Possible Adrenal or Pituitary issues? POTS? Video of pupils..

[KimPlus2]

My story is a long one, but I'll try to keep it short.

Starting on May 23rd I began suffering from daily panic attacks (when I've never had them before), severe dizziness/faintness when standing up (vision goes black for 3-10 seconds), extremely high heart rate (had a 48 hour holter monitor test done, no heart problems, just a heart rate that goes up to 165 bpm just when standing up/walking to kitchen which is not a long walk, it is normal when sitting down), excessive sweating (although it IS summer), thirst and urination.  I also get headaches that last for a couple days at a time on the top of my head and the left side of my forehead (very rarely on the right side) and fluctuating pupils.  My pupils fluctuate nearly all day long, but especially if there is bright light.  I did a flashlight test which showed even more fluctuation.  

Here is a link to a video of my pupils:  http://www.youtube.com/watch?v=dIu1TI961XQ

I am female, 21 years old with asthma and overweight.  I had just lost about 35 pounds (from working out and eating healthy) when this all started to happen, and now it is so bad that I can barely walk around my house and take care of my kids, let alone work out with the vigor that I previously had.  I still eat healthy but am not losing weight.  About 1 year ago I had twins and lost quite a bit of blood but have since recovered.  (Not sure if this would help, just thought I should add it in just in case!)  

My doctor thinks that I'm probably just "anxiety ridden" because I have twins but I am POSITIVE that is not the case.  He is not taking me seriously and that is why I am here.  I am currently taking 40 mg of Celexa and 50 mg beta-blocker atenolol and neither one helps my heart rate from speeding up.  On top of that I am taking 250/50 advair (have been taking for 2 years) and albuterol as needed.  Thyroid seems fine, B12 levels in normal range but on the low side so I am taking a supplement.  I'm wondering if this could possibly be a problem with my adrenal glands and/or pituitary gland?  I'm not looking for a diagnosis (but if you have one, I'd be glad to hear it!), I just want to know where to go from here.  If you need any more information, I'd be glad to share it.

Thank you,
Kim

[O22012]

Albuterol made my symptoms worse.

[Kavbear]

I don't have any scientific information but wanted to thank you guys for the information you are posting about anxiety and I hope the conversation continues. I started having periods of "anxiety" and "depression" when I was 14, looking back it was POTS. The doctors said it was in my head and I did not agree but I was 14 so I believed the doctors and had the labels.
I know now I have POTS but with the labels all over my medical history I have trouble getting some doctors to listen even with the darn Mayo files so information like this is helpful to me!

[beenthere8280]

Stress, weight loss, lots of cardio, and low carb diet can lead to adrenal burnout. I am a personal trainer, and I see this all the time. Replace cardio with yoga, stretching, pilates or weight training . This will help you rest and rebuild those burned out glands. If you drink coffee, switch to green tea. Sugar and refined carbohydrates are a big no-no. I  recommend a book written by an endocrinologist called "The Schwartzbein Principle". There are no drugs that are going to solve this problem. But there are plenty of things you can do to turn it around. Good luck.

[Heiferly]

No harm, no foul.  You're right that docs often mistake the symptoms of dysautonomias such as POTS for anxiety, and misdiagnosis/delayed diagnosis is a MAJOR problem because of this.  

From what I see, the primary involvement of norepinephrine in anxiety is as a neurotransmiter within the central nervous system, which to the best of my knowledge would not affect plasma norepinephrine levels because these are tied to activity in the peripheral nervous system.  Someone feel free to correct me if I'm wrong, but I believe that is why they have a separate test for NE within cerebral-spinal fluid in the first place.

There have been studies showing elevated plasma NE levels in certain psychiatric disorders, such as depression and social phobia.  To the best of my knowledge the recent studies on other types of anxiety (besides the anxiety disorder social phobia, and perhaps PTSD) have not shown significantly elevated plasma NE levels.  I say *recent* studies because there are myriad studies from the 80s and thereabouts showing 'elevated plasma NE in anxiety' and even postulating 'autonomic dysfunction related to anxiety' but I'm guessing this is the budding of the discovery that these weren't indeed psychiatry cases but actually patients with a unique form of dysautonomia:  POTS.

Regarding elevated plasma/urine NE in depression (which is less dramatic than the numbers seen in hyperadrenergic POTS, from what I can see):  

http://www.pnas.org/content/102/23/8303.abstract
http://www.ncbi.nlm.nih.gov/pubmed/15518669

You're absolutely right that norepinephrine in the peripheral nervous system at high levels can cause panic.  They physiological changes these high levels cause are essentially the evolutionary fight/flight response we have to situations of sudden danger, so if your body suddenly goes into fight/flight mode, your mind can easily go into panic mode.  This seems to be related to the mechanism of panic attacks in some way, according to one of my text books, due to an abnormality in the temporal poles and the right parahippocampal area of the brain.

(Kandel, Schwartz, & Jessell.  Principles of Neural Science, 3rd ed.  Norwalk, CT:  Appleton & Lange. p. 881.)

On the other hand, according to research, most POTS patients don't seem to have as much of a problem with the physical fight/flight symptoms triggering emotional anxiety/panic:

"Patients with POTS are sometimes clinically diagnosed as having anxiety disorders such as panic disorder.  ... Unfortunately, this questionnaire includes somatic anxiety symptoms (such as palpitation) which can result from a hyperadrenergic state such as is seen in POTS.  When a newer, cognitive-based measure of anxiety (the Anxiety Sensitivity Index12) is used, there was a trend toward less anxiety in the patients with POTS than the general population (15±10 vs. 19±9; P=0.063)"

(http://cogprints.org/4802/1/raj.htm  
The Postural Tachycardia Syndrome (POTS): Pathophysiology, Diagnosis & Management.  Indian Pacing Electrophysiol. J.  2006;6(2):84-99.)

I personally would rate one of my top sources of anxiety as doctors who keep accusing me of being anxious or depressed when I don't feel that I am.  :-p

[LivingInHope]

I apologize for the misinformation I caused.  Your comment did make me do further research, and I saw there are certain emotions listed for related to norepinephrine, and I think I may have made an incorrect assumption from something I had read when I applied it to emotion in general.  I didn't remember if I said it in my post on this thread, but looked back and there it was today.  I thought I may have said it elsewhere, unfortunately.  I'm sorry all.

I seemed to be reading it was part of the autonomic nervous system and was something that helped to maintain blood pressure and speed up the heartrate with no conscious effort.  It seems like from what I've been looking at that it is not the catecholamine that goes up in response to anxiety.  But if norepinephrine went too high, I read it could actually cause panic.  

I have had high normetanephrines in a 24 hour urine and high norepinephrine in a sitting blood sample.  Since in the same blood sample, my epinephrine was normal, I felt after reading what I did that I could say confidentally it was not anxiety causing this unusually high level of norepinephrine.

So many doctors seem to just write people off as anxious.  Take a cardiologist I saw recently, for instance.

[Heiferly]

I will follow up with a full response later when I have time.  But for now, allow me to clarify briefly.

You said, "Norepinephrine is part of the autonomic nervous system and is not controlled by emotion."  I merely responded to your statement to point out that norepinephrine is not the sole domain of the ANS, and is indeed part of the neurochemical process behind emotion.  I agree with you that a blanket statement "norepinephrine is controlled by emotion" would also be false.  

A discussion of anxiety feedback loops (mindbody) as they pertain to neurotransmitters is necessarily complex, and I'll need to get back to you after I yank a few neuro textbooks off my shelves to get citations for you.  

I'm sorry I wasn't more clear, and further that I still am unable to completely clarify this, but I don't have sufficient time at the moment to pull citations.  I'll try to get to this as soon as my schedule allows.  I think we/our sources are in agreement, we just may not have been crystal clear in our initial statements.  At any rate, the discussion is enlightening, so I hope to continue it soon.

[LivingInHope]

I was speaking to anxiety specifically and norepineprhine.  Would you site your source, Heiferly?  Because I could be wrong here (having read somewhere some bad info).   Here are some things I just found....

http://www.neurogenesis.com/Neurotransmitters/norepinephrine.php
"Optimal levels of this transmitter can stimulate a sense of wellbeing or even create a euphoric effect in stressful situations. Yet excess norepinephrine can fuel the physiological expressions of fear and anxiety, as may be the case for people who suffer from anxiety disorders."

I see here that excess norepinephrine can fuel anxiety, but it doesn't mention anxiety causing norepineprhine to rise.

http://www.everydayhealth.com/specialists/emo_health/wolever/qa/anxiety-increasing-blood-pressure/index.aspx
"Your question also brings into play the effect of stress on blood pressure. The research in this area is challenging, in part because it's difficult to establish an agreed-upon definition of stress. Nevertheless, when individuals are in a stressful situation — say, speaking publicly — the body responds by increasing the secretion of epinephrine (adrenaline) and cortisol, often referred to as stress hormones. These hormonal elevations can result in an increase in blood pressure, a faster heart rate, and a constriction of the blood vessels. When the stressful condition is over, the system gradually returns to baseline, and blood pressure returns to normal."

I see epinephrine and cortisol are stress hormones here.  That the body can react to anxiety by secreting these hormones.

http://www.ndrf.org/ans.html

"The most important of these transmitters in the autonomic nervous system are acetylcholine and norepinephrine. In the parasympathetic system, acetylcholine is responsible for most of these transmissions between the afferent and efferent nerves of the system and between the efferent nerve endings and the cells or organs that they subserve. Acetylcholine also serves to transmit nerve-to-nerve messages in the afferent nerves and the brain centers of the sympathetic nervous system. However, the final transmission of messages from the sympathetic nerves to the end-organs or cells that they innervate is conveyed by the release of norepinephrine (noradrenaline) with at least one important exception, namely the sympathetically conveyed stimulus to the sweat glands which is transmitted by acetylcholine. A stimulus to contraction of the blood vessels is required in order to maintain the blood pressure when we arise from bed in the morning, so as to prevent fainting from excessive pooling of blood in the lower body. This stimulus is conveyed by norepinephrine release within the walls of the blood vessels from the nerve endings of the sympathetic nerves that innervate each blood vessel."

"The sympathetic nervous system is even more automatic and only exceptionally susceptible to any voluntary control."

"Control of the rate and strength of cardiac contractions is also under the predominant control of the sympathetic nervous system. Thus, a fall in blood pressure resulting from traumatic injury causing blood loss is sensed by pressure-sensitive parts of the arteries called baroreceptors. Evidence of reduced arterial distension is sensed by these baroreceptors and conveyed by the parasympathetic (mainly the glossopharyngeal) nerves to the cardiovascular control center in the medulla, called the nucleus tractus solitarii. From these nuclei sympathetic stimuli conveyed by the cardiac nerves cause acceleration of the heart rate, probably complemented by simultaneous reduction in the parasympathetic stimuli via the vagus nerves which slow the heart rate. Although pain, anxiety, fear and injuries or blood loss would involuntarily increase the sympathetic stimulation to cardiac acceleration, most of us are unable to influence either this effect or the consequences of blood loss per se on cardiac acceleration."

[Heiferly]

Quick correction:  norepinephrine is part of emotional processing, and is not solely somatic.  Nonetheless, controlled laboratory testing of norepinephrine levels can be useful in explaining the source of symptoms in some forms of dysautonomia and helping to detect/evaluate pheochromocytoma or neuroblastoma.

[LivingInHope]

To: Kim
IMPORTANT... I got this off yahoo about Celexa... note the last listing of serious side effects:
"Call your doctor at once if you have any of these serious side effects:

■seizure (convulsions);
■tremors, shivering, muscle stiffness or twitching;
■problems with balance or coordination; or
■agitation, confusion, sweating, fast heartbeat."

[DizzyJ]

Find a doctor that will take you seriously, Your symptoms need to be evaluated by a specialist. There are several possibilites and only a doctor can say for sure. But I would not wait, a heart rate of 165 bpm needs to be looked into.

[LivingInHope]

I recommend you get your norepinephrine tested, including standing and a fasting plasma free metanephrines (inactive metabolites of catecholamines epinephrine and norepinephrine and helpful toward ruling out pheochromocytoma).   High norepinephrine I've read, can actually cause a panic attack.  Norepinephrine is part of the autonomic nervous system and is not controlled by emotion.  If norepinephrine and/or normetanephrines levels are way up, you can make a physical, convincing argument to your doctor besides telling him/her that it is not anxiety inducing your panic.  

It is probably the celexa combatting your losing weight and possibly aggravating your headache.  I took celexa for several months and it definitely seemed to be a migraine aggravant.  I also gained I think 35 pounds taking it!  Some of the weight came off when I stopped.  It's weird, because a migraine preventative that worked the longest for me was a different SSRI  (also made me gain weight), serzone generic (I understand the name brand was taken off the market... Serzone caused liver damage being the reason).

[evo123]

Hiya Kim,

I'm glad to see you have posted your post here.  You will get advice and comfort from this community.

I have left a post on your original question.

Take care.

Eve

[halbashes]

Based on your description, I would absolutely recommend that you be evaluated for Dysautonomia.  POTS seems most likely, though I am not at all a doctor.  There are many different types of Dysautonomia.  Have you ever had a Tilt Table Test?

I'd recommend making an appointment with either a Cardiologist, or a Neurologist at an academic teaching hospital for proper diagnosis.  You may also want to see a Dysautonomia Specialist.

Have you checked your blood pressure recently?  Many Dysautonomia patients have a tendency toward low blood pressure.  Still other patients may have normal, to high blood pressure with abnormal fluctuations throughout the day.

Diagnosing Dysautonomia:
http://www.medhelp.org/health_pages/Neurological-Disorders/Diagnosing-Dysautonomia/show/827?cid=196

Dysautonomia Specialists:
http://www.medhelp.org/health_pages/Neurological-Disorders/Dysautonomia-Specialists/show/717?cid=196

Further Reading:
http://www.medhelp.org/health_pages/Neurological-Disorders/Further-Reading-on-Dysautonomia/show/696?cid=196