS usually are triggered in the following settings:
with quiet upright posture (such as standing in line, standing in a shower, or even sitting at a desk for long periods),
after being in a warm environment (such as in hot summer weather, a hot crowded room, a hot shower or bath),
immediately after exercise,
after emotionally stressful events (seeing blood or gory scenes, being scared or anxious).
in some people, after eating, when blood flow shifts to the intestines during digestion.
if fluid and salt intake are inadequate
It is thought that we all would develop NMH provided that the environmental conditions were sufficiently severe: for example, if we did not take in enough fluids or salt, or were subjected to extremely prolonged periods of upright posture or to very warm environments. The reflex response that results in lowered blood pressure simply occurs at an earlier point in some individuals. Each person's susceptibility is affected by a number of factors, including genetics, diet, psychological make-up, and the presence of other medical disorders including infection, inflammation, or allergy. Some people may develop NMH or POTS during tilt testing, but not be affected much in regular daily life. A person is treated for NMH or POTS when there is enough early triggering of symptoms to interfere with normal activity.
How are NMH and POTS diagnosed?
NMH and POTS cannot be detected with routine, resting blood pressure or heart rate screening. The diagnoses can be made with a prolonged standing test or a tilt table test. Although a 10-minute test is all that is needed to diagnose POTS, this is too brief for diagnosing NMH, which usually requires at least a 45-minute period of upright posture. Many hospitals and academic centers throughout the world perform tilt table testing. It allows careful measurement of the heart rate and blood pressure responses to the head-up position, usually at a 70-degree angle, in an almost standing position. The usual reason for performing a tilt table test in the past had been for the evaluation of recurrent fainting. Many people with NMH develop adaptations to keep from fainting, such as crossing their legs, fidgeting, or sitting or lying down when they get lightheaded or tired. However, during the tilt table test they must remain still, and they cannot call upon these natural defenses. As a result, fainting can occur for the first time during the tilt table test. Increased fatigue and malaise often occur for a few days after the test is performed.
What causes NMH or POTS?
The answer to this question isn't well understood at present. We suspect NMH and POTS have genetic origins in many people, because it is not uncommon for us to find several affected individuals with some form of orthostatic intolerance in the same family. No gene for NMH has been identified, but one rare genetic cause has been found for POTS. One trait seen with increased frequency in those with CFS and orthostatic intolerance is excessive joint mobility, for reasons that are not yet clear. A number of persons with NMH or POTS report that their symptoms began after an infection or physical trauma (such as a flu, mononucleosis, a car accident, or surgery). Other environmental factors may also play a role, but more research is needed before we will know what actually causes either condition. Some investigators have noted an overlap in the symptoms of fatigue and conditions in which there is too little room for the spinal cord in the neck or as it emerges from the skull (conditions known as cervical spine stenosis or Chiari malformation). It needs to be emphasized that these conditions do not explain the presence of POTS or NMH in the vast majority of patients, and further studies are needed regarding the best methods to diagnose and treat these abnormalities.
One of the most common and treatable problems identified in those with NMH and POTS is a low salt (sodium) intake in the diet. Salt helps us retain fluid in the blood vessels, and helps maintain a healthy blood pressure. Salt has received bad press in the last couple of decades because a high salt diet in some individuals with high or high-normal blood pressure can lead to further increases in blood pressure, and thereby to heart disease and stroke. This has led to general health recommendations to "cut down on salt." As we are finding, this general recommendation isn't right for all people.
In adults, an average blood pressure is 120/70. An adult's systolic blood pressure [the top number] is considered low if it is below 100, and it is considered elevated if it is above 140. An adult's diastolic blood pressure [the bottom number] is considered high if it is over 90. Normal values for BP in children and adolescents vary by age and weight. Individuals can have NMH at a wide range of resting blood pressures. It may be slightly more common in those whose systolic BP is in the 90-110 range. For individuals with NMH, a low salt intake may be unhealthy, and reducing sodium intake may move them from feeling good to developing the symptoms of fatigue and lightheadedness described earlier. In experimental work earlier this century, severe short-term salt depletion led to fatigue and mental dulling in the adult research participants.
What are NMH and POTS?
Neurally mediated hypotension refers to a drop in blood pressure that occurs after being upright. We define NMH by a drop in systolic BP of 25 mm Hg (compared to the BP measured when the person is lying flat) during standing or upright tilt table testing. Although NMH may be slightly more common in people with a low resting blood pressure, most people who develop NMH during standing have a normal resting blood pressure. NMH is an abnormality in the regulation of blood pressure during upright posture. It occurs when too little blood circulates back to the heart when people are upright, and triggers an abnormal reflex interaction between the heart and the brain. NMH is sometimes known by the following names: the fainting reflex, delayed orthostatic hypotension, neurocardiogenic syncope, vasodepressor syncope, vaso-vagal syncope. Syncope is the medical term for fainting.
Postural tachycardia syndrome refers to an exaggerated increase in heart rate with standing. A healthy individual usually has a slight increase in heart rate-by about 10-15 beats per minute--within the first 10 minutes of standing. POTS is considered present if the heart rate increases by 30 beats per minute, or if it reaches 120 beats per minute or higher over the first 10 minutes of standing. POTS is an abnormality in the regulation of heart rate, not necessarily in the resting heart itself. Some patients with POTS in the first 10 minutes of upright standing or tilt testing will go on to develop NMH if the test is continued; the two conditions often are found together, and they are not mutually exclusive diagnoses.
How does upright posture lead to these problems?
When a healthy individual stands up, gravity causes about 10-15% of his or her blood to settle in the abdomen or limbs. This pooling of blood means that less blood reaches the brain, the result of which can be a feeling of lightheadedness, seeing stars, darkening of vision, or even fainting. For most of us, this lightheaded feeling is infrequent when we stand up because the body turns on a series of rapid reflex responses. To make up for the lower amount of blood returning to the heart immediately after standing, the body releases norepinephrine and epinephrine (also known as adrenaline). These substances typically cause the heart to beat a little faster and with more force (a familiar feeling after we exercise or are frightened), and cause the blood vessels to tighten or constrict. The end result is more blood returning to the heart and brain. Most of the time, we are unaware of these reflex changes in blood flow when we stand up.
When people with either NMH or POTS are upright, they appear to pool a larger amount of blood in vessels below the heart. More blood settles in the limbs the longer the person remains upright. The body responds by releasing more norepinephrine or epinephrine, in an attempt to cause more constriction of the blood vessels. For a variety of reasons, not all of which are well understood, the blood vessels do not seem to respond normally to these substances (either they dilate too much or they do not constrict efficiently). Because the heart remains able to respond, we often see an increased heart rate.
In those with POTS, the main result of excessive pooling of blood during upright posture is an exaggerated rise in heart rate. In those with NMH, the main result is a reflex lowering of blood pressure. Some of this is caused by a "miscommunication" between the heart and the brain, both of which usually are structurally normal. Just when the heart needs to beat faster to pump blood to the brain and prevent fainting, the brain sends out the message that the heart rate should be slowed down, and the blood vessels should dilate further. These actions take even more blood away from the central part of the circulation where it is needed. At this time, it is not entirely clear why some people develop NMH and some develop POTS, although it may relate in part to the balance of epinephrine and norepinephrine release in the system.
Which symptoms can be caused by NMH or POTS?
Any time the brain is getting too little blood flow, the usual result is a lightheaded or spacey feeling. Recurrent lightheadedness is a common symptom of both NMH and POTS. If lightheadedness is severe, individuals may have dimming of their vision, may hear sounds as though they were far away, and may have nausea or vomiting. They may faint because not enough blood is getting to the brain. Fainting is helpful, in that it restores a person to the flat position, removing the effect of gravity on blood pooling in the limbs, and allowing more blood to return to the heart. Following the episodes of lightheadedness or fainting, most people feel tired for several hours (sometimes more than a day) and their thinking can be somewhat foggy. Some patients with NMH experience prolonged fatigue after a modest amount of physical activity, or after sustaining quiet activity like sitting at a desk. This fatigue after exertion or sustained activity can also last 24-72 hours, and can interfere with many daily activities.
While fainting has been considered a classic symptom of NMH, we have found that many persons who develop NMH during tilt table testing do not faint in day-to-day life. Chronic fatigue, muscle aches (or myalgias), headaches, and mental confusion can be prominent symptoms of NMH in these individuals. The mental confusion takes the form of difficulty concentrating, staying on task, paying attention, remembering, or finding the right words. Some describe being in a "mental fog." Some develop worse fatigue after mentally demanding activities, such as reading and concentrating. This may occur because the blood vessels of the limbs dilate rather than constrict in response to mental tasks, allowing more blood to pool.
In persons with POTS, a fast heart rate is a defining feature, and awareness of vigorous or skipped heart beats (palpitations) is common. In addition, patients can experience lightheadedness, intolerance of exercise, fatigue, visual blurring, weakness, imbalance, headaches, shakiness, clamminess, anxiety, shortness of breath, and the same type of mental fogginess that those with NMH describe.
It has now been established that there is a substantial overlap between syndromes of orthostatic intolerance on the one hand, and either chronic fatigue syndrome (CFS) or fibromyalgia (FM) on the other. It needs to be emphasized that not all those with NMH or POTS have CFS or FM, and not all with CFS or FM have NMH or POTS.
When do NMH and POTS lead to symptoms?
Symptoms of NMH and POTS usually are triggered in the following settings:
with quiet upright posture (such as standing in line, standing in a shower, or even sitting at a desk for long periods),
after being in a warm environment (such as in hot summer weather, a hot crowded room, a hot shower or bath),
immediately after exercise,
after emotionally stressful events (seeing blood or gory scenes, being scared or anxious).
in some people, after eating, when blood flow shifts to the intestines during digestion.
if fluid and salt intake are inadequate
It is thought that we all would develop NMH provided that the environmental conditions were sufficiently severe: for example, if we did not take in enough fluids or salt, or were subjected to extremely prolonged periods of upright posture or to very warm environments. The reflex response that results in lowered blood pressure simply occurs at an earlier point in some individuals. Each person's susceptibility is affected by a number of factors, including genetics, diet, psychological make-up, and the presence of other medical disorders including infection, inflammation, or allergy. Some people may develop NMH or POTS during tilt testing, but not be affected much in regular daily life. A person is treated for NMH or POTS when there is enough early triggering of symptoms to interfere with normal activity.
How are NMH and POTS diagnosed?
NMH and POTS cannot be detected with routine, resting blood pressure or heart rate screening. The diagnoses can be made with a prolonged standing test or a tilt table test. Although a 10-minute test is all that is needed to diagnose POTS, this is too brief for diagnosing NMH, which usually requires at least a 45-minute period of upright posture. Many hospitals and academic centers throughout the world perform tilt table testing. It allows careful measurement of the heart rate and blood pressure responses to the head-up position, usually at a 70-degree angle, in an almost standing position. The usual reason for performing a tilt table test in the past had been for the evaluation of recurrent fainting. Many people with NMH develop adaptations to keep from fainting, such as crossing their legs, fidgeting, or sitting or lying down when they get lightheaded or tired. However, during the tilt table test they must remain still, and they cannot call upon these natural defenses. As a result, fainting can occur for the first time during the tilt table test. Increased fatigue and malaise often occur for a few days after the test is performed.
What causes NMH or POTS?
The answer to this question isn't well understood at present. We suspect NMH and POTS have genetic origins in many people, because it is not uncommon for us to find several affected individuals with some form of orthostatic intolerance in the same family. No gene for NMH has been identified, but one rare genetic cause has been found for POTS. One trait seen with increased frequency in those with CFS and orthostatic intolerance is excessive joint mobility, for reasons that are not yet clear. A number of persons with NMH or POTS report that their symptoms began after an infection or physical trauma (such as a flu, mononucleosis, a car accident, or surgery). Other environmental factors may also play a role, but more research is needed before we will know what actually causes either condition. Some investigators have noted an overlap in the symptoms of fatigue and conditions in which there is too little room for the spinal cord in the neck or as it emerges from the skull (conditions known as cervical spine stenosis or Chiari malformation). It needs to be emphasized that these conditions do not explain the presence of POTS or NMH in the vast majority of patients, and further studies are needed regarding the best methods to diagnose and treat these abnormalities.
One of the most common and treatable problems identified in those with NMH and POTS is a low salt (sodium) intake in the diet. Salt helps us retain fluid in the blood vessels, and helps maintain a healthy blood pressure. Salt has received bad press in the last couple of decades because a high salt diet in some individuals with high or high-normal blood pressure can lead to further increases in blood pressure, and thereby to heart disease and stroke. This has led to general health recommendations to "cut down on salt." As we are finding, this general recommendation isn't right for all people.
In adults, an average blood pressure is 120/70. An adult's systolic blood pressure [the top number] is considered low if it is below 100, and it is considered elevated if it is above 140. An adult's diastolic blood pressure [the bottom number] is considered high if it is over 90. Normal values for BP in children and adolescents vary by age and weight. Individuals can have NMH at a wide range of resting blood pressures. It may be slightly more common in those whose systolic BP is in the 90-110 range. For individuals with NMH, a low salt intake may be unhealthy, and reducing sodium intake may move them from feeling good to developing the symptoms of fatigue and lightheadedness described earlier. In experimental work earlier this century, severe short-term salt depletion led to fatigue and mental dulling in the adult research participants.
How are NMH and POTS treated?
How are NMH and POTS treated?
Treatment of these conditions is often quite challenging. Because patients have a different mix of underlying contributors to their orthostatic intolerance, therapy has to be tailored to the individual, and usually requires persistence and a willingness to try multiple methods. The approach we use has been based on the available evidence from formal studies and from our experiences treating large numbers of individuals. We use a stepped approach. Step 1 focuses on non-pharmacologic treatments, Step 2 involves use of a single medication, and Step 3 involves rational and judicious use of more than one medication.
Step 1:
a. Avoid prolonged sitting quiet standing, warm environments, and vasodilating medications.
Where practical, avoid circumstances that commonly bring on symptoms. For example, shop at non-peak hours to avoid long lines. Take shorter showers and baths and aim for a cooler water temperature. Avoid saunas, hot tubs, and lying on a hot beach. Avoid standing still for prolonged periods in hot environments, and on very hot days. Flex your leg muscles and shift your weight when you are standing still. You may also want to avoid alcohol because it causes loss of fluids and often leads to dilation of the veins, which can "steal" blood away from the central circulation. Many with NMH are quite intolerant of alcohol. High carbohydrate meals have been shown to reduce blood vessel constriction in response to upright stress, so a lower carbohydrate intake and frequent small meals may help. Caffeine intake (including caffeine in soft drinks) affects some people with NMH or POTS positively and some in an adverse way, so examine whether caffeine is helping you or making symptoms worse.
An important aspect of treating NMH or POTS is to review your current medications and nutritional supplements with your doctor or health care provider to ensure that these do not have the potential to make your symptoms worse. Narcotic medications (like codeine, morphine, oxycodone) and phenothiazine anti-emetics (like Phenergan or Compazine) can lead to more blood pooling, and niacin can cause vasodilation. Many patients develop hypotension when treated with high doses of nortriptyline, amitryptiline, or similar tricyclic antidepressants; low doses of these medications often are tolerated.
b. Use postural maneuvers and pressure garments.
Certain postures and physical maneuvers can help reduce NMH and POTS symptoms when people are upright, mainly by using contraction of the leg muscles to pump blood back to the heart and by compressing the abdomen to reduce the amount of blood that pools in the intestinal circulation. These small changes may be important, as even a small increase in blood return to the heart can help maintain an adequate blood flow to the brain. Many patients have adopted these postures without knowing why. The helpful maneuvers include:
standing with one's legs crossed
squatting
standing with one leg on a chair
bending forward from the waist (such as leaning over a shopping cart)
sitting in the knee-chest position
sitting in a low chair
leaning forward with hands on the knees when sitting.
Some of these postures are less conspicuous than others. Sitting in a low chair (such as a camping stool) is helpful because it causes the legs to be brought up toward the abdomen, and probably reduces the amount of blood pooling in the intestinal circulation. For similar reasons, avoid sitting in a high chair with the legs dangling freely, as there is no resistance to blood pooling unless the muscles are actively contracting. One young woman found she could sit longer without symptoms if she put her feet on a low foot rest (this probably required more leg muscle contraction than regular sitting, and may have also compressed the abdomen better). Some patients get worse if they adopt these postures, so they may not be right for everyone. Another technique has been shown to help reduce the frequency of fainting, and involves 2 minutes of maximum contraction of the arms (gripping one hand with the other and pushing the arms away) at the start of lightheadedness.
Another time-honored recommendation is to elevate the head of the bed slightly by 10-15o, so that the head is higher than the feet, a position that appears to help the body retain fluid at night rather than lose fluid into the urine.
Several research studies have shown that if blood vessels can be compressed from the outside (using tight compression garments or military anti-shock trousers), the abnormal heart rate and BP changes of NMH or POTS can be reduced or eliminated. Waist-high support hose can prevent some of the excessive pooling of blood in the legs (knee-high support socks help somewhat), as can garments that increase abdominal compression (these work by preventing excessive amounts of blood pooling in the intestinal circulation), such as abdominal binders and abdominal corsets.
c. Treat contributing medical conditions
Attention to other medical conditions is crucial to ensuring that the NMH or POTS treatments are as effective as they can be. In particular, preventing activation of even mild asthma and allergies has been important in keeping our patients from developing a worsening of symptoms. In patients with asthma, we usually try to reduce reliance on albuterol and other beta-agonist inhalers, as these medications can mimic the effect of too much epinephrine, and can aggravate NMH in particular. Endometriosis and other painful conditions may aggravate symptoms, and ovarian vein varices in women with pelvic pain are associated with fatigue and worse orthostatic intolerance. Sinusitis, anxiety disorders, depression, and infections of any sort are examples of other conditions that need appropriate medical attention when present.
Allergies or delayed hypersensitivities to food proteins (most commonly cow's milk protein) can co-exist with orthostatic intolerance, and unless they are addressed they can obscure any improvements that might otherwise come with medications and postural changes. Dr. Kevin Kelly has identified the following symptoms that should prompt us to think further about the possibility of a food allergy or hypersensitivity: upper abdominal pain, gastroesophageal reflux, and appetite disturbance (filling up too quickly, picky appetite), sometimes with recurrent mouth ulcers, headaches, sinusitis, and either constipation or diarrhea. If hypersensitivity to a food protein is playing a role, substantial improvements can result from strict exclusion of offending foods. We would emphasize that this dietary treatment is not part of the standard treatment of NMH and POTS in our clinic, and is only considered on the basis of the specific symptoms mentioned above. Given the potential dangers of unsupervised diets, be sure to discuss these issues with your doctor or health care provider.
d. Increase salt and fluid intake
NMH and POTS are most often treated with a combination of increased salt and water intake. The increased salt and water help ensure that the blood vessels are filled better, and that the heart receives an adequate amount of blood even during upright posture. We recommend at least 2 liters of fluid per day. Our patients who drink fluids regularly throughout the day seem to do better than those who don't take this task seriously. Keep in mind that prolonged periods of sleeping (more than 12 hours) may interfere with the ability to keep up with fluid needs. We recommend drinking fluids every 2 hours throughout the day. As a result, it is important to have easy access to fluids at work or at school.
For those who have been on a low salt intake we recommend an increase in the amount of salt they add to their food. The Appendix to this document contains a list of high salt foods. For some mildly affected individuals, an increased intake of salt and fluids may be all that is needed. Most of those with more severe symptoms require one of several medications in addition to the increased salt and fluid intake. The increased salt and fluid intake should be continued regardless of which of these medications is added.
e. Physical therapy and exercise
Exercise is important in regaining the effects that fitness brings in counteracting NMH or POTS. Because exercise can make NMH or POTS symptoms worse in the period before effective treatment has been found, it must be done carefully at first. When you and your doctor feel you are ready, begin a regular regimen of exercise, finding something that does not make you lightheaded and doing it for brief periods at first, increasing gradually. For example, one girl who had been ill for several years began functioning better once two of the NMH medications were working for her. She began exercising on a treadmill, but this made her lightheaded, so she switched to a reclining exercise bike. Although she started with only 2 minutes a day, she increased this in small increments up to 30 minutes 3 times a week after about three months. Walking, water jogging (the water acts as a compressing force to counteract blood pooling in the limbs), stretching, and Tai Chi or yoga may be gentle ways to ease back into exercise. Remember to warm up slowly before, and cool down gradually after exercise. If you plan to exercise outdoors, remember that extreme heat will worsen NMH or POTS.
A group of our physical therapist colleagues in Baltimore, led by Rick Violand, PT, have helped us to identify a relatively high frequency of postural asymmetries and areas of adverse mechanical tension in the nervous system as contributors to pain, lightheadedness, and fatigue in many of our patients with orthostatic intolerance. These postural restrictions have helped explain why some patients were finding that exercise led to substantially worse symptoms. Among those who have the worst of these postural restrictions, several weeks of gentle manual physical therapy often prepares them to tolerate the mild aerobic exercise that would have caused a flare-up beforehand. We think careful attention must be paid to postural asymmetries and restrictions in mobility during the physical examination, and the diagnostic expertise of a physical therapist may be essential to identifying problems. Manual techniques that our colleagues employ include gentle neural mobilization (or neural tension work), myofascial release, and cranio-sacral therapy.
Steps 2 and 3
For those with more frequent or more severe symptoms, the physical maneuvers, dietary changes, and physical therapy of Step 1 may need to be supplemented by medications. Most of the drugs in common use for NMH and POTS help to improve the ability of the vessels to constrict and return blood to the heart when we stand, some effect the amount of salt and fluid the kidney returns to the blood stream, and some effect the release or action of norepinephrine or epinephrine.
While many of the medications listed below have been used by cardiologists and other physicians for years to treat NMH or POTS, few have been studied formally in those with POTS, NMH, or chronic fatigue syndrome. Some have been tested in patients who have fainted one or more times, but are otherwise healthy; some have been tested in those with ongoing symptoms due to POTS, and some have been tested in NMH patients who were diagnosed with chronic fatigue syndrome. This handout is based upon available research and our experience with NMH and POTS patients, most of whom came to see us because of chronic fatigue syndrome.
The treatments listed require persistence, commitment, and the willingness to try several possible drugs and combinations over an extended period of time. Because there is a risk of serious side effects with some of the drugs (such as elevated blood pressure, elevated sodium levels, lowered potassium levels, or depression) careful monitoring is required. The following lists medications that have been reported to help improve symptoms or tilt table responses in patients with NMH or POTS:
Medications that increase blood volume:
Fludrocortisone (Florinef)
Oral contraceptive pills
Clonidine
Erythropoietin
Medications that interfere with the release or action of epinephrine and norepinephrine:
Beta-blockers (e.g., atenolol, propranolol)
Disopyramide (Norpace)
Angiotensin converting enzyme inhibitors
Medications that improve vasoconstriction:
Stimulants: (e.g., methylphenidate [Ritalin] or dextroamphetamine [Dexedrine])
Midodrine (Proamatine)
Ephedrine and pseudoephedrine (Sudafed)
Theophylline (low-dose)
Selective serotonin reuptake inhibitors (examples include fluoxetine [Prozac], sertraline [Zoloft], and paroxetine [Paxil]). These medications may also affect the central nervous system reflex pathways in NMH as well.
Some of the above medications no doubt work in more than one way. For example, fludrocortisone improves the ability of the blood vessel to constrict in addition to expanding blood volume. Your health care provider should work with you to determine the best possible combination for your personal situation.
Does treatment cure the problem?
It needs to be stressed that, when successful, the medications for NMH and POTS usually do not cure the problem. Rather, they help control symptoms. When medications are stopped or when salt intake is reduced, symptoms frequently reappear. Many with NMH or POTS have symptoms resurface or worsen at busy or stressful times (making an oral presentation in class, having company over for Thanksgiving, rushing for a meeting on a hot day and forgetting to drink), when they have an infection, or when their allergies are more active. The intravenous infusion of saline solutions has been shown in experimental settings to help reduce symptoms, and the judicious use of IV fluids periodically has a role.
Even after successful treatment, many women with NMH and POTS describe a worsening of symptoms in the days around the start of a menstrual period. Some women choose to take birth control pills on a 28 day cycle, or continuously, in addition to their NMH or POTS medications. This is done to avoid symptoms related to hormone changes, and should be discussed with your health care provider.
The question of what happens over the long term has not been adequately studied, and the optimal duration of medical treatment is still being worked out. Unfortunately, despite appropriate doses of the available medications for neurally mediated hypotension, some people with NMH or POTS do not experience an improvement in symptoms, and some are intolerant of the medications. This emphasizes the need for more research on this problem. Many adult women who have orthostatic intolerance describe an improvement in symptoms when they have been pregnant, and often describe pregnancy as the time when they felt "the best ever." The improvement may be due to an expansion of blood volume that occurs naturally with pregnancy.
Finally, we suggest you take an active role in your care. If you have POTS, it might be helpful to learn how to take your pulse. If you have NMH, you may want to purchase a home blood pressure monitor - we suggest the kind with a cuff that goes around your upper arm, not around your wrist or on your finger. Heart rate and BP do not have to be taken routinely each day, but having this information during flare-ups of symptoms may provide helpful insights. Being able to monitor your blood pressure at home or take your own pulse won't replace visits to your physician or health care provider, but may make those visits more productive, as this information may reflect how you are responding to a high salt/high fluid diet or to medications.
Treatment of these conditions is often quite challenging. Because patients have a different mix of underlying contributors to their orthostatic intolerance, therapy has to be tailored to the individual, and usually requires persistence and a willingness to try multiple methods. The approach we use has been based on the available evidence from formal studies and from our experiences treating large numbers of individuals. We use a stepped approach. Step 1 focuses on non-pharmacologic treatments, Step 2 involves use of a single medication, and Step 3 involves rational and judicious use of more than one medication.
Step 1:
a. Avoid prolonged sitting quiet standing, warm environments, and vasodilating medications.
Where practical, avoid circumstances that commonly bring on symptoms. For example, shop at non-peak hours to avoid long lines. Take shorter showers and baths and aim for a cooler water temperature. Avoid saunas, hot tubs, and lying on a hot beach. Avoid standing still for prolonged periods in hot environments, and on very hot days. Flex your leg muscles and shift your weight when you are standing still. You may also want to avoid alcohol because it causes loss of fluids and often leads to dilation of the veins, which can "steal" blood away from the central circulation. Many with NMH are quite intolerant of alcohol. High carbohydrate meals have been shown to reduce blood vessel constriction in response to upright stress, so a lower carbohydrate intake and frequent small meals may help. Caffeine intake (including caffeine in soft drinks) affects some people with NMH or POTS positively and some in an adverse way, so examine whether caffeine is helping you or making symptoms worse.
An important aspect of treating NMH or POTS is to review your current medications and nutritional supplements with your doctor or health care provider to ensure that these do not have the potential to make your symptoms worse. Narcotic medications (like codeine, morphine, oxycodone) and phenothiazine anti-emetics (like Phenergan or Compazine) can lead to more blood pooling, and niacin can cause vasodilation. Many patients develop hypotension when treated with high doses of nortriptyline, amitryptiline, or similar tricyclic antidepressants; low doses of these medications often are tolerated.
b. Use postural maneuvers and pressure garments.
Certain postures and physical maneuvers can help reduce NMH and POTS symptoms when people are upright, mainly by using contraction of the leg muscles to pump blood back to the heart and by compressing the abdomen to reduce the amount of blood that pools in the intestinal circulation. These small changes may be important, as even a small increase in blood return to the heart can help maintain an adequate blood flow to the brain. Many patients have adopted these postures without knowing why. The helpful maneuvers include:
standing with one's legs crossed
squatting
standing with one leg on a chair
bending forward from the waist (such as leaning over a shopping cart)
sitting in the knee-chest position
sitting in a low chair
leaning forward with hands on the knees when sitting.
Some of these postures are less conspicuous than others. Sitting in a low chair (such as a camping stool) is helpful because it causes the legs to be brought up toward the abdomen, and probably reduces the amount of blood pooling in the intestinal circulation. For similar reasons, avoid sitting in a high chair with the legs dangling freely, as there is no resistance to blood pooling unless the muscles are actively contracting. One young woman found she could sit longer without symptoms if she put her feet on a low foot rest (this probably required more leg muscle contraction than regular sitting, and may have also compressed the abdomen better). Some patients get worse if they adopt these postures, so they may not be right for everyone. Another technique has been shown to help reduce the frequency of fainting, and involves 2 minutes of maximum contraction of the arms (gripping one hand with the other and pushing the arms away) at the start of lightheadedness.
Another time-honored recommendation is to elevate the head of the bed slightly by 10-15o, so that the head is higher than the feet, a position that appears to help the body retain fluid at night rather than lose fluid into the urine.
Several research studies have shown that if blood vessels can be compressed from the outside (using tight compression garments or military anti-shock trousers), the abnormal heart rate and BP changes of NMH or POTS can be reduced or eliminated. Waist-high support hose can prevent some of the excessive pooling of blood in the legs (knee-high support socks help somewhat), as can garments that increase abdominal compression (these work by preventing excessive amounts of blood pooling in the intestinal circulation), such as abdominal binders and abdominal corsets.
c. Treat contributing medical conditions
Attention to other medical conditions is crucial to ensuring that the NMH or POTS treatments are as effective as they can be. In particular, preventing activation of even mild asthma and allergies has been important in keeping our patients from developing a worsening of symptoms. In patients with asthma, we usually try to reduce reliance on albuterol and other beta-agonist inhalers, as these medications can mimic the effect of too much epinephrine, and can aggravate NMH in particular. Endometriosis and other painful conditions may aggravate symptoms, and ovarian vein varices in women with pelvic pain are associated with fatigue and worse orthostatic intolerance. Sinusitis, anxiety disorders, depression, and infections of any sort are examples of other conditions that need appropriate medical attention when present.
Allergies or delayed hypersensitivities to food proteins (most commonly cow's milk protein) can co-exist with orthostatic intolerance, and unless they are addressed they can obscure any improvements that might otherwise come with medications and postural changes. Dr. Kevin Kelly has identified the following symptoms that should prompt us to think further about the possibility of a food allergy or hypersensitivity: upper abdominal pain, gastroesophageal reflux, and appetite disturbance (filling up too quickly, picky appetite), sometimes with recurrent mouth ulcers, headaches, sinusitis, and either constipation or diarrhea. If hypersensitivity to a food protein is playing a role, substantial improvements can result from strict exclusion of offending foods. We would emphasize that this dietary treatment is not part of the standard treatment of NMH and POTS in our clinic, and is only considered on the basis of the specific symptoms mentioned above. Given the potential dangers of unsupervised diets, be sure to discuss these issues with your doctor or health care provider.
d. Increase salt and fluid intake
NMH and POTS are most often treated with a combination of increased salt and water intake. The increased salt and water help ensure that the blood vessels are filled better, and that the heart receives an adequate amount of blood even during upright posture. We recommend at least 2 liters of fluid per day. Our patients who drink fluids regularly throughout the day seem to do better than those who don't take this task seriously. Keep in mind that prolonged periods of sleeping (more than 12 hours) may interfere with the ability to keep up with fluid needs. We recommend drinking fluids every 2 hours throughout the day. As a result, it is important to have easy access to fluids at work or at school.
For those who have been on a low salt intake we recommend an increase in the amount of salt they add to their food. The Appendix to this document contains a list of high salt foods. For some mildly affected individuals, an increased intake of salt and fluids may be all that is needed. Most of those with more severe symptoms require one of several medications in addition to the increased salt and fluid intake. The increased salt and fluid intake should be continued regardless of which of these medications is added.
e. Physical therapy and exercise
Exercise is important in regaining the effects that fitness brings in counteracting NMH or POTS. Because exercise can make NMH or POTS symptoms worse in the period before effective treatment has been found, it must be done carefully at first. When you and your doctor feel you are ready, begin a regular regimen of exercise, finding something that does not make you lightheaded and doing it for brief periods at first, increasing gradually. For example, one girl who had been ill for several years began functioning better once two of the NMH medications were working for her. She began exercising on a treadmill, but this made her lightheaded, so she switched to a reclining exercise bike. Although she started with only 2 minutes a day, she increased this in small increments up to 30 minutes 3 times a week after about three months. Walking, water jogging (the water acts as a compressing force to counteract blood pooling in the limbs), stretching, and Tai Chi or yoga may be gentle ways to ease back into exercise. Remember to warm up slowly before, and cool down gradually after exercise. If you plan to exercise outdoors, remember that extreme heat will worsen NMH or POTS.
A group of our physical therapist colleagues in Baltimore, led by Rick Violand, PT, have helped us to identify a relatively high frequency of postural asymmetries and areas of adverse mechanical tension in the nervous system as contributors to pain, lightheadedness, and fatigue in many of our patients with orthostatic intolerance. These postural restrictions have helped explain why some patients were finding that exercise led to substantially worse symptoms. Among those who have the worst of these postural restrictions, several weeks of gentle manual physical therapy often prepares them to tolerate the mild aerobic exercise that would have caused a flare-up beforehand. We think careful attention must be paid to postural asymmetries and restrictions in mobility during the physical examination, and the diagnostic expertise of a physical therapist may be essential to identifying problems. Manual techniques that our colleagues employ include gentle neural mobilization (or neural tension work), myofascial release, and cranio-sacral therapy.
Steps 2 and 3
For those with more frequent or more severe symptoms, the physical maneuvers, dietary changes, and physical therapy of Step 1 may need to be supplemented by medications. Most of the drugs in common use for NMH and POTS help to improve the ability of the vessels to constrict and return blood to the heart when we stand, some effect the amount of salt and fluid the kidney returns to the blood stream, and some effect the release or action of norepinephrine or epinephrine.
While many of the medications listed below have been used by cardiologists and other physicians for years to treat NMH or POTS, few have been studied formally in those with POTS, NMH, or chronic fatigue syndrome. Some have been tested in patients who have fainted one or more times, but are otherwise healthy; some have been tested in those with ongoing symptoms due to POTS, and some have been tested in NMH patients who were diagnosed with chronic fatigue syndrome. This handout is based upon available research and our experience with NMH and POTS patients, most of whom came to see us because of chronic fatigue syndrome.
The treatments listed require persistence, commitment, and the willingness to try several possible drugs and combinations over an extended period of time. Because there is a risk of serious side effects with some of the drugs (such as elevated blood pressure, elevated sodium levels, lowered potassium levels, or depression) careful monitoring is required. The following lists medications that have been reported to help improve symptoms or tilt table responses in patients with NMH or POTS:
Medications that increase blood volume:
Fludrocortisone (Florinef)
Oral contraceptive pills
Clonidine
Erythropoietin
Medications that interfere with the release or action of epinephrine and norepinephrine:
Beta-blockers (e.g., atenolol, propranolol)
Disopyramide (Norpace)
Angiotensin converting enzyme inhibitors
Medications that improve vasoconstriction:
Stimulants: (e.g., methylphenidate [Ritalin] or dextroamphetamine [Dexedrine])
Midodrine (Proamatine)
Ephedrine and pseudoephedrine (Sudafed)
Theophylline (low-dose)
Selective serotonin reuptake inhibitors (examples include fluoxetine [Prozac], sertraline [Zoloft], and paroxetine [Paxil]). These medications may also affect the central nervous system reflex pathways in NMH as well.
Some of the above medications no doubt work in more than one way. For example, fludrocortisone improves the ability of the blood vessel to constrict in addition to expanding blood volume. Your health care provider should work with you to determine the best possible combination for your personal situation.
Does treatment cure the problem?
It needs to be stressed that, when successful, the medications for NMH and POTS usually do not cure the problem. Rather, they help control symptoms. When medications are stopped or when salt intake is reduced, symptoms frequently reappear. Many with NMH or POTS have symptoms resurface or worsen at busy or stressful times (making an oral presentation in class, having company over for Thanksgiving, rushing for a meeting on a hot day and forgetting to drink), when they have an infection, or when their allergies are more active. The intravenous infusion of saline solutions has been shown in experimental settings to help reduce symptoms, and the judicious use of IV fluids periodically has a role.
Even after successful treatment, many women with NMH and POTS describe a worsening of symptoms in the days around the start of a menstrual period. Some women choose to take birth control pills on a 28 day cycle, or continuously, in addition to their NMH or POTS medications. This is done to avoid symptoms related to hormone changes, and should be discussed with your health care provider.
The question of what happens over the long term has not been adequately studied, and the optimal duration of medical treatment is still being worked out. Unfortunately, despite appropriate doses of the available medications for neurally mediated hypotension, some people with NMH or POTS do not experience an improvement in symptoms, and some are intolerant of the medications. This emphasizes the need for more research on this problem. Many adult women who have orthostatic intolerance describe an improvement in symptoms when they have been pregnant, and often describe pregnancy as the time when they felt "the best ever." The improvement may be due to an expansion of blood volume that occurs naturally with pregnancy.
Finally, we suggest you take an active role in your care. If you have POTS, it might be helpful to learn how to take your pulse. If you have NMH, you may want to purchase a home blood pressure monitor - we suggest the kind with a cuff that goes around your upper arm, not around your wrist or on your finger. Heart rate and BP do not have to be taken routinely each day, but having this information during flare-ups of symptoms may provide helpful insights. Being able to monitor your blood pressure at home or take your own pulse won't replace visits to your physician or health care provider, but may make those visits more productive, as this information may reflect how you are responding to a high salt/high fluid diet or to medications.
SUGGESTIONS FOR A HIGH SODIUM DIET
An adult requires between 2000 and 3000 milligrams (mg) of sodium to maintain health. Although health advice in the last two decades has suggested that a low salt intake helps prevent heart disease and stroke, many individuals with orthostatic intolerance cannot tolerate this low salt diet. We believe that individuals with neurally mediated hypotension or postural tachycardia syndrome need to take in much higher amounts of salt.
The exact amount needed is different for each individual, and is often affected by your taste for salty foods, but it is difficult to take too much, provided that you have access to lots of fluids if you become thirsty. A few individuals have been unable to tolerate an increase in sodium intake without developing increased weight gain, headache, or agitation.
Table salt is also an excellent source of sodium, as it has 2300 mg of sodium per teaspoon. Salt tablets are a way of getting enough sodium without dramatically changing the taste of your foods. If you decide to increase your sodium intake with salt tablets, we suggest that you start slowly, and work gradually up to 900-1000 mg three times a day. Some patients tolerate even higher doses. The amount tolerated varies from person to person. By stepping up your dose slowly, you can determine how much is optimal for you within this range. Remember that if you change your diet to increase sodium intake from your food, you may not need as many salt tablets. Some of our patients report better tolerance of a buffered salt tablet (the commercially available brand contains 450 mg sodium chloride and 30 mg potassium chloride). Salt tablets are available without a prescription.
As for fluid intake, be sure to drink at least 2 liters of fluid a day. Water is fine, but some prefer sports drinks (which have the advantage of a higher sodium content), and other commercially available rehydration fluids contain substantially more sodium than sports drinks. The following are high salt foods to help with your needs:
Breads and cereals: Mg sodium
Noodles, potatoes, rice from instant mixes 500
Wheaties (1 cup) 400
Waffles (one) 355
All Bran (½ cup) 285
Cheerios (1 cup) 260
Rice Krispies (1 cup) 260
Saltine crackers (6) 200
Dairy Products:
Parmesan cheese (1 oz.) 450
Processed cheese and cheese spreads (1 oz.) 320
Cottage cheese (½ cup) 230
Meat, poultry, fish:
Enchilada 1300
TV dinner (1) 1200
Sweet-n-sour pork (1 serving) 1100
Lasagna (1 serving) 1000
Soup, canned (1 cup) 895
Fish-n-chips (1 serving) 750
Hamburger (1) 690
Hot dog (1) 550
Tuna, canned (½ cup) 535
Corn beef (1 oz) 530
Fried chicken (1 serving) 530
Pizza, cheese (1 slice) 500
Pork-n-beans, chili (1 cup) 460
Luncheon meat (1 slice) 300
Bacon (4 slices) 280
Snacks, condiments:
Pretzel Stix, 1 tray (28 g) 1460
Soysauce (1 tbsp) 870
Olives, green (4) 600
Salted nuts (½ cup) 420
Olives, ripe (4) 400
Fruit pie (1/8 pie serving) 355
The exact amount needed is different for each individual, and is often affected by your taste for salty foods, but it is difficult to take too much, provided that you have access to lots of fluids if you become thirsty. A few individuals have been unable to tolerate an increase in sodium intake without developing increased weight gain, headache, or agitation.
Table salt is also an excellent source of sodium, as it has 2300 mg of sodium per teaspoon. Salt tablets are a way of getting enough sodium without dramatically changing the taste of your foods. If you decide to increase your sodium intake with salt tablets, we suggest that you start slowly, and work gradually up to 900-1000 mg three times a day. Some patients tolerate even higher doses. The amount tolerated varies from person to person. By stepping up your dose slowly, you can determine how much is optimal for you within this range. Remember that if you change your diet to increase sodium intake from your food, you may not need as many salt tablets. Some of our patients report better tolerance of a buffered salt tablet (the commercially available brand contains 450 mg sodium chloride and 30 mg potassium chloride). Salt tablets are available without a prescription.
As for fluid intake, be sure to drink at least 2 liters of fluid a day. Water is fine, but some prefer sports drinks (which have the advantage of a higher sodium content), and other commercially available rehydration fluids contain substantially more sodium than sports drinks. The following are high salt foods to help with your needs:
Breads and cereals: Mg sodium
Noodles, potatoes, rice from instant mixes 500
Wheaties (1 cup) 400
Waffles (one) 355
All Bran (½ cup) 285
Cheerios (1 cup) 260
Rice Krispies (1 cup) 260
Saltine crackers (6) 200
Dairy Products:
Parmesan cheese (1 oz.) 450
Processed cheese and cheese spreads (1 oz.) 320
Cottage cheese (½ cup) 230
Meat, poultry, fish:
Enchilada 1300
TV dinner (1) 1200
Sweet-n-sour pork (1 serving) 1100
Lasagna (1 serving) 1000
Soup, canned (1 cup) 895
Fish-n-chips (1 serving) 750
Hamburger (1) 690
Hot dog (1) 550
Tuna, canned (½ cup) 535
Corn beef (1 oz) 530
Fried chicken (1 serving) 530
Pizza, cheese (1 slice) 500
Pork-n-beans, chili (1 cup) 460
Luncheon meat (1 slice) 300
Bacon (4 slices) 280
Snacks, condiments:
Pretzel Stix, 1 tray (28 g) 1460
Soysauce (1 tbsp) 870
Olives, green (4) 600
Salted nuts (½ cup) 420
Olives, ripe (4) 400
Fruit pie (1/8 pie serving) 355
INFORMATION ON MEDICATIONS USED FOR TREATING NMH OR POTS
INFORMATION ON MEDICATIONS USED FOR TREATING NMH OR POTS
Very few of the medications listed below have been tested in formal clinical trials in those with CFS. Some drugs have been tested in clinical trials in those who faint but are otherwise healthy. Some drugs are typically given in combination with others (for example, Florinef), but rigorous studies of combination therapy have not yet been done. The information presented is based on the available research, and the clinical experience of our group and others who study orthostatic intolerance.
1. FLUDROCORTISONE
Brand name: Florinef
Type of drug: a mineralocorticoid steroid
Indication: NMH or POTS
Action: Florinef acts in the kidney to help the kidney retain sodium that would otherwise be lost in the urine, and it may also help blood vessels constrict more readily in response to epinephrine and norepinephrine. It helps the body avidly retain the salt you eat. It does so at the expense of losing potassium into the urine, so it is important to take in adequate amounts of potassium each day (a list of foods high in potassium is appended). We recommend potassium supplements when people start on Florinef, regardless of the serum potassium level, and especially if individuals remain on the drug for several months. A sustained release potassium preparation (containing 8-20 mEq) given once daily has been well tolerated by our patients.
In our clinical trial of Florinef in adult chronic fatigue syndrome patients with NMH, the drug was not effective when given by itself. Several studies suggest the drug is helpful in treating NMH and POTS when given in combination with an increased intake of salt and other medications (for example, with a low dose of a beta blocker), but no rigorous studies of combination therapy have been conducted, and no studies in adolescents have been performed.
Common confusions: Cortisone and fludrocortisone differ. Florinef has none of the anti-inflammatory properties of cortisone or prednisone, and it has no effect on blood sugar as cortisone does. Florinef is not a muscle building (anabolic) steroid. NMH or POTS patients taking Florinef should be on a high salt diet.
Common side effects: To reduce the chance of Florinef causing an elevated blood sodium level, make sure to drink lots of fluids while taking Florinef. Some individuals complain of headache after Florinef and some develop worse CFS symptoms (more lightheadedness or fatigue), abdominal discomfort of a new type or severity, new chest discomfort, or tearfulness and depression. Depression occurs in fewer than 1 in 20 patients, but patients need to be aware of this when they start on the drug, and to know to stop Florinef if such depressed mood occurs. Some have found that minor side effects will disappear after a couple of weeks, and it is worth persevering with the medication provided that the side effects are minor. Some develop worse acne on Florinef. The tablet has a tiny amount of lactose in it, and may cause discomfort to those who are extremely allergic to milk protein. Special pharmacies can compound the drug without lactose or milk protein (e.g, Abrams Royal Pharmacy, 8220 Abrams Rd., Dallas, TX 75231; Tel: 214-349-8000; Fax: 214-341-7966).
With high doses, or even low doses over a long period of time, Florinef can lead to an elevation of blood pressure (BP), especially when other medications like oral contraceptives are added to the regimen. For this reason, we recommend that BP be monitored carefully, especially in the weeks after starting on the drug, and monthly once a stable dose is achieved.
Suggested doses for patients with NMH or POTS: Because the optimal dose can vary considerably, we suggest that those who use Florinef begin with a low dose and increase it gradually. We recommend beginning with a week of increasing salt and fluid before starting on Florinef to ensure better tolerance of the drug. Once you are ready to start, begin with 1/4 tablet per day (0.025 mg). If the 1/4 tablet dose is tolerated for 4-7 days, increase to ½ tablet for 4-7 days, then to 3/4 tablet or a full 0.1 mg tablet. By stepping up the dose gradually, you can better determine the right dose (some patients may only need ½ tablet or ¾ tablet). Some patients report that splitting the dose (half in the morning and half with the evening meal) provides a more even effect, but occasionally people have to return to a once a day morning dose because the Florinef taken later in the day causes them to develop insomnia.
Each patient's tolerance of the drug, and response to it is somewhat different, so we recommend regular visits while the doses are being adjusted. If there is no improvement, or more bothersome side effects appear (worse headaches, substantial weight gain, and certainly depressed mood) we recommend stopping the medication. If people continue to experience some benefit from week to week at a particular dose, it makes sense to continue on that dose. If there are no adverse effects on a dose of 0.1 mg per day, but no impressive therapeutic benefits have occurred after about a month, we will try increases to a maximum of 0.15 or 0.2 mg (1 ½ - 2 tablets) per day. Whether further increases would be beneficial is unclear. If unsure about whether the drug is having a beneficial effect, it can be stopped for a few days to see if symptoms worsen. When Florinef is helping, but only incompletely, we usually continue this medication and then add other classes of medication to it.
Comments: It is important to be sure that you are taking an adequate amount of fluid. We recommend checking the serum electrolytes periodically, but the optimal frequency for doing so is not established. Because licorice root can have the same effect on blood pressure as Florinef, combining these two medications should be avoided. If BP increases over time, a reduction in the Florinef dose may be indicated.
Use in pregnancy: consult with your health care provider.
2. ATENOLOL
Brand names: Tenormin (other similar medications like propranolol or metoprolol may be as effective, but the greatest experience has been with atenolol, and we will focus on atenolol here).
Type of drug: a beta-blocker
Indications: NMH and POTS
Action: Atenolol blocks the effects of adrenaline (epinephrine), and acts both to decrease the heart rate and to prevent the forceful heart contractions that may help trigger NMH.
Common side effects: Some individuals complain of headaches or fatigue after atenolol, and others have worse lightheadedness or worse symptoms in general. If these problems arise, we usually stop the medication. Like other beta-blocker drugs, atenolol can lead to constriction of the airways in individuals with a history of asthma. If cough or wheezing develop soon after starting the drug, it may need to be stopped. For those with mild asthma, our impression has been that an inhaled steroid (eg, Pulmicort, Flovent) may allow patients to tolerate the beta-blocker without increased airway reactivity. Atenolol can also cause emotional depression. Atenolol is less likely than other beta-blocker drugs (such as propranolol [Inderal]) to lead to nightmares, confusion, and hallucinations. Atenolol and other beta-blocker drugs can interfere with the body's ability to correct low blood sugar, so the drug must be used with extreme caution (if at all) in diabetics. The activity of the drug can be decreased when it is used in conjunction with non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin).
Doses: The usual starting dose of atenolol for older adolescents and adults is 12.5-25 mg per day, but doses of up to 100 mg per day are used. For those with NMH, we usually aim for 1 mg of atenolol for every kg of body weight. For example, an individual weighing 62 kg (136 lb) would likely do well with between 50 and 75 mg of medication per day. People are unlikely to tolerate higher doses if their resting heart rate is below 50 beats per minute. The ideal dose for those with POTS is not well defined, and some authorities believe that lower doses may be preferable. Further study is needed to determine whether patients would do better with one form of beta blocker (selective beta blocker like atenolol) versus another (non-selective beta-blocker like propranolol).
Use in pregnancy: consult with your health care provider.
3. STIMULANTS
Brand names: Ritalin, Dexedrine, Adderall, and others. No studies have compared the relative efficacy of one to the others for those with NMH or POTS.
Indications: NMH or POTS
Action: The stimulant medications available for the treatment of attention deficit disorder are effective as vasoconstrictor drugs for the treatment of NMH and POTS. By improving constriction of blood vessels in the peripheral circulation, they improve the amount of blood flow returning to the heart. These medications may also exert their beneficial effects through actions on the central nervous system as well.
Doses: The maximum dose depends on the individual's weight. We begin with low doses, increasing once it is clear the patient tolerates the drug.
Dextroamphetamine: Dexedrine spansules are the sustained release form of the medication, and because they contain no milk protein they are the ones we use first for patients with milk allergy. The average starting dose for adolescents and adults is one 5 mg Dexedrine spansule each morning for 3 days or so. If there is no apparent improvement at this dose by that time, we increase the dose to two of the 5 mg spansules in the morning (at the same time). After another 3-4 days, if there is no improvement, increase to 3 spansules (15 mg) in the morning. The top dose is different for each person, and further increases may be needed.
Methylphenidate: the dose of methylphenidate depends on the individual's weight, but we usually try to keep the dose below approximately 0.5 mg per kg of body weight. We begin with low doses, increasing once it is clear the patient tolerates the drug. The starting dose for school-age children as well as adolescents and adults is 5 mg, given first thing in the morning, repeated if necessary 4 hours later. Unless the 5 mg once or twice daily is enough to control symptoms, we recommend increasing the dose to one of the following:
10 mg in the AM and 4 hours later
10 mg in the AM, 5 mg four hours later
10 mg in the AM, 5 mg four hours later, and 5 mg four hours after the 2nd dose
The maximum dose can be substantially higher, up to about 1 mg of drug for every kg of body weight, but a dose of as little as 5 mg per day may be all that is required. One adolescent, for example, had her best response on a regimen of 15 mg per dose given three times a day.
Expected therapeutic effects: The short-acting forms of methylphenidate or dextroamphetamine usually start to take effect after 30-45 minutes or so, and the duration of effect is usually 4 hours or so. If the stimulant medications are working at a particular dose, we expect individuals to feel less lightheadedness, headache, or fatigue. There may also be improvement in the ability to concentrate and stay on task. Individuals usually know soon after taking the first few doses if the drug is having a beneficial effect at that dose. The stimulants are controlled substances, so the prescriptions have to be written more frequently, and physicians cannot ask for refills on the same prescription.
Side effects: The main side effects of the stimulants are insomnia, a reduction in appetite, moodiness, and occasionally abdominal pain. Some patients describe increased lightheadedness, agitation, and other bothersome symptoms. If these develop, we usually stop the drug and move on to other medication trials.
Comment: We have found these medications to be particularly helpful for those who had a history of hyperactivity or attention deficit disorder in childhood, or a family member with the disorder, either alone or in combination with other NMH treatments.
Use in pregnancy: consult with your health care provider.
4. MIDODRINE
Brand name: ProAmatine
Type of drug: Midodrine is classified as an alpha-1 agonist, or vasoconstrictor drug. Unlike the stimulant drugs, it is not thought to have direct central nervous system effects.
Action: The main effects of midodrine are to cause blood vessels to tighten, thereby reducing the amount of blood that pools in the abdomen and legs, shifting that blood volume into the central circulation where we want it to be. The drug has been used in thousands of individuals around the world, and appears to be well tolerated.
Side effects: The main side effects from midodrine in those with orthostatic hypotension (a condition similar to, but not the same as, neurally mediated hypotension) are: high blood pressure when lying down in 15-20%, itching (also called pruritis) in 10-15%, pins and needles sensation in 5-10%, urinary urgency/full bladder in 5%.
Common side effects to be expected include a sense of the scalp tingling, and the hair on the arms and neck standing on end. These changes are signs that the drug is working, and are not reasons to discontinue the drug. Adolescents and young adults with NMH and POTS should not be at risk for the same degree of high blood pressure as those with orthostatic hypotension (whose average age is closer to 50-60 years), but one needs to watch for this.
Dose: A conservative starting dose for midodrine is 2.5 mg three times daily to ensure that the dose is tolerated. A reasonable dose progression follows:
2.5 mg three times a day for 1-2 days (Each dose taken approximately 4 hours apart).
5.0 mg three times a day for 1-2 days
7.5 mg three times a day for 1-2 days
10.0 mg three times a day
If there is substantial improvement at a lower dose, then it may be wise to stay at this dose for a longer period. It is not always necessary to march up to the 10 mg three times a day dose. The drug effect lasts only about 3-4 hours, so the medication may need to be spaced differently once it is clear that it is having a beneficial effect.
Use in pregnancy: consult with your health care provider.
5. SELECTIVE SEROTONIN REUPTAKE INHIBITORS
The selective serotonin re-uptake inhibitor (SSRI) medications most commonly used for those with NMH or POTS are Paxil, Zoloft, and Prozac, but others in this class of antidepressant medications are likely to work as well. The doses used to treat NMH or POTS are similar to those used for the treatment of depression; as with the other medications for NMH and POTS, it makes sense to start at a low dose and to increase gradually (allowing 2-4 weeks for the medication to begin working after a particular dose increase). With Zoloft, for example, we usually begin with a dose of 12.5 - 25 mg per day, increasing to 50 mg per day if needed after 2-4 weeks, then adjusting upwards depending on the response. Some patients describe worse orthostatic intolerance or fatigue on the SSRIs. In patients with increased anxiety or depressed mood, these medications may be particularly helpful, but one does not need to have either anxiety or depression for the SSRIs to help with NMH or POTS.
Use in pregnancy: Several studies suggest they are safe, but consult with your health care provider.
6. DISOPYRAMIDE
Brand name: Norpace
Type of drug: an anti-arrhythmic, anti-cholinergic drug
Indication: NMH (no studies in POTS)
Action: Norpace blocks the response to adrenaline (epinephrine), and prevents the forceful heart contractions that occur in neurally mediated hypotension.
Side effects: Some individuals complain of headaches or fatigue after Norpace, and others have worse lightheadedness. Other possible side effects are dry mouth, constipation, blurred vision, and impaired urination. This drug can activate glaucoma in some individuals. Norpace should not be taken with erythromycin, clarithromycin, azithromycin, phenothiazines, trimethoprim-sulfamethoxazole, cisapride, or other Class 1a anti-arrhythmic agents because of the potential for triggering serious heart rhythm abnormalities. For similar reasons, it should be used with great caution in those on tricyclic antidepressants. Due to its ability to reduce the forcefulness of the heart's pumping action and to trigger arryhthmias, its use should be considered very carefully in those with heart disease. Use of the drug by those already taking beta-blockers or calcium channel blockers requires similar caution.
Doses: typically the dose for older adolescents and adults is 100-200 mg of the CR (sustained release) preparation twice daily, although higher doses are sometimes tolerated, and lower doses are sometimes effective. It is preferable to take it on an empty stomach, an hour before or two hours after eating, but it can be taken with food to reduce stomach irritation. Some individuals with medication sensitivities need to have the drug started at 100 mg each morning for a week, with increases of 50 or 100 mg per week (using the 150 mg CR capsule).
Use in pregnancy: Consult with your health care provider.
7. CLONIDINE
Clonidine is a medication first introduced for control of high blood pressure, but it can also improve blood volume in a subset of those with orthostatic intolerance. It works in part by reducing sympathetic nervous system outflow from the brain.
It is also used as a drug for those with attention deficit disorder, and has been reported to help reduce anxiety, reduce withdrawal symptoms in those who are on narcotic medications, and improve sleep. There is also some evidence that it can improve stomach emptying in patients with delayed gastric motility. We have found that a proportion of patients with CFS benefit from it.
The starting dose is ½ a tablet (0.05 mg) at night for 3-7 days, then increasing to a full 0.1 mg tablet at night. Higher doses are sometimes tolerated. Side effects can include worse fatigue and lightheadedness (due to its ability to lower blood pressure), and dry mouth. If side effects are mild in the first week, we usually ask patients to continue on the drug to see if these effects resolve and the therapeutic benefit becomes evident over the next few weeks. If side effects are more impressive, we suggest stopping the medication.
If people have been taking clonidine for a prolonged period of time, they need to wean off it slowly to avoid developing rebound hypertension.
For those who are allergic to milk protein the Mylan brand form is lactose free.
Very few of the medications listed below have been tested in formal clinical trials in those with CFS. Some drugs have been tested in clinical trials in those who faint but are otherwise healthy. Some drugs are typically given in combination with others (for example, Florinef), but rigorous studies of combination therapy have not yet been done. The information presented is based on the available research, and the clinical experience of our group and others who study orthostatic intolerance.
1. FLUDROCORTISONE
Brand name: Florinef
Type of drug: a mineralocorticoid steroid
Indication: NMH or POTS
Action: Florinef acts in the kidney to help the kidney retain sodium that would otherwise be lost in the urine, and it may also help blood vessels constrict more readily in response to epinephrine and norepinephrine. It helps the body avidly retain the salt you eat. It does so at the expense of losing potassium into the urine, so it is important to take in adequate amounts of potassium each day (a list of foods high in potassium is appended). We recommend potassium supplements when people start on Florinef, regardless of the serum potassium level, and especially if individuals remain on the drug for several months. A sustained release potassium preparation (containing 8-20 mEq) given once daily has been well tolerated by our patients.
In our clinical trial of Florinef in adult chronic fatigue syndrome patients with NMH, the drug was not effective when given by itself. Several studies suggest the drug is helpful in treating NMH and POTS when given in combination with an increased intake of salt and other medications (for example, with a low dose of a beta blocker), but no rigorous studies of combination therapy have been conducted, and no studies in adolescents have been performed.
Common confusions: Cortisone and fludrocortisone differ. Florinef has none of the anti-inflammatory properties of cortisone or prednisone, and it has no effect on blood sugar as cortisone does. Florinef is not a muscle building (anabolic) steroid. NMH or POTS patients taking Florinef should be on a high salt diet.
Common side effects: To reduce the chance of Florinef causing an elevated blood sodium level, make sure to drink lots of fluids while taking Florinef. Some individuals complain of headache after Florinef and some develop worse CFS symptoms (more lightheadedness or fatigue), abdominal discomfort of a new type or severity, new chest discomfort, or tearfulness and depression. Depression occurs in fewer than 1 in 20 patients, but patients need to be aware of this when they start on the drug, and to know to stop Florinef if such depressed mood occurs. Some have found that minor side effects will disappear after a couple of weeks, and it is worth persevering with the medication provided that the side effects are minor. Some develop worse acne on Florinef. The tablet has a tiny amount of lactose in it, and may cause discomfort to those who are extremely allergic to milk protein. Special pharmacies can compound the drug without lactose or milk protein (e.g, Abrams Royal Pharmacy, 8220 Abrams Rd., Dallas, TX 75231; Tel: 214-349-8000; Fax: 214-341-7966).
With high doses, or even low doses over a long period of time, Florinef can lead to an elevation of blood pressure (BP), especially when other medications like oral contraceptives are added to the regimen. For this reason, we recommend that BP be monitored carefully, especially in the weeks after starting on the drug, and monthly once a stable dose is achieved.
Suggested doses for patients with NMH or POTS: Because the optimal dose can vary considerably, we suggest that those who use Florinef begin with a low dose and increase it gradually. We recommend beginning with a week of increasing salt and fluid before starting on Florinef to ensure better tolerance of the drug. Once you are ready to start, begin with 1/4 tablet per day (0.025 mg). If the 1/4 tablet dose is tolerated for 4-7 days, increase to ½ tablet for 4-7 days, then to 3/4 tablet or a full 0.1 mg tablet. By stepping up the dose gradually, you can better determine the right dose (some patients may only need ½ tablet or ¾ tablet). Some patients report that splitting the dose (half in the morning and half with the evening meal) provides a more even effect, but occasionally people have to return to a once a day morning dose because the Florinef taken later in the day causes them to develop insomnia.
Each patient's tolerance of the drug, and response to it is somewhat different, so we recommend regular visits while the doses are being adjusted. If there is no improvement, or more bothersome side effects appear (worse headaches, substantial weight gain, and certainly depressed mood) we recommend stopping the medication. If people continue to experience some benefit from week to week at a particular dose, it makes sense to continue on that dose. If there are no adverse effects on a dose of 0.1 mg per day, but no impressive therapeutic benefits have occurred after about a month, we will try increases to a maximum of 0.15 or 0.2 mg (1 ½ - 2 tablets) per day. Whether further increases would be beneficial is unclear. If unsure about whether the drug is having a beneficial effect, it can be stopped for a few days to see if symptoms worsen. When Florinef is helping, but only incompletely, we usually continue this medication and then add other classes of medication to it.
Comments: It is important to be sure that you are taking an adequate amount of fluid. We recommend checking the serum electrolytes periodically, but the optimal frequency for doing so is not established. Because licorice root can have the same effect on blood pressure as Florinef, combining these two medications should be avoided. If BP increases over time, a reduction in the Florinef dose may be indicated.
Use in pregnancy: consult with your health care provider.
2. ATENOLOL
Brand names: Tenormin (other similar medications like propranolol or metoprolol may be as effective, but the greatest experience has been with atenolol, and we will focus on atenolol here).
Type of drug: a beta-blocker
Indications: NMH and POTS
Action: Atenolol blocks the effects of adrenaline (epinephrine), and acts both to decrease the heart rate and to prevent the forceful heart contractions that may help trigger NMH.
Common side effects: Some individuals complain of headaches or fatigue after atenolol, and others have worse lightheadedness or worse symptoms in general. If these problems arise, we usually stop the medication. Like other beta-blocker drugs, atenolol can lead to constriction of the airways in individuals with a history of asthma. If cough or wheezing develop soon after starting the drug, it may need to be stopped. For those with mild asthma, our impression has been that an inhaled steroid (eg, Pulmicort, Flovent) may allow patients to tolerate the beta-blocker without increased airway reactivity. Atenolol can also cause emotional depression. Atenolol is less likely than other beta-blocker drugs (such as propranolol [Inderal]) to lead to nightmares, confusion, and hallucinations. Atenolol and other beta-blocker drugs can interfere with the body's ability to correct low blood sugar, so the drug must be used with extreme caution (if at all) in diabetics. The activity of the drug can be decreased when it is used in conjunction with non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin).
Doses: The usual starting dose of atenolol for older adolescents and adults is 12.5-25 mg per day, but doses of up to 100 mg per day are used. For those with NMH, we usually aim for 1 mg of atenolol for every kg of body weight. For example, an individual weighing 62 kg (136 lb) would likely do well with between 50 and 75 mg of medication per day. People are unlikely to tolerate higher doses if their resting heart rate is below 50 beats per minute. The ideal dose for those with POTS is not well defined, and some authorities believe that lower doses may be preferable. Further study is needed to determine whether patients would do better with one form of beta blocker (selective beta blocker like atenolol) versus another (non-selective beta-blocker like propranolol).
Use in pregnancy: consult with your health care provider.
3. STIMULANTS
Brand names: Ritalin, Dexedrine, Adderall, and others. No studies have compared the relative efficacy of one to the others for those with NMH or POTS.
Indications: NMH or POTS
Action: The stimulant medications available for the treatment of attention deficit disorder are effective as vasoconstrictor drugs for the treatment of NMH and POTS. By improving constriction of blood vessels in the peripheral circulation, they improve the amount of blood flow returning to the heart. These medications may also exert their beneficial effects through actions on the central nervous system as well.
Doses: The maximum dose depends on the individual's weight. We begin with low doses, increasing once it is clear the patient tolerates the drug.
Dextroamphetamine: Dexedrine spansules are the sustained release form of the medication, and because they contain no milk protein they are the ones we use first for patients with milk allergy. The average starting dose for adolescents and adults is one 5 mg Dexedrine spansule each morning for 3 days or so. If there is no apparent improvement at this dose by that time, we increase the dose to two of the 5 mg spansules in the morning (at the same time). After another 3-4 days, if there is no improvement, increase to 3 spansules (15 mg) in the morning. The top dose is different for each person, and further increases may be needed.
Methylphenidate: the dose of methylphenidate depends on the individual's weight, but we usually try to keep the dose below approximately 0.5 mg per kg of body weight. We begin with low doses, increasing once it is clear the patient tolerates the drug. The starting dose for school-age children as well as adolescents and adults is 5 mg, given first thing in the morning, repeated if necessary 4 hours later. Unless the 5 mg once or twice daily is enough to control symptoms, we recommend increasing the dose to one of the following:
10 mg in the AM and 4 hours later
10 mg in the AM, 5 mg four hours later
10 mg in the AM, 5 mg four hours later, and 5 mg four hours after the 2nd dose
The maximum dose can be substantially higher, up to about 1 mg of drug for every kg of body weight, but a dose of as little as 5 mg per day may be all that is required. One adolescent, for example, had her best response on a regimen of 15 mg per dose given three times a day.
Expected therapeutic effects: The short-acting forms of methylphenidate or dextroamphetamine usually start to take effect after 30-45 minutes or so, and the duration of effect is usually 4 hours or so. If the stimulant medications are working at a particular dose, we expect individuals to feel less lightheadedness, headache, or fatigue. There may also be improvement in the ability to concentrate and stay on task. Individuals usually know soon after taking the first few doses if the drug is having a beneficial effect at that dose. The stimulants are controlled substances, so the prescriptions have to be written more frequently, and physicians cannot ask for refills on the same prescription.
Side effects: The main side effects of the stimulants are insomnia, a reduction in appetite, moodiness, and occasionally abdominal pain. Some patients describe increased lightheadedness, agitation, and other bothersome symptoms. If these develop, we usually stop the drug and move on to other medication trials.
Comment: We have found these medications to be particularly helpful for those who had a history of hyperactivity or attention deficit disorder in childhood, or a family member with the disorder, either alone or in combination with other NMH treatments.
Use in pregnancy: consult with your health care provider.
4. MIDODRINE
Brand name: ProAmatine
Type of drug: Midodrine is classified as an alpha-1 agonist, or vasoconstrictor drug. Unlike the stimulant drugs, it is not thought to have direct central nervous system effects.
Action: The main effects of midodrine are to cause blood vessels to tighten, thereby reducing the amount of blood that pools in the abdomen and legs, shifting that blood volume into the central circulation where we want it to be. The drug has been used in thousands of individuals around the world, and appears to be well tolerated.
Side effects: The main side effects from midodrine in those with orthostatic hypotension (a condition similar to, but not the same as, neurally mediated hypotension) are: high blood pressure when lying down in 15-20%, itching (also called pruritis) in 10-15%, pins and needles sensation in 5-10%, urinary urgency/full bladder in 5%.
Common side effects to be expected include a sense of the scalp tingling, and the hair on the arms and neck standing on end. These changes are signs that the drug is working, and are not reasons to discontinue the drug. Adolescents and young adults with NMH and POTS should not be at risk for the same degree of high blood pressure as those with orthostatic hypotension (whose average age is closer to 50-60 years), but one needs to watch for this.
Dose: A conservative starting dose for midodrine is 2.5 mg three times daily to ensure that the dose is tolerated. A reasonable dose progression follows:
2.5 mg three times a day for 1-2 days (Each dose taken approximately 4 hours apart).
5.0 mg three times a day for 1-2 days
7.5 mg three times a day for 1-2 days
10.0 mg three times a day
If there is substantial improvement at a lower dose, then it may be wise to stay at this dose for a longer period. It is not always necessary to march up to the 10 mg three times a day dose. The drug effect lasts only about 3-4 hours, so the medication may need to be spaced differently once it is clear that it is having a beneficial effect.
Use in pregnancy: consult with your health care provider.
5. SELECTIVE SEROTONIN REUPTAKE INHIBITORS
The selective serotonin re-uptake inhibitor (SSRI) medications most commonly used for those with NMH or POTS are Paxil, Zoloft, and Prozac, but others in this class of antidepressant medications are likely to work as well. The doses used to treat NMH or POTS are similar to those used for the treatment of depression; as with the other medications for NMH and POTS, it makes sense to start at a low dose and to increase gradually (allowing 2-4 weeks for the medication to begin working after a particular dose increase). With Zoloft, for example, we usually begin with a dose of 12.5 - 25 mg per day, increasing to 50 mg per day if needed after 2-4 weeks, then adjusting upwards depending on the response. Some patients describe worse orthostatic intolerance or fatigue on the SSRIs. In patients with increased anxiety or depressed mood, these medications may be particularly helpful, but one does not need to have either anxiety or depression for the SSRIs to help with NMH or POTS.
Use in pregnancy: Several studies suggest they are safe, but consult with your health care provider.
6. DISOPYRAMIDE
Brand name: Norpace
Type of drug: an anti-arrhythmic, anti-cholinergic drug
Indication: NMH (no studies in POTS)
Action: Norpace blocks the response to adrenaline (epinephrine), and prevents the forceful heart contractions that occur in neurally mediated hypotension.
Side effects: Some individuals complain of headaches or fatigue after Norpace, and others have worse lightheadedness. Other possible side effects are dry mouth, constipation, blurred vision, and impaired urination. This drug can activate glaucoma in some individuals. Norpace should not be taken with erythromycin, clarithromycin, azithromycin, phenothiazines, trimethoprim-sulfamethoxazole, cisapride, or other Class 1a anti-arrhythmic agents because of the potential for triggering serious heart rhythm abnormalities. For similar reasons, it should be used with great caution in those on tricyclic antidepressants. Due to its ability to reduce the forcefulness of the heart's pumping action and to trigger arryhthmias, its use should be considered very carefully in those with heart disease. Use of the drug by those already taking beta-blockers or calcium channel blockers requires similar caution.
Doses: typically the dose for older adolescents and adults is 100-200 mg of the CR (sustained release) preparation twice daily, although higher doses are sometimes tolerated, and lower doses are sometimes effective. It is preferable to take it on an empty stomach, an hour before or two hours after eating, but it can be taken with food to reduce stomach irritation. Some individuals with medication sensitivities need to have the drug started at 100 mg each morning for a week, with increases of 50 or 100 mg per week (using the 150 mg CR capsule).
Use in pregnancy: Consult with your health care provider.
7. CLONIDINE
Clonidine is a medication first introduced for control of high blood pressure, but it can also improve blood volume in a subset of those with orthostatic intolerance. It works in part by reducing sympathetic nervous system outflow from the brain.
It is also used as a drug for those with attention deficit disorder, and has been reported to help reduce anxiety, reduce withdrawal symptoms in those who are on narcotic medications, and improve sleep. There is also some evidence that it can improve stomach emptying in patients with delayed gastric motility. We have found that a proportion of patients with CFS benefit from it.
The starting dose is ½ a tablet (0.05 mg) at night for 3-7 days, then increasing to a full 0.1 mg tablet at night. Higher doses are sometimes tolerated. Side effects can include worse fatigue and lightheadedness (due to its ability to lower blood pressure), and dry mouth. If side effects are mild in the first week, we usually ask patients to continue on the drug to see if these effects resolve and the therapeutic benefit becomes evident over the next few weeks. If side effects are more impressive, we suggest stopping the medication.
If people have been taking clonidine for a prolonged period of time, they need to wean off it slowly to avoid developing rebound hypertension.
For those who are allergic to milk protein the Mylan brand form is lactose free.
Saturday, January 24, 2009
What is stress?
Stress is simply a fact of nature—forces from the outside world affecting the individual. The individual responds to stress in ways that affect the individual as well as their environment. Hence, all living creatures are in a constant interchange with their surroundings (the ecosystem), both physically and behaviorally. This interplay of forces, or energy, is of course present in the relationships between all matter in the universe, whether it is living (animate) or not living (inanimate). However, there are critical differences in how different living creatures relate to their environment. These differences have far-reaching consequences for survival. Because of the overabundance of stress in our modern lives, we usually think of stress as a negative experience, but from a biological point of view, stress can be a neutral, negative, or positive experience.
In general, stress is related to both external and internal factors. External factors include the physical environment, including your job, your relationships with others, your home, and all the situations, challenges, difficulties, and expectations you're confronted with on a daily basis. Internal factors determine your body's ability to respond to, and deal with, the external stress-inducing factors. Internal factors which influence your ability to handle stress include your nutritional status, overall health and fitness levels, emotional well-being, and the amount of sleep and rest you get.
Stress has driven evolutionary change (the development and natural selection of species over time). Thus, the species that adapted best to the causes of stress (stressors) have survived and evolved into the plant and animal kingdoms we now observe. Man is the most adaptive creature on the planet because of the evolution of the human brain, especially the part called the neo-cortex. This adaptability is largely due to the changes and stressors that we have faced and mastered. Therefore, we, unlike other animals, can live in any climate or ecosystem, at various altitudes, and avoid the danger of predators. Moreover, most recently, we have learned to live in the air, under the sea, and even in space, where no living creatures that we know of have ever survived. So then, what is so bad about stress?
In general, stress is related to both external and internal factors. External factors include the physical environment, including your job, your relationships with others, your home, and all the situations, challenges, difficulties, and expectations you're confronted with on a daily basis. Internal factors determine your body's ability to respond to, and deal with, the external stress-inducing factors. Internal factors which influence your ability to handle stress include your nutritional status, overall health and fitness levels, emotional well-being, and the amount of sleep and rest you get.
Stress has driven evolutionary change (the development and natural selection of species over time). Thus, the species that adapted best to the causes of stress (stressors) have survived and evolved into the plant and animal kingdoms we now observe. Man is the most adaptive creature on the planet because of the evolution of the human brain, especially the part called the neo-cortex. This adaptability is largely due to the changes and stressors that we have faced and mastered. Therefore, we, unlike other animals, can live in any climate or ecosystem, at various altitudes, and avoid the danger of predators. Moreover, most recently, we have learned to live in the air, under the sea, and even in space, where no living creatures that we know of have ever survived. So then, what is so bad about stress?
A brief history of stress
A key to the understanding of the negative aspects of stress is the concept of milieu interieur (the internal environment of the body), which was first advanced by the great French physiologist Claude Bernard. In this concept, he described the principles of dynamic equilibrium. In dynamic equilibrium, constancy, a steady state (situation) in the internal bodily environment, is essential to survival. Therefore, external changes in the environment or external forces that change the internal balance must be reacted to and compensated for if the organism is to survive. Examples of such external forces include temperature, oxygen concentration in the air, the expenditure of energy, and the presence of predators. In addition, diseases were also stressors that threatened the constancy of the milieu interieur.
The great neurologist Walter Cannon coined the term homeostasis to further define the dynamic equilibrium that Bernard had described. He also was the first to recognize that stressors could be emotional as well as physical. Through his experiments, he demonstrated the "fight or flight" response that man and other animals share when threatened. Further, Cannon traced these reactions to the release of powerful neurotransmitters from a part of the adrenal gland, the medulla. (Neurotransmitters are the body's chemicals that carry messages to and from the nerves.) The adrenal medulla secretes two neurotransmitters, epinephrine (also called adrenaline) and norepinephrine (noradrenaline), in the response to stress. The release of these neurotransmitters leads to the physiologic effects seen in the fight or flight response, for example, a rapid heart rate, increased alertness, etc.
Hans Selye, another early scientist who studied stress, extended Cannon's observations. He included, as part of the body's stress response system, the pituitary gland, a small gland at the base of the brain. He described the control by this gland of the secretion of hormones (for example, cortisol) that are important in the physiological response to stress by the other part of the adrenal gland known as the cortex. Additionally, Selye actually introduced the term stress from physics and engineering and defined it as "mutual actions of forces that take place across any section of the body, physical or psychological."
In his experiments, Selye induced stress in rats in a variety of ways. He found typical and constant psychological and physical responses to the adverse situations that were imposed on the rats. In rats exposed to constant stress, he observed enlargement of the adrenal glands, gastrointestinal ulcers, and a wasting away (atrophy) of the immune (defense) system. He called these responses to stress the general adaptation (adjustment) or stress syndrome. He discovered that these processes, which were adaptive (healthy, appropriate adjustment) and normal for the organism in warding off stress, could become much like illnesses. That is, the adaptive processes, if they were excessive, could damage the body. Here then is the beginning of an understanding of why stress, really overstress, can be harmful, and why the word stress has earned such a bad name
The great neurologist Walter Cannon coined the term homeostasis to further define the dynamic equilibrium that Bernard had described. He also was the first to recognize that stressors could be emotional as well as physical. Through his experiments, he demonstrated the "fight or flight" response that man and other animals share when threatened. Further, Cannon traced these reactions to the release of powerful neurotransmitters from a part of the adrenal gland, the medulla. (Neurotransmitters are the body's chemicals that carry messages to and from the nerves.) The adrenal medulla secretes two neurotransmitters, epinephrine (also called adrenaline) and norepinephrine (noradrenaline), in the response to stress. The release of these neurotransmitters leads to the physiologic effects seen in the fight or flight response, for example, a rapid heart rate, increased alertness, etc.
Hans Selye, another early scientist who studied stress, extended Cannon's observations. He included, as part of the body's stress response system, the pituitary gland, a small gland at the base of the brain. He described the control by this gland of the secretion of hormones (for example, cortisol) that are important in the physiological response to stress by the other part of the adrenal gland known as the cortex. Additionally, Selye actually introduced the term stress from physics and engineering and defined it as "mutual actions of forces that take place across any section of the body, physical or psychological."
In his experiments, Selye induced stress in rats in a variety of ways. He found typical and constant psychological and physical responses to the adverse situations that were imposed on the rats. In rats exposed to constant stress, he observed enlargement of the adrenal glands, gastrointestinal ulcers, and a wasting away (atrophy) of the immune (defense) system. He called these responses to stress the general adaptation (adjustment) or stress syndrome. He discovered that these processes, which were adaptive (healthy, appropriate adjustment) and normal for the organism in warding off stress, could become much like illnesses. That is, the adaptive processes, if they were excessive, could damage the body. Here then is the beginning of an understanding of why stress, really overstress, can be harmful, and why the word stress has earned such a bad name
What are the signs and symptoms of poorly managed stress?
Excess stress can manifest itself in a variety of emotional, behavioral, and even physical symptoms, and the symptoms of stress vary enormously among different individuals. Common somatic (physical) symptoms often reported by those experiencing excess stress include sleep disturbances, muscle tension, headache, gastrointestinal disturbances, and fatigue. Emotional and behavioral symptoms that can accompany excess stress include nervousness, anxiety, changes in eating habits including overeating, loss of enthusiasm or energy, and mood changes. Of course, none of these signs or symptoms means for certain that there is an elevated stress level since all of these symptoms can be caused by other medical and/or psychological conditions.
It is also known that people under stress have a greater tendency to engage in unhealthy behaviors, such as excessive use or abuse of alcohol and drugs, cigarette smoking, and making poor nutritional choices, than their less-stressed counterparts. These unhealthy behaviors can further increase the severity of symptoms related to stress, often leading to a "vicious cycle" of symptoms and unhealthy behaviors.
The experience of stress is highly individualized. What constitutes overwhelming stress for one person may not be perceived as stress by another. Likewise, the symptoms and signs of poorly managed stress will be different for each person.
Who is most vulnerable to stress?
Stress comes in many forms and affects people of all ages and all walks of life. No external standards can be applied to predict stress levels in individuals—one need not have a traditionally stressful job to experience workplace stress, just as a parent of one child may experience more parental stress than a parent of several children. The degree of stress in our lives is highly dependent upon individual factors such as our physical health, the quality of our interpersonal relationships, the number of commitments and responsibilities we carry, the degree of others' dependence upon us, expectations of us, the amount of support we receive from others, and the number of changes or traumatic events that have recently occurred in our lives.
Some generalizations, however, can be made. People with adequate social support networks report less stress and overall improved mental health in comparison to those without adequate social contacts. People who are poorly nourished, who get inadequate sleep, or who are physically unwell also have a reduced capacity to handle pressures and stresses of everyday life and may report higher stress levels. Some stressors are particularly associated with certain age groups or life stages. Children, teens, working parents, and seniors are examples of the groups who often face common stressors related to life transitions.
It is also known that people under stress have a greater tendency to engage in unhealthy behaviors, such as excessive use or abuse of alcohol and drugs, cigarette smoking, and making poor nutritional choices, than their less-stressed counterparts. These unhealthy behaviors can further increase the severity of symptoms related to stress, often leading to a "vicious cycle" of symptoms and unhealthy behaviors.
The experience of stress is highly individualized. What constitutes overwhelming stress for one person may not be perceived as stress by another. Likewise, the symptoms and signs of poorly managed stress will be different for each person.
Who is most vulnerable to stress?
Stress comes in many forms and affects people of all ages and all walks of life. No external standards can be applied to predict stress levels in individuals—one need not have a traditionally stressful job to experience workplace stress, just as a parent of one child may experience more parental stress than a parent of several children. The degree of stress in our lives is highly dependent upon individual factors such as our physical health, the quality of our interpersonal relationships, the number of commitments and responsibilities we carry, the degree of others' dependence upon us, expectations of us, the amount of support we receive from others, and the number of changes or traumatic events that have recently occurred in our lives.
Some generalizations, however, can be made. People with adequate social support networks report less stress and overall improved mental health in comparison to those without adequate social contacts. People who are poorly nourished, who get inadequate sleep, or who are physically unwell also have a reduced capacity to handle pressures and stresses of everyday life and may report higher stress levels. Some stressors are particularly associated with certain age groups or life stages. Children, teens, working parents, and seniors are examples of the groups who often face common stressors related to life transitions.
Teen stress
As one example of stress related to a life transition, the teen years often bring about an increase in perceived stress as young adults learn to cope with increasing demands and pressures. Studies have shown that excessive stress during the teen years can have a negative impact upon both physical and mental health later in life. For example, teen stress is a risk factor for the development of depression, a serious condition that carries an increased risk of suicide.
Fortunately, effective stress-management strategies can diminish the ill effects of stress. The presence of intact and strong social support networks among friends, family, and religious or other group affiliations can help reduce the subjective experience of stress during the teen years. Recognition of the problem and helping teens to develop stress-management skills can also be valuable preventive measures. In severe cases, a physician or other health care provider can recommend treatments or counseling that can reduce the long-term risks of teen stress.
What is the healthy response to stress?
A key aspect of a healthy adaptational response to stress is the time course. Responses must be initiated rapidly, maintained for a proper amount of time, and then turned off to ensure an optimal result. An over-response to stress or the failure to shut off a stress response can have negative biological consequences for an individual. Healthy human responses to stress involve three components:
The brain handles (mediates) the immediate response. This response signals the adrenal medulla to release epinephrine and norepinephrine.
The hypothalamus (a central area in the brain) and the pituitary gland initiate (trigger) the slower maintenance response by signaling the adrenal cortex to release cortisol and other hormones.
Many neural (nerve) circuits are involved in the behavioral response. This response increases arousal (alertness, heightened awareness), focuses attention, inhibits feeding and reproductive behavior, reduces pain perception, and redirects behavior.
The combined results of these three components of the stress response maintain the internal balance (homeostasis), increase energy production and utilization, and alter electrolyte (chemical elements) and fluid balance in the body. They also gear up the organism for a quick reaction through the sympathetic nervous system (SNS). The SNS operates by increasing the heart rate, increasing blood pressure, redirecting blood flow to the heart, muscles, and brain and away from the gastrointestinal tract, and releasing fuel (glucose and fatty acids) to help fight or flee the danger.
Fortunately, effective stress-management strategies can diminish the ill effects of stress. The presence of intact and strong social support networks among friends, family, and religious or other group affiliations can help reduce the subjective experience of stress during the teen years. Recognition of the problem and helping teens to develop stress-management skills can also be valuable preventive measures. In severe cases, a physician or other health care provider can recommend treatments or counseling that can reduce the long-term risks of teen stress.
What is the healthy response to stress?
A key aspect of a healthy adaptational response to stress is the time course. Responses must be initiated rapidly, maintained for a proper amount of time, and then turned off to ensure an optimal result. An over-response to stress or the failure to shut off a stress response can have negative biological consequences for an individual. Healthy human responses to stress involve three components:
The brain handles (mediates) the immediate response. This response signals the adrenal medulla to release epinephrine and norepinephrine.
The hypothalamus (a central area in the brain) and the pituitary gland initiate (trigger) the slower maintenance response by signaling the adrenal cortex to release cortisol and other hormones.
Many neural (nerve) circuits are involved in the behavioral response. This response increases arousal (alertness, heightened awareness), focuses attention, inhibits feeding and reproductive behavior, reduces pain perception, and redirects behavior.
The combined results of these three components of the stress response maintain the internal balance (homeostasis), increase energy production and utilization, and alter electrolyte (chemical elements) and fluid balance in the body. They also gear up the organism for a quick reaction through the sympathetic nervous system (SNS). The SNS operates by increasing the heart rate, increasing blood pressure, redirecting blood flow to the heart, muscles, and brain and away from the gastrointestinal tract, and releasing fuel (glucose and fatty acids) to help fight or flee the danger.
How does the response to stress work?
How does the response to stress work?
While the complete story is not fully known, scientists understand much about how the response to stress works. The two main systems involved are the hypothalamic-pituitary-adrenal (HPA) axis and the SNS. (These systems are described later.) Triggered (activated) primarily by an area in the brain stem (lowest part of brain) called the locus coeruleus, the SNS secretes epinephrine and norepinephrine. The five most important concepts to remember about these two systems are that:
1. They are governed by a feedback loop to regulate their response. (In a feedback loop, increased amounts of a substance—for example, a hormone—inhibit the release of more of that substance, while decreased amounts of the substance stimulate the release of more of that substance.)
2. They interact with each other.
3. They influence other brain systems and functions.
4. Genetic (inherited) variability affects the responses of both systems. (That is, depending on their genes, different people can respond differently to similar stresses.)
5. Prolonged or overwhelming responses of these systems can be harmful to an individual.
What is the role of the hypothalamus-pituitary-adrenal (HPA) axis (grouping) in stress?
The HPA axis is a grouping of responses to stress by the brain and the pituitary and adrenal glands. First, the hypothalamus (a central part of the brain) releases a compound called corticotrophin releasing factor (CRF), which was discovered in 1981. The CRF then travels to the pituitary gland, where it triggers the release of a hormone, adrenocorticotrophic hormone (ACTH). ACTH is released into the bloodstream and causes the cortex of the adrenal gland to release the stress hormones, particularly cortisol, which is a corticosteroid hormone. Cortisol increases the availability of the body's fuel supply (carbohydrate, fat, and glucose), which is needed to respond to stress. However, if cortisol levels remain elevated for too long, then muscle breaks down, there is a decreased inflammatory response, and suppression of the immune (defense) system occurs.
Because they suppress the immune system, corticosteroids in measured doses are used to treat many illnesses that are characterized by inflammation or an overactive immune system, such as asthma and inflammatory bowel disease. For the same reason, they are used to help reduce the chances that our body will immunologically reject a transplanted organ. Corticosteroids also can cause fluid retention and high blood pressure. Therefore, it is critical that the response to corticosteroids be carefully controlled (modulated). This control usually is accomplished by a feedback mechanism in which increased cortisol levels feeding back to the hypothalamus and pituitary turn off production of ACTH. In addition, extremely high levels of cortisol can cause depression and psychosis, which disappear when the levels return to normal.
While the complete story is not fully known, scientists understand much about how the response to stress works. The two main systems involved are the hypothalamic-pituitary-adrenal (HPA) axis and the SNS. (These systems are described later.) Triggered (activated) primarily by an area in the brain stem (lowest part of brain) called the locus coeruleus, the SNS secretes epinephrine and norepinephrine. The five most important concepts to remember about these two systems are that:
1. They are governed by a feedback loop to regulate their response. (In a feedback loop, increased amounts of a substance—for example, a hormone—inhibit the release of more of that substance, while decreased amounts of the substance stimulate the release of more of that substance.)
2. They interact with each other.
3. They influence other brain systems and functions.
4. Genetic (inherited) variability affects the responses of both systems. (That is, depending on their genes, different people can respond differently to similar stresses.)
5. Prolonged or overwhelming responses of these systems can be harmful to an individual.
What is the role of the hypothalamus-pituitary-adrenal (HPA) axis (grouping) in stress?
The HPA axis is a grouping of responses to stress by the brain and the pituitary and adrenal glands. First, the hypothalamus (a central part of the brain) releases a compound called corticotrophin releasing factor (CRF), which was discovered in 1981. The CRF then travels to the pituitary gland, where it triggers the release of a hormone, adrenocorticotrophic hormone (ACTH). ACTH is released into the bloodstream and causes the cortex of the adrenal gland to release the stress hormones, particularly cortisol, which is a corticosteroid hormone. Cortisol increases the availability of the body's fuel supply (carbohydrate, fat, and glucose), which is needed to respond to stress. However, if cortisol levels remain elevated for too long, then muscle breaks down, there is a decreased inflammatory response, and suppression of the immune (defense) system occurs.
Because they suppress the immune system, corticosteroids in measured doses are used to treat many illnesses that are characterized by inflammation or an overactive immune system, such as asthma and inflammatory bowel disease. For the same reason, they are used to help reduce the chances that our body will immunologically reject a transplanted organ. Corticosteroids also can cause fluid retention and high blood pressure. Therefore, it is critical that the response to corticosteroids be carefully controlled (modulated). This control usually is accomplished by a feedback mechanism in which increased cortisol levels feeding back to the hypothalamus and pituitary turn off production of ACTH. In addition, extremely high levels of cortisol can cause depression and psychosis, which disappear when the levels return to normal.
How do the connections in the brain work in stress?
How do the connections in the brain work in stress?
The HPA axis and the locus coeruleus systems are linked through the hypothalamus and an area of the brain known as the limbic system. The limbic system is the control area for emotion and the processing area for memory. These linkages are critical. For example, if you see the bushes rustling, your locus coeruleus immediately starts things (the stress response) rolling. However, when you see that it is not a mountain lion but a golden retriever in the bush, your memory of the tameness of the dog will turn off the stress response. Similarly, if a person is nervous before a public-speaking engagement and the first minute or two goes well, this happy feeling will turn down the activity of the locus coeruleus. These internal adjustments are why experienced public speakers often start off with a joke. It's as much to calm themselves (if the joke goes well) as it is to entertain you.
The connections also include the endogenous (within the body) opiate (opium-like) system and the reward (dopamine) system. Thereby, during stress, pain is reduced and an extremely happy feeling (euphoria) may result. These connections partially account for "runner's high" and have a great deal to do with why we like roller coasters and scary movies.
Here's how the connections work. The limbic system performs an emotional analysis and memory review of the information provided by the senses. Then, the multiplicity of connections allows us to determine whether the current stress is:
one that has been mastered in the past and successfully adapted to, not a threat at all, or a clear and present danger.
All of this internal activity must occur in milliseconds, and it does.
The HPA axis and the locus coeruleus systems are linked through the hypothalamus and an area of the brain known as the limbic system. The limbic system is the control area for emotion and the processing area for memory. These linkages are critical. For example, if you see the bushes rustling, your locus coeruleus immediately starts things (the stress response) rolling. However, when you see that it is not a mountain lion but a golden retriever in the bush, your memory of the tameness of the dog will turn off the stress response. Similarly, if a person is nervous before a public-speaking engagement and the first minute or two goes well, this happy feeling will turn down the activity of the locus coeruleus. These internal adjustments are why experienced public speakers often start off with a joke. It's as much to calm themselves (if the joke goes well) as it is to entertain you.
The connections also include the endogenous (within the body) opiate (opium-like) system and the reward (dopamine) system. Thereby, during stress, pain is reduced and an extremely happy feeling (euphoria) may result. These connections partially account for "runner's high" and have a great deal to do with why we like roller coasters and scary movies.
Here's how the connections work. The limbic system performs an emotional analysis and memory review of the information provided by the senses. Then, the multiplicity of connections allows us to determine whether the current stress is:
one that has been mastered in the past and successfully adapted to, not a threat at all, or a clear and present danger.
All of this internal activity must occur in milliseconds, and it does.
What are the effects of stress on medical and psychological conditions?
There is now evidence that points to abnormal stress responses as causing various diseases or conditions. These include anxiety disorders, depression, high blood pressure, and cardiovascular disease, certain gastrointestinal diseases, some cancers, and even the process of aging itself. Stress also seems to increase the frequency and severity of migraine headaches, episodes of asthma, and fluctuations of blood sugar in diabetics. There also is scientific evidence showing that people experiencing psychological stress are more prone to develop colds and other infections than their less-stressed peers. Overwhelming psychological stress (such as the events of 9-11) can cause both temporary (transient) and long-lasting (chronic) symptoms of a serious psychiatric illness called posttraumatic stress disorder (PTSD).
Conclusions about the effects of stress
Uncontrollable, unpredictable, and constant stress has far-reaching consequences on our physical and mental health. Stress can begin in the womb and recur throughout life. One of the pathological (abnormal) consequences of stress is a learned helplessness that leads to the hopelessness and helplessness of clinical depression, but in addition, many illnesses, such as chronic anxiety states, high blood pressure, heart disease, and addictive disorders, to name a few, also seem to be influenced by chronic or overwhelming stress.
Nature, however, has provided us with wonderful processes (mechanisms) to cope with stressors through the HPA axis and the locus coeruleus/sympathetic nervous system. Furthermore, research has shown us the biological processes (mechanisms) that explain what we all intuitively know is true—which is, that too much stress, particularly when we cannot predict it or control its recurrence, is harmful to our health.
Conclusions about the effects of stress
Uncontrollable, unpredictable, and constant stress has far-reaching consequences on our physical and mental health. Stress can begin in the womb and recur throughout life. One of the pathological (abnormal) consequences of stress is a learned helplessness that leads to the hopelessness and helplessness of clinical depression, but in addition, many illnesses, such as chronic anxiety states, high blood pressure, heart disease, and addictive disorders, to name a few, also seem to be influenced by chronic or overwhelming stress.
Nature, however, has provided us with wonderful processes (mechanisms) to cope with stressors through the HPA axis and the locus coeruleus/sympathetic nervous system. Furthermore, research has shown us the biological processes (mechanisms) that explain what we all intuitively know is true—which is, that too much stress, particularly when we cannot predict it or control its recurrence, is harmful to our health.
How can we manage stress?
If we think about the causes of stress, the nature of the stress response, and the negative effects of some types of stress (prolonged, unexpected, or unmanageable stress), several healthy management strategies become clear. A first step in stress management is exercise. You see, since the stress response prepares us to fight or flee, our bodies are primed for action. Unfortunately, however, we usually handle our stresses while sitting at our desk, standing at the watercooler, or behind the wheel stuck in traffic. Exercise on a regular basis helps to turn down the production of stress hormones and neurochemicals. Thus, exercise can help avoid the damage to our health that prolonged stress can cause. In fact, studies have found that exercise is a potent antidepressant, anxiolytic (combats anxiety), and sleeping aid for many people.
For centuries in Eastern religious traditions, the benefits of meditation and other relaxation techniques have been well known. Now, Western medicine and psychology have rediscovered that particular wisdom, translated it into simple nonspiritual methods and scientifically verified its effectiveness. Thus, one or two 20-30 minute meditation sessions a day can have lasting beneficial effects on health. Indeed, advanced meditators can even significantly control their blood pressure and heart rate as well.
Elimination of drug use and no more than moderate alcohol use are important for the successful management of stress. We know that people, when stressed, seek these outlets, but we also know that many of these substances sensitize (make even more responsive) the stress response. As a result, small problems produce big surges of stress chemicals. What's more, these attempts with drugs and alcohol to mask stress often prevent the person from facing the problem directly. Consequently, they are not able to develop effective ways to cope with or eliminate the stress.
In fact, even prescription drugs for anxiety, such as diazepam (Valium), lorazepam (Ativan), or alprazolam (Xanax), can be counterproductive in the same way. Therefore, these medications should only be used cautiously under the strict guidance of a physician. If, however, stress produces a full-blown psychiatric problem, like posttraumatic stress disorder (PTSD), clinical depression, or anxiety disorders, then psychotropic medications, particularly the selective serotonin reuptake inhibitors (SSRIs), are extremely useful. Examples of SSRIs include sertraline (Zoloft), paroxetine (Paxil), or fluoxetine (Prozac).
We know that chronic or uninterrupted stress is very harmful. It is important, therefore, to take breaks and decompress. Take a lunch break and don't talk about work. Take a walk instead of a coffee break. Use weekends to relax, and don't schedule so many events that Monday morning will seem like a relief. Learn your stress signals. Take regular vacations or even long weekends or mental-health days at intervals that you have learned are right for you.
Create predictability in your work and home life as much as possible. Structure and routine in your life can't prevent the unexpected from happening. However, they can provide a comfortable framework from which to respond to the unexpected. Think ahead and try to anticipate the varieties of possibilities, good and bad, that may become realities at work or home. Generate scenarios and response plans. You may find that the "unexpected" really doesn't always come out of the blue. With this kind of preparation, you can turn stress into a positive force to work for your growth and change.
For those who may need help dealing with stress, stress-management counseling in the form of individual or group therapy is offered by various mental-health-care providers. Stress counseling and group discussion therapy have proven to reduce stress symptoms and improve overall health and attitude.
For centuries in Eastern religious traditions, the benefits of meditation and other relaxation techniques have been well known. Now, Western medicine and psychology have rediscovered that particular wisdom, translated it into simple nonspiritual methods and scientifically verified its effectiveness. Thus, one or two 20-30 minute meditation sessions a day can have lasting beneficial effects on health. Indeed, advanced meditators can even significantly control their blood pressure and heart rate as well.
Elimination of drug use and no more than moderate alcohol use are important for the successful management of stress. We know that people, when stressed, seek these outlets, but we also know that many of these substances sensitize (make even more responsive) the stress response. As a result, small problems produce big surges of stress chemicals. What's more, these attempts with drugs and alcohol to mask stress often prevent the person from facing the problem directly. Consequently, they are not able to develop effective ways to cope with or eliminate the stress.
In fact, even prescription drugs for anxiety, such as diazepam (Valium), lorazepam (Ativan), or alprazolam (Xanax), can be counterproductive in the same way. Therefore, these medications should only be used cautiously under the strict guidance of a physician. If, however, stress produces a full-blown psychiatric problem, like posttraumatic stress disorder (PTSD), clinical depression, or anxiety disorders, then psychotropic medications, particularly the selective serotonin reuptake inhibitors (SSRIs), are extremely useful. Examples of SSRIs include sertraline (Zoloft), paroxetine (Paxil), or fluoxetine (Prozac).
We know that chronic or uninterrupted stress is very harmful. It is important, therefore, to take breaks and decompress. Take a lunch break and don't talk about work. Take a walk instead of a coffee break. Use weekends to relax, and don't schedule so many events that Monday morning will seem like a relief. Learn your stress signals. Take regular vacations or even long weekends or mental-health days at intervals that you have learned are right for you.
Create predictability in your work and home life as much as possible. Structure and routine in your life can't prevent the unexpected from happening. However, they can provide a comfortable framework from which to respond to the unexpected. Think ahead and try to anticipate the varieties of possibilities, good and bad, that may become realities at work or home. Generate scenarios and response plans. You may find that the "unexpected" really doesn't always come out of the blue. With this kind of preparation, you can turn stress into a positive force to work for your growth and change.
For those who may need help dealing with stress, stress-management counseling in the form of individual or group therapy is offered by various mental-health-care providers. Stress counseling and group discussion therapy have proven to reduce stress symptoms and improve overall health and attitude.
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