I went to a seminar on chronic fatigue syndrome on 13 September 2014
One of the talks was by a Dr.Chris O’Callaghan (a general physician from the Austin Hospital in Melbourne), about orthostatic intolerance and about connective tissue hyperelasticity syndromes.
There is some overlap between the two, but it became apparent to me that there must be an overlap with ADHD as well- and it appears that the mechanism is difficulty maintaining blood flow to the brain while sitting or standing for a long while.
I have already got statistics that point to ADHD occurring in a cluster with a number of other syndromes: OCD, Tourettes, Autistic spectrum disorders, anxiety disorders, mood disorders, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, migraines and premenstrual dysphoria.
In addition there is a strong statistical association between fibromyalgia and joint hypermobility
Many people have significant connective tissue hyperelasticity (in the top 20% of a normally distributed curve of connective tissue elasticity) without clinically abnormal joint hypermobility. Only a very small minority have defined syndromes like Marfan’s syndrome or Ehler’s Danlos syndrome.
To make the matter worse many older individuals will develop stiffening of connective tissues around joints that have been traumatised by instability- so they may not have obvious joint hypermobility.
The bottom line is that anyone with any degree of tissue hyperelasticity is prone to difficulty maintaining cerebral circulation when standing due to the elasticity of vein walls (and possible other mechanisms).
This is because we tend to pool about 600ml of our circulating blood volume (total is 5 litres) in the sphlanchnic circulation (ie the veins around the intestines) on standing.
Also the problem can manifest in very subtle ways- often after prolonged sitting or standing.
It may not always be linked to acute symptoms such as dizziness or visual changes on standing up fast, though I am
finding as I explore the issue with patients that many will have intermittent problems with acute symptoms of orthostatic hypotension: namely feeling dizzy or lightheaded, or having mental confusion or dullness, or simple word finding difficulty.
The problem is worse when hot, or when vasodilated due to alcohol, when relatively dehydrated,and I suspect, when unfit and one does not have a tight trim abdomen.
There are a range of syndromes- the best defined of which is POTS.
That is uncommon- though I personally had it for about 3 months in 2012 following an episode of emotional trauma and depression. I mention that because it is clear that emotional trauma can facilitate the overrecruitment of “freeze” responses as a habitual reaction to stress- and such a mechanism would worsen the functional dysautonomia.
This mechanism would also provide a clear mechanistic explanation of one of the positive feedback loops that helps maintain symptomatology in an emotionally traumatised individual.
However quite clearly the vast majority of orthostatic intolerance is more mild and subtle and is usually missed.
Broadly speaking my suspicion is that many ADD_ inattentive symptoms may well be related to cerebral hypoxia,
and many of the hyperactive symptoms may be related to a very strong sympathetic drive as the body tries to maintain cerebral perfusion against gravity.
This would fit exceedingly well with a pattern of getting fatigued, or fidgety and hyperactive when standing for a while and would account for many of the memory lapses and episodes of forgetfulness in ADHD.
I have thought for some time that the ADHD symptom cluster most closely resembles a low grade intermittent acute brain syndrome.
Equally, anyone with such tissue hyperelasticity would be much more prone to upper cervical spine malalignments about which I have already commented. The association between upper cervical malalignments and the dyspraxias, and dysgnosias seen in many ADHD patients has been clearly demonstrated by the work done by the orthopedic surgeon Heiner Biedermann and associates in Central Europe over the last 40 years.
Biedermann has also demonstrated a strong association between appropriate manual therapy to the cervical spine and substantial improvement or even resolution of ADHD symptoms in school age children.
To round it all off psychostimulants like dexamphetamine and methylphenidate are proven to increase cerebral blood flow.
Since the lecture I have been checking as many patients as I can in the time available, and a substantial majority have a bigger and more persistent increase in heart rate on standing than they should. The most dramatically affected one had a heart rate increase of 40bpm when laid down for 10 minutes and then stood for 10 minutes.
I have personally certainly aborted a couple of episodes of onset of mental fogginess by having a couple of quick glasses of water (rapid blood volume expansion)- and since pushing water and being careful to work more with posture, abdominal breathing.
I have also noted a tendency to higher resting pulse (80-95) if I was not strict with fluid intake in the week, and came home in much better shape on days I had had plenty of water.
This whole association is rather exciting:
1) It gives us another physical marker to look for in ADHD symptoms.
2) It gives us an excellent explanation for the efficacy of psychostimulants- the dopamine explanation is not a complete one- and certainly does not explain the variability in symptoms from day to day that most people experience even when on stimulants.
3) It offers a series of potential extra interventions that are low cost and easy to implement- and it provides a very sound reason for us to all work on our fitness.
4) It also points to the possibility that transient orthostatic intolerance may be an issue in other illnesses and acute behavioural disturbances- the one here that comes to mind is when everyone gets together for Christmas lunch, eats and drinks too much then gets drowsy and irritable.
The simple interventions that Dr O’Callaghan suggested are
1) Increase intake of water. A large glass of plain water will push up blood volume for 60-90 minutes.
2) Higher salt intake- much higher.
It is of note that only this montha large study was published in the NEJM that finally debunked the ie a that low salt intake protects against cardiac death.
(It actually CAUSES increased risk).
3) General cardiovascular fitness.
4) Improve core strength and posture– this is a biggie as it tightens the tummy.
In addition I would suggest-
5) Work to build the habit of abdominal breathing as this will compress the abdomen on the in breath.
6) Mindful movement training will reduce the risk of injury associated with ligamentous laxity. It will also help to improve the balance and coordination problems that are so common in ADHD. These problems also rob working memory from more important tasks involved with earning our living.
My own suggestion is that the cheapest and most time efficient way to handle items 4-6 is Tai Chi/Qi Gong.
This also has the advantage that it can be practiced in street clothing and does not need special equipment or time to cool down.
This is all rather pleasing to me– especially as my colleagues at work have links to a local university, so there is the real possibility of getting some research done to test some easily definable hypotheses that can be formed into meaningful questions with objective numerical definable end points.
It would be very easy to monitor heart rate, blood pressure, skin galvanometry, heart rate variability and response of all these to posture and changes of posture- and the associations with ADHD symptomatology.
Very simple studies- low cost, no major ethics committee hurdles etc.
Equally- improvement in some of these figures with stimulant medication would be easily demonstrable.
My notes from the full lecture follow- containing a more specific list of likely symptom clusters. There will be some repetition of points already made above:
ORTHOSTATIC INTOLERANCE and DISORDERS OF ELASTICITY
Dr Chris O’Callaghan- lecture 13 September 2014 Alfred Hospital Melbourne
Additional side notes by “MindBody”
Maintenance of Blood Pressure Homeostasis
Blood pressure regulation when supine is simple- there are no major pressure gradients
When upright gravitation presents considerable challenges and the blood pressure has to be maintained at a level which will pump enough blood uphill to perfuse the brain.
This is complicated by the problem that when upright about 600ml of blood gravitates into the abdominal cavity and sits within the sphlanchnic circulation.
The problem is worse after a meal- when more blood flow is diverted to the gut.
It is also worse when there is relative dehydration or relative vasodilation
(being too hot, alcohol, other conditions causing facial flushing).
The physiology required to adjust blood pressure needs to be
My personal observation– NOT Dr O’ Callaghan:
It also will to some extent act in a predictive way- i.e. it is likely that adjustments will start to occur when we decide to stand up and also when we prepare to face a particular situation.
In the latter case our view of that situation as threatening rather than pleasantly challenging will initiate a different emotion/behaviour/physiological response program.
Symptoms of Orthostatic Intolerance
feeling faint or dizzy
visual disturbances (including sometimes complete, temporary, loss of vision as cerebral perfusion fails)
neck and shoulder pains– often in a “coat-hanger” distribution involving the neck and shoulders
Physical Signs and symptoms related to the body’s attempts to correct the situation:
vigorous activation of a sympathetic response:
cold extremities- including Raynaud’s phenomenon and chilblains
NB the physical symptoms are like quitting Heroin “Cold Turkey”-pale, sweaty, goosebumps, dilated pupils
Manifestations in longer term/recurrent orthostatic intolerance
poor concentration (especially after lunch)
word finding difficulty
feeling light headed
agitation – broadly more likely to manifest as anxiety in females and anger in males.
Syndromes associated with orthostatic intolerance:
POTS (postural orthostatic tachycardia syndrome)
sympathetic hyperactivation syndromes
Sympathetic Hyperactivation Syndromes
Low Blood Sugar
Low Blood Pressure
Fear Provoking Stimuli
- In all cases the symptom cluster and physical signs are largely identical.
- The interoceptive signature of these syndromes is highly likely to cause the affected individual to label non threatening stimuli associated with the event as causative.(IE Every time I go out and socialise [sit or stand for a long while] I feel these symptoms therefore socialising must cause my anxiety)[Point 2 is an addition of mine based on my understanding of Antonio Damasio’s “Somatic Marker Hypothesis” and the concept of “Co-arising” as applied in Mindfulness integrated CBT].
- It is usual for medical practitioners, psychologists and most psychiatrists to mislabel these symptoms as “Anxiety”- then do something really stupid like prescribe an SSRI. [Point 3 is also an addition of mine, based on decades of very wearing experience as a member and, unfortunately a patient of, the allopathic medical profession].
avoidance patterns- i.e. avoiding getting up quickly
avoiding hot environments
preferring tight fitting clothing– corsets, elastic clothing designed for athletes
self medicating the stress symptoms with alcohol- or worse
DIAGNOSIS OF ORTHOSTATIC INTOLERANCE
Essentially requires confirming that symptoms are related to gravity and to inadequate circulation.
The major symptoms have been listed above.
Relationship to gravity
more obvious- but most patients have become very good at not getting up quickly – so avoiding provoking these symptoms.
prolonged upright posture- either sitting or standing
queueing at the supermarket
standing for a long while at parties
sitting for long at the dinner table
at the onset of exercise
afterwards when the combination of vasodilation to cool down and muscle hyperaemia robs circulating blood volume
High Altitude- mountains, or especially planes ( abrupt change in altitude)
Swimming- while in the water the compression improves available circulating blood volume, but when you come out (esp of hot water) this advantage is lost and there can be a sharp drop in available blood volume.
A Tilt table test is rarely necessary- and problematic symptoms can occur in the absence of overt Postural Tachycardia Syndrome.
Education– especially re triggers such as heat, dehydration and alcohol
Sodium Intake aim for as much as can be tolerated- about 10g/day (yes that is correct- the American Heart Foundation recommendation of 2.3g/day is now understood to be based on very bad science).
a glass of plain water will elevate Blood Pressure for about 90 minutes- much better than a solute based drink like Gatorade
Compression Garments very helpful for a small subset of patients
Adrenergic– midodrine (available via Special Access Scheme).
Phenylephrine Sudafed P— the other sort causes too many palpitations.
(Footnote from me– it is known that psychostimulants increase cerebral perfusion– and most of the neurocognitive symptoms are indistinguishable from ADHD– an interesting pair of observations).
no good evidence
Further suggestions by AK
- Fitness training
- Tai Chi (emphasis on abdominal breathing pattern)
- Hot then cold showers– esp finishing swimming sessions/spa sessions with a cold shower to stimulate vasoconstriction
JOINT HYPERMOBILITY SYNDROMES
Connective tissue elasticty is distributed according to a normal curve.
Assessment of joint hypermobility syndromes is clinical- using the “Beighton score” but is somewhat subjective. Additionally many adults will lose their hyper-elasticity as they scar up due to the multiple injuries they are prone to because of their lax ligaments. It is also of note that individuals with tissue hyper-elasticity syndromes are far more prone to spinal subluxations (as mentioned by Dr O’Callaghan in his talk). In the book “Manual Therapy in Children” the editor and lead author, Heiner Biedermann MD (Orthopaedic Surgeon), discusses the fact that a common compensatory pattern arising in children with birth injury to the upper cervical spine (estimated at at least 30% of the population in the population studies referenced in that book) involves shortening of the hamstrings- another factor that would obscure an underlying tissue hyper-elasticity syndrome.
Dr O’Callaghan suggests that most athletes, dancers musicians & artists fall within the top 20% of most elastic joints- but that the top 5% run the risk of being “too floppy to dance” and are the most vulnerable to physical and psychological illness as a consequence of their ligamentous laxity and secondary issues with autonomic dysregulation.
Ehler’s Danlos Syndrome specifically has an occurrence rate of 1:5000- so is rare even amongst individuals with tissue hyperelasticity.
Ehler’s Danlos is also very difficult to diagnose and assess as diagnostic criteria are not straightforward or easy to quantify.
Given the importance placed upon achieving full lotus position for meditations in some Buddhist traditions I personally suggest that most mystics probably come from this group as well, and that high emotional sensitivity is an expected side effect of an autonomic nervous system rendered difficult to control by joint hyper-elasticity.
The Zen school especially stresses sitting posture- and particularly the master Dogen – who asserted that the whole of the Buddha’s dharma could be experienced by sitting in full lotus position.There are a number of physiological reasons that that should be beneficial for a hyperelastic and emotionally labile individual – but that will be the subject of another day’s writing.
Additionally- Dr O’ Callaghan notes that selective mating amongst like minded individuals is likely to produce offspring in the “too floppy to dance” category.
Tissue hyperelasticity is determined by multiple different genes and as a rule genetic screening is not a clinically useful exercise.
However- given the characteristics noted above, it is highly likely that individuals with more elastic connective tissue will share many common desirable psychological characteristics such as artistic sensibility, creativity, emotional sensitivity and enthusiasm for sporting activity or for dance– so selective inbreeding amongst this group producing offspring with progressively greater tissue elasticity is to be expected.
Given this observation my own suggestion is that for such individuals maintenance of muscle tone, avoidance of injury and training in mindful movement is likely to be the factor that will make the difference between a happy and successful life and a life on the invalid pension.
The implications for social policy in terms of encouraging moderate working hours, limited hours of “screen interface time” – (especially computers) and ample physical activity in the workplace and in leisure time are obvious. This is the reason that the Chinese Government has so strongly encouraged Tai Chi in the workplace.