Ep. 38 Dysautonomia

Episode Summary

Join Dr. Dan Bates and Justine Feitelson in this episode of 'It's Not In Your Head,' where they delve into dysautonomia and its impacts on chronic pain patients. They discuss various symptoms, such as orthostatic intolerance, gastrointestinal issues, and urinary problems, and provide actionable conservative management strategies for both patients and clinicians. From dietary adjustments and hydration tips to specialized exercises and medications, this episode is packed with valuable insights to help you identify, manage and mitigate the effects of various forms of dysautonomia.

Episode Overview:

The goal of this episode is to help patients and clinicians manage complex chronic pain, particularly where dysautonomia and sensitization overlap. The podcast intentionally focuses on practical management of symptom clusters rather than listing every possible underlying cause.

What Is Dysautonomia?

Dysautonomia refers to dysfunction of the autonomic nervous system, responsible for regulating unconscious bodily functions like heart rate, digestion, and temperature control. The symptoms can involve multiple systems and vary widely between individuals but tend to follow certain patterns, especially among people with chronic pain and related disorders. The discussion uses real-world examples and clinical anecdotes to explain the complexity and two-way nature (brain-body feedback loops) of dysautonomia.

Populations Commonly Affected

Several groups are especially prone to sensitization and dysautonomia:

• People with long COVID (neuroinflammatory effects)

• Neurodivergent individuals with sensory overlaps

• Those diagnosed with POTS (Postural Orthostatic Tachycardia Syndrome)

• Patients with hypermobility syndromes (e.g., Ehlers-Danlos Syndrome)

• People with diabetes experiencing autonomic neuropathies

Main Types and Symptom Buckets

Orthostatic Intolerance

Symptoms: Rapid heart rate on standing, fatigue, dizziness, lightheadedness, sometimes low blood pressure. Distinguished from POTS by specific blood pressure changes.

Gastrointestinal Issues

Common symptoms include nausea, vomiting, bloating, diarrhea, constipation, reflux, and difficulty eating. The hosts explain how these often relate to “gut-brain axis” disruptions and discuss management basics.

Urinary Symptoms

Frequent or urgent urination, incomplete emptying, interstitial cystitis-like symptoms. The hosts encourage clinicians to ask about these empathetically, acknowledging the stigma and discomfort for patients.

Secretomotor and Thermoregulatory Issues

These include excessive sweating, dry mouth, trouble regulating body temperature, and dry skin. The root cause is often an imbalance between the sympathetic and parasympathetic nervous systems.

Locomotor Issues

Manifest as dry eyes, blurry vision, light sensitivity, and impaired pupil response, sometimes affecting motor control because of altered sensory input.

Sexual Dysfunction

Sexual symptoms are acknowledged as widespread, underdiscussed, and impactful on quality of life; patients and clinicians are encouraged to break stigma by initiating conversation.

Conservative and Medical Management Strategies

Orthostatic Intolerance

• Compression stockings (20–40 mmHg)

• High salt intake (two teaspoons/10g per day)

• At least three liters of fluids daily

• Avoid prolonged standing or sitting; use position changes and adapt exercise for tolerance

• Electrolyte supplements as needed

Medical therapies: For true POTS, options include medications like propranolol, with further lines of therapy or referral to specialists as needed.

Gastrointestinal Management

• Eat a healthy, varied diet with low processed foods

• Smart meal timing, smaller frequent meals

• Identify and avoid personal trigger foods (caffeine, alcohol, gluten, dairy, etc.)

• Seek specialist input for persistent or complex symptoms (gastroenterologist, dietician)

Symptom-Specific Interventions

• Urinary: Avoid misleading supplements; specialist referral for dominant urinary symptoms

• Secretomotor: Use effective deodorants, dress in layers, manage temperature with fans or cooling methods

• Vision: FL 41 lenses for light sensitivity, eye drops for dryness, eye exercises for tracking and convergence

• Exercise/Movement: Use lying or seated exercises for those with intolerance to standing, focus on stability and gradual progression

Sympathetic Overdrive and Anxiety

• Mindfulness and diaphragmatic breathing

• Select SSRIs for severe anxiety; avoid benzodiazepines due to dependence risk

• In select cases, consider sympathetic ganglion blocks, particularly in patients with PTSD or extreme autonomic arousal

Patient Empowerment and Team-Based Care

• Patients are encouraged to take ownership: implement foundational lifestyle steps (hydration, diet, basic exercise) to maximize what specialists can offer.

• Clinicians should “see the matrix”, recognize patterns, and efficiently guide referrals. Collaboration and open communication are critical for optimal outcomes