Psychological and Psychiatric Support; When, Why and What to Do

Abstract

Postural tachycardia syndrome (PoTS) is neither a mental health disorder nor is it caused by mental health issues. Nonetheless, like all health conditions, mental health difficulties can negatively impact on outcomes in PoTS. Anxiety and mood disturbances can be precipitated by the symptom burden, and may exacerbate symptoms thereafter if not well managed. Clearly, there are significant quality of life (QoL) impacts for people with PoTS to adjust to. There is some controversy about whether mood and anxiety disorders are more common in those with PoTS. Review of the literature suggests that mood challenges in PoTS are equivalent to other health disorders with equivalent magnitude of symptom burden and disability. The anxiety seen in PoTS patients seems to take a specific form and be somatically and attentionally based, rather than cognitive. Indeed, PoTS is associated with evidence of sympathetic dysregulation with symptoms overlapping with somatic aspects of anxiety. This can easily be mistaken for anxiety by observers, or misinterpreted as threatening or scary by the patient; thereafter initiating or exacerbating an anxious response cycle. Effective management therefore requires a balance of symptom monitoring and acceptance/tolerance of the symptoms. Over-attending can easily tip over into hyper-vigilance, which can cause an anxiety disorder. Conversely, and quite commonly in clinical practice, patients can present with dissociative coping strategies to avoid unpleasant sensations and emotions. There is also some evidence that PoTS compromises cognitive functioning, which can be distressing for patients and potentially affect their ability to engage in daily educational and occupational activities. PoTS patients often have a history of pushing through pain or discomfort to get on and achieve what they need to. This can result in a ‘boom and bust’ profile, and possibly syncope (where physical pre-syncopal cues are tuned out as well as other PoTS symptoms). Conversely, some patients with PoTS are so adept at compensating for autonomic dysregulation that they are less likely to faint than the general population. Since PoTS has a unique thumbprint in each patient, generalizations must be made with caution. Review of the psychological data suggests, however, that most patients would benefit from high quality and timely support to help them manage this challenging condition, and in this chapter we suggest therapeutic considerations and approaches for interested clinicians.

Appendices

Appendix

Table 1 Table A1

Summary of Mental Health Recommendations in PoTS

Patients with PoTS are at risk of experiencing at least modest depressive and anxiety symptoms, and are at significantly increased risk of experiencing insomnia and suicidal ideation. They warrant and should have access to mental health assessment, treatment and support. We would advocate that:

• Given the likelihood of patients being referred to mental health professionals, they and allied disciplines should be educated about PoTS and how to refer appropriately if they suspect it.

• Most patients with long-term conditions would benefit from, and all should have ready access on request, to psychological support.

• Introducing this support as early as possible is likely to be a very important factor in preventing QoL deterioration and associated secondary factors such as reactive depression, avoidance and physical deconditioning.

• Uptake and engagement is likely to be increased if therapeutic support is offered as part of standard treatment and is seen as endorsed by a medical consultant active in the patient’s care.

• CBT has a good evidence base in LTCs assuming a patient is motivated and has cognitive capacity.

• Evidence supporting the value of Mindfulness-based CBT and ACT in the context of chronic illness is increasing.

• These ‘third wave’ CBT approaches are likely to be helpful in appropriately modifying vigilance to somatic changes, and tolerating the frustrations that come with ill-health, while continuing to engage in manageable activities which enhance QoL.

• Therapists with a good understanding of supporting patients with chronic health issues, and experience with formulating and treatment in the context of multiple co-morbidities, are most likely to benefit patients.

• It can be very challenging making all the necessary life adaptations to live with PoTS. It can help patients to know that after the hard work of adjusting to what they cannot do and prioritizing and appreciating what they can do, many patients with PoTS report enjoying happy and fulfilling lives.