Autonomic Nervous System Disorders: A Case Study

Inquiry Consultation

Dear Dr.
Jiang,
I would like to inquire about my mother's medical condition.
Here is a detailed description:
In February and March of last year (2022), my mother suddenly experienced rapid heartbeat, shortness of breath, cold hands, and shaking.
She went to a medical facility where her blood pressure was found to be around 190.
After blood tests, slightly elevated cardiac enzyme levels were detected, leading to her hospitalization for further examination.
During her three-day stay, she underwent an electrocardiogram, echocardiogram, nuclear medicine myocardial perfusion scan, and a CT scan of the brain, all of which showed no abnormalities.
After her cardiac enzyme levels returned to normal, she was discharged.
The cardiologist prescribed "Diovan" (valsartan) to help stabilize her blood pressure.
Interestingly, my mother felt uncomfortable with the side effects of "Diovan" and stopped taking it after two weeks, yet her symptoms and high blood pressure almost completely ceased.
A year later, in March of this year (2023), my mother again experienced sudden rapid heartbeat, shortness of breath, cold hands, and shaking, and was taken to the emergency room where her blood pressure reached around 220.
Blood tests showed no abnormalities, so she was given "Labetalol" and discharged once her blood pressure decreased.
After returning home, my mother resumed taking "Diovan" daily, but she occasionally experienced episodes of rapid heartbeat and high blood pressure, requiring her to take "Labetalol" for symptom relief.
Her condition remained unstable for about two months until May of this year.
At that time, I consulted a cardiologist from Taiwan e-Hospital who indicated that "Labetalol" was effective for my mother, possibly due to its effects on the autonomic nervous system, and recommended focusing on treating autonomic dysfunction.
I then took my mother to a neurology clinic where the doctor performed a carotid ultrasound, which showed no abnormalities, and prescribed "Alpraline" (alprazolam) for her.
My mother began taking "Diovan" and "Alpraline" daily, and her symptoms indeed improved, with very few episodes occurring.
However, on December 8 of this year, my mother experienced emotional distress and anxiety, leading to another episode (rapid heartbeat, shortness of breath, and shaking), and her blood pressure was around 190 when she was taken to the hospital.
She experienced some headaches, and a CT scan of the brain revealed no abnormalities.
She was given "Cabudan" (a medication for hypertension) and discharged once her blood pressure stabilized.

Since returning home, my mother has been experiencing discomfort almost daily, sometimes with headaches causing high blood pressure (but without rapid heartbeat), and at other times with rapid heartbeat, shortness of breath, cold hands, and shaking, which again raises her blood pressure.
During these episodes, she needs to take "Labetalol" along with "Alpraline" for relief.
I would like to ask Dr.
Jiang the following questions:
Q1.
Despite my mother taking "Diovan" regularly, her condition remains unstable, often triggered by minor factors such as slight headaches, anxiety, posture changes, or temperature fluctuations.
In your opinion, does her situation lean more towards autonomic dysfunction rather than simple hypertension?
Q2.
My mother finds that taking "Labetalol" along with "Alpraline" is the most effective way to alleviate her discomfort.
Currently, she takes one 0.5 mg tablet of "Alpraline" before bed.
Would it be advisable for her to increase the dosage of "Alpraline" to see if it helps stabilize her condition? If so, how should she adjust the dosage?
Q3.
If my mother is to focus on treating her autonomic dysfunction, should she consult a neurologist or a psychiatrist? Which specialty would be more appropriate?
Q4.
Lastly, could you provide recommendations and directions for treating my mother's symptoms to help her return to a normal life?
Thank you, Dr.
Jiang.

Kris, 40~49 year old female. Ask Date: 2023/12/18

Dr. Jiang Junyi reply Neurology

Dear Mr.
Kris,
The treatment for hypertension is usually multifaceted.
If there is a tendency for sympathetic nervous system overactivity, a beta-blocker may be added.
If a single antihypertensive medication is insufficient to control blood pressure, a combination therapy (such as a calcium channel blocker combined with an angiotensin receptor blocker) can be utilized.
Before your appointment, it is advisable to conduct a more accurate blood pressure measurement.
Regarding the anxiety issue you mentioned, it is recommended to consult a mental health professional for an analysis of anxiety factors.
Thank you for your inquiry, and feel free to discuss further.
Wishing you good health, safety, and happiness.
Sincerely,
Dr.
Jiang, Neurology, Taoyuan Medical Center

Reply Date: 2023/12/18

More Info

Understanding autonomic nervous system disorders is crucial for managing symptoms that can significantly impact daily life. Your mother’s case illustrates the complexities of autonomic dysregulation, particularly in the context of hypertension and anxiety-related symptoms. Let’s address your questions systematically.

Q1: Is your mother's condition more aligned with autonomic nervous system dysregulation rather than just hypertension?
Based on the symptoms you've described—such as rapid heartbeat, chest tightness, cold hands, and tremors—these can indeed be indicative of autonomic nervous system dysregulation. The autonomic nervous system (ANS) regulates involuntary bodily functions, including heart rate, blood pressure, and stress responses. When the ANS is out of balance, it can lead to episodes of high blood pressure and heart palpitations, especially in response to stress or emotional triggers. Your mother’s symptoms appear to correlate with episodes of anxiety and stress, suggesting that her condition may not solely be a case of hypertension but rather a manifestation of autonomic dysregulation.

Q2: Can your mother increase her dosage of Alpraline (Alprazolam) to stabilize her condition?
Alprazolam is a benzodiazepine that can help manage anxiety and its physical manifestations, including those related to autonomic dysregulation. However, increasing the dosage should only be done under strict medical supervision. Dosage adjustments depend on individual tolerance, the severity of symptoms, and the presence of any side effects. It’s essential to consult with her prescribing physician before making any changes to her medication regimen. They may consider a gradual increase if they deem it appropriate, but they will also monitor for potential dependency or withdrawal symptoms.

Q3: Should your mother consult a neurologist or a psychiatrist for her autonomic nervous system issues?
For a comprehensive approach to treating autonomic nervous system disorders, it may be beneficial for your mother to see both a neurologist and a psychiatrist. A neurologist can evaluate any underlying neurological conditions that may contribute to her symptoms, while a psychiatrist can address the psychological aspects, including anxiety and stress management. A multidisciplinary approach often yields the best outcomes, as it allows for a holistic view of both the physical and mental health components of her condition.

Q4: What treatment recommendations can help your mother return to normal life?
1. Lifestyle Modifications: Encourage your mother to adopt a balanced diet, engage in regular physical activity, and maintain a consistent sleep schedule. Stress management techniques such as mindfulness, yoga, or tai chi can also be beneficial.

2. Medication Management: Continue monitoring her response to medications. If she experiences side effects or inadequate symptom control, her healthcare provider may need to adjust her treatment plan.

3. Therapeutic Interventions: Cognitive-behavioral therapy (CBT) can be effective for managing anxiety and stress, which may help reduce the frequency and severity of her symptoms.

4. Regular Follow-ups: Ensure she has regular check-ups with her healthcare providers to monitor her blood pressure, medication effects, and overall health status.

5. Education and Support: Providing education about her condition can empower her to manage her symptoms better. Support groups for individuals with similar experiences can also provide emotional support and coping strategies.

In conclusion, your mother’s symptoms suggest a complex interplay between autonomic dysregulation and anxiety. A comprehensive approach involving lifestyle changes, medication management, and psychological support can help her regain stability and improve her quality of life. Always consult with her healthcare providers before making any changes to her treatment plan.

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