Hospitals see anecdotes like this play out from time to time: pressure from marital relations causing anxiety and gastric ulcers in patients. Once the stress is lifted, the patient recovers, only for the symptoms to reappear when the stress returns.

With greater social tension from the global financial crisis and economic downturn, clinics are seeing a rise in the number of patients with dysautonomia.

These patients go from department to department, undergoing all sorts of tests in the vain search for the cause of their ailments, all the while in a constant state of anxiety. With limited time for diagnosis and treatment, doctors strive fruitlessly to attend to these patients complaining of numerous odd symptoms, and often dismiss them as whiners.

Dysautonomia is a challenge to our rigid medical system. Who will listen to the voice of the sufferers? How can we soothe an imbalanced mind?

"Dysautonomia is an issue that needs to be addressed by each department," says Chu Yiu-tong, head of psychiatric medicine at Far Eastern Memorial Hospital (FEMH). It is the result of overexcitement of the autonomic nervous system, and the symptoms it causes can spread throughout the body, including the brain, heart, digestive organs and respiratory system. Therefore, doctors of all specialties must be able to recognize and identify it.

Dysautonomia is not a well-defined illness, nor is it a new disease of civilization. It is a general term for a state of physical and psychological imbalance and dysfunction.

In bygone days, the term "neurasthenia," meaning "weak nervous system," was used to describe various forms of insomnia and bodily discomfort whose causes couldn't be determined. Later it was found that the problem lay with the autonomic nervous system, and that it was not weakness, but overexcitement. Thus the name was changed to "dysautonomia."

The terms "imbalance" and "weakness" are both used in traditional Chinese medicine to describe nerve function. But, explains Dr. Eric Lin of the Psychiatric Department at Taipei City Hospital's Songde branch, in the language of Western medicine, the psychiatric term "neurosis" more closely describes dysautonomia.

In fact, neurosis is not the same as dysautonomia. Indeed, the term "neurosis" can no longer be found in the World Health Organization's International Classification of Diseases or the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the reasons being that there is too much variation in the definition of "neurosis" and that the boundaries between mild mental disorders are vague. Thus numerous terms have been coined to describe these disorders, such as "sleep disorder" and "post-traumatic stress disorder."

Do you constantly experience stomach pain, palpitations and bodily discomfort, but are unable to find the cause? Perhaps it's not your stomach, heart, or some other organ at fault, but your nervous system.

Rooted in the nervous system

Although the definition of dysautonomia is not sufficiently precise-it's not clear whether it's even a disease-it's a known fact that it stems from overexcitement of the sympathetic nervous system. And with the number of sufferers and the distress caused by the symptoms, it's gradually becoming a burden on modern society.

How does dysautonomia cause bodily disharmony?

The human nervous system consists of central and peripheral nerves, and the autonomic nerves are part of the peripheral nervous system. One of the 12 paired cranial nerves, the vagus nerve extends downward from the medulla oblongata (the lower portion of the brainstem), then branches out. Controlling the function of organs such as the heart, stomach and intestines, it is the best-known channel of the autonomic nervous system (see graphic on p. 92). As implied by its name, the autonomic nervous system, in most situations, automatically regulates breathing, heartbeat and circulation, and is difficult to control consciously.

The autonomic nervous system is divided into sympathetic and parasympathetic parts which complement each other in regulating physiological functions. The sympathetic nervous system produces reactions such as pupil dilation, goose bumps, quickened heart rate, increased blood flow, slowed intestinal peristalsis, elevated blood pressure, contraction of peripheral blood vessels, and increased adrenaline secretion. The functions of the parasympathetic nervous system are complementary.

Chu points out that the autonomic nervous system is stimulated by the external environment, and is influenced by numerous factors including a person's hormones, personality and health conditions. When a person is under stress, the autonomic nervous system produces an immediate response, and once the stress is gone, it will return to the former balanced state. But when there's excessive or long-term stress, the equilibrium is disrupted. It's like a rubber ball trapped under a rock for a long time: when the rock is lifted away, the ball is unable to resume its original shape because its elasticity has been exhausted.

One day a 40-something journalist started experiencing dizziness while on assignment abroad. At first she thought it was from work overload, and that she'd recover after catching up with her work. But after her two-week assignment was over and she stopped taking sleep medication, she started having insomnia.

Suddenly, one sleepless night, her heart started racing and she had trouble breathing. She rushed to the ER and began enduring a series of grueling cardio exams. She underwent everything from an electrocardiogram, echocardiogram and exercise ECG to a myocardial perfusion scan, but they couldn't find the cause of her chest tightness, palpitations or tachycardia. Right when she was debating whether to undergo an invasive cardiac catheterization exam, she was seeking psychiatric help for another problem-insomnia-when the doctor told her the source of her symptoms was not her heart, but dysautonomia. Her symptoms dissipated after she started taking anti-anxiety meds. It was like a miracle to her.

"Calmness is the path to freedom." Learning to relax, slow down, and be calm can help prevent neural imbalance caused by prolonged stress.

Treat the symptom?

The number of dysautonomia sufferers is not insignificant. According to the Epidemiologic Catchment Area Study carried out in the US, 30% of the population have experienced dysautonomia symptoms such as mild depression. The figure for Taiwan is estimated to be not much different, but unfortunately not many among them are aware of the cause of their ailment, nor do they seek psychiatric help.

Figures from US research indicate that 15-20% of family practice patients are actually psychiatric patients. As for medical and emergency patients in Taiwan, dysautonomia (neurosis) sufferers are a frequent sight among them.

Dysautonomia shows both psychological and physiological symptoms: mental anxiety and irritability, and possible physical discomfort anywhere from head to toe. Some will visit a respiratory specialist due to tightness in the chest and shortness of breath, others will go to cardiology for palpitations and high blood pressure, still others will seek the help of a gastroenterologist for diarrhea or bloating. Some suffering headache, dizziness or numbness in the extremities will see a neurologist; others will visit an ear, nose and throat specialist for help with tinnitus, dizziness or the sensation of a foreign object in the throat; still others will consult a urologist for frequent urination. Those with atopic dermatitis may talk to a dermatologist, and those with a stiff neck and shoulders may be treated by shiatsu massage. Symptoms can appear all over the body, but the physiological cause cannot be found. What they don't realize is that the problem isn't with their organs, but is instead neurological.

"Patients often have a tendency to compound anxiety with nervousness," says Dr. Lin. He uses household appliances as a metaphor: after checking to see that the appliance itself has no problem, it's necessary to test for an unstable power supply or see if the plug is correctly seated.

Says Dr. Lin, in general, most patients who come for psychiatric treatment have already sought help in other departments, being referred to psychiatry only after exhausting all other options. Yet, given that it's a problem with the nervous system, why are neurologists hard-pressed to test for it?

Chu laments that there is no equipment or test data available at present to correctly diagnose the overexcitement of the autonomic nervous system. Doctors rely on questioning and the elimination of alternatives.

The torment of insomnia experienced by dysautonomia sufferers is difficult for others to understand.

Listening to the patient

"It's most important to listen to the patient," says Chu. Experienced physicians gain the knowledge they need via questioning. Consider for instance a patient seeking treatment for headache. If the patient says that he has had headaches since childhood, and underwent a computed tomography (CT) exam that turned out negative, then there's an 80% chance that anxiety or hormonal imbalance are causing the headaches. If there were no headaches in the past, and the headache is accompanied by vomiting and double vision, then there's the possibility of stroke or brain tumor, mandating CT tests.

As for dysautonomia patients with numbness in their hands and feet, they can be tested with neural transmission exams, ultrasound tests and hot/cold water tests to rule out the possibility that their symptoms are diabetic in nature. Says Chu, some patients feel more at ease after knowing their test results are negative, and all that's needed is a prescription of tranquilizers. More serious cases requiring counseling will be referred to psychiatry, but some patients balk, saying, "I'm not crazy; why should I see a psychiatrist?"

Dysautonomia causing heart palpitations, chest constriction and tachycardia are the most alarming to patients, especially after there's been a news report of myocardial infarction or sudden death, when cardiology departments become overcrowded with patients.

Believing it better to be safe than sorry, some patients will insist on undergoing as many tests as they can to find a physiological cause. Yet the source of their anxiety is still dysautonomia. Media personalities like SET anchor Chen Yaling and actress Ariel Lin, who suffer from mitral valve prolapse, are good examples.

Dr. Lin notes that incomplete valve closure is graded on a scale of seriousness from one to four. "Practically everyone has it; the only difference is degree of seriousness." Mild mitral valve prolapse is not life threatening, and to relieve the symptoms cardiologists prescribe propranolol, a beta blocker, as well as alprazolam, which mitigates anxiety and relaxes muscles. Both drugs are also used by psychiatrists to suppress an overexcited sympathetic nervous system.

Autonomic nervous system and internal organs

Who's at risk?

The age of dysautonomia sufferers ranges from the teens to the 50s or 60s, and the ailment affects both men and women. But from a clinical standpoint, higher-risk groups can be identified.

According to Dr. Lin's clinical studies, the condition is most likely to appear for the first time in young women in their 20s or 30s. Female patients outnumber males by two to three times, and he conjectures that the reason is that the autonomic nervous system is affected by hormones. Therefore women are easily afflicted by dysautonomia before and after menstruation, after giving birth, and during menopause.

Personality is also a key factor.

Psychologists divide personalities into types A, B and C. In general, people who insist on everything being perfect, who walk, talk and eat quickly, who are stubborn, competitive and ambitious, who anger easily and who are punctual are considered Type A personalities. These people are more likely to come down with dysautonomia.

Besides the wide range of physical symptoms that most patients seek treatment for, there are psychiatric symptoms defined as neuroses, including anxiety, panic attacks, obsessive-compulsive disorders, hypochondria, hysteria, dissociative disorders and depression. Among these, the most typical symptom is panic attacks, which can trigger palpitations and tightness of the chest.

Seeing the forest and the trees

With recent advances in the study of cranial nerves, medical scholars have confirmed that the feelings of discomfort and anxiety produced by dysautonomia do indeed have biological causes; it is not due to people creating their own problems or complaining about nothing, as some doctors and family members claim. Treatments should be targeted at both body and mind, rather than merely where it hurts.

Currently, the principal treatments used by psychiatrists are medication and counseling.

Dr. Lin points out that antidepressants, anti-anxiety meds, muscle relaxants, beta blockers and tranquilizers can alter the amount of the neurotransmitter serotonin in the brain, alleviating anxiety.

Besides taking medication, Dr. Lin recommends exercise as a way of mitigating anxiety. He says that the body secretes natural opiates during exercise, producing feelings of euphoria. Walking is a good way to relieve stress: a brisk 40-minute walk may reduce anxiety levels by about 14%. At the same time, exercise can boost serotonin levels, helping improve sleep.

"Another method is to shift the focus of attention," says Dr. Lin. He suggests that instead of resisting it with willpower, it is better to turn one's thoughts to other things. Meditation, relaxation and yoga can calm patients down, helping alleviate the dysautonomia.

As for diet, bland meals are preferable. Eating more foods that boost the ability to cope with stress and improve neuron function, such as high-calcium dairy products, magnesium-rich nuts and leafy greens, and DHA from deep-sea fish oils can help combat stress and soothe the mind.

Can dysautonomia be cured?

"It's not an acute disease; it comes and goes. It appears particularly easily in times of stress, seasonal change or gloomy, rainy weather," says Dr. Lin. After one incidence the chances of another are 50%, and this probability rises to 80% after two attacks.

Tony Wu, a psychiatrist at Yu Kang Clinic, says that dysautonomia is a yellow alert for the body and mind. If it's ignored, the condition will worsen, possibly causing damage to nerves and heart muscles, or leading to serious consequences like high blood pressure, diabetes, breakdowns, or even sudden death. For instance, if left untreated, 50% of panic attacks will develop into depression, with 20% worsening into deep depression. Thus, taking notice of the calls from their body and mind and taking steps to reduce the chance of recurrence is of considerable importance to dysautonomia sufferers. "Remember to take it easy!" suggests Wu.

In sum, though dysautonomia is not officially classified as a disease, it is a bodily warning that should not be ignored. It challenges modern medicine's tendencies not to see the forest for the trees, and should remind us that disorders and imbalances are not just in the nerves.