When I heard my new specialist did autonomic testing, I should have felt grateful. Many people with mast cell activation syndrome (MCAS) and Ehlers-Danlos syndrome (EDS) also struggle with dysautonomia, dysfunction of the autonomic nervous system. (See also: clusterfuck.) Despite being diagnosed with MCAS five years ago and having the symptoms of dysautonomia, no one referred me for testing.
To be honest, I was scared. While relaying your pee to your refrigerator for 24 hours for MCAS testing is exhausting, I’d heard too many stories about people fainting and vomiting during autonomic testing. While I was so dizzy in the first years of my MCAS diagnosis that I often crawled across my condo, I never actually passed out. Sometimes the fear of not knowing is worse than the experience.
I knew standing increased my blood pressure and made me feel terrible. When the pandemic began, the lines at grocery store deterred me from getting food. Luckily, I can now afford delivery, but some items are not available. If I have to go into a I store, I lean on a shopping cart to avoid losing my balance. After falling down the stairs several times, I stopped using them completely. (On more than one occasion, I’ve been asked if I avoid the stairs because my service dog is too short. Why is it so hard to accept invisible disabilities?!)
Tilt Table Test
Knowing fully well you may be minutes away from passing out or vomiting, the first task after being strapped to the Frankenstein table is to be totally calm to get a baseline reading of your vitals. After five years of MCAS and one epidural blood patch, I excel dissociating from my body. Super handy for medical procedures; not so great for processing emotion. (See also: reasons I need therapy.)
The goal of the tilt table is to measure your blood pressure and heart rate when you go from lying to standing. By using the table, instead of your muscles, we can better understand if the brain signals to the body are lagging.
“Okay you ready?” the doctor asked. I nodded and she pushed the button. The table motor chugged as it hoisted me up to 70 degrees. I braced for the worst.
As the table stopped rising, the pull of gravity took over. Within that split second, I decided:
YEP, I’M FUCKED UP.
What I remember is the heaviness of my body and the doctor’s incessant questioning. I felt like I was wearing a Kevlar suit and about to be sucked through the ground. I decided I would fight the tilt table with deep breathing and calm thoughts. As everything became quiet, dark, and slow, I tried to focus my eyes on a spot on the carpet like they teach you in yoga to keep your balance. Same thing, right?
What actually happened was documented by video. The doctor asked, “How are you doing?”
I responded, “Good.”
I WAS NOT GOOD.
“Any dizziness?” she asked.
“No, I just feel super heavy,” I said.
STOP ASKING ME QUESTIONS.
“Any headache?” she asked.
“Super, super heavy,” I groaned.
SHUT UP. I AM BEING CRUSHED INTO A TINY DIAMOND.
Instead of speaking my mind, I politely closed my eyes.
Within a few minutes, the pressure subsided and I just felt weak.
After 10 minutes, the doctor lowered the table and asked, “How are you feeling?”
“My legs are all tingly,” I said. “There’s pain in my muscles.” Then I realized the pain was the blood rushing back into my legs. They had been numb the whole time I was standing.
As my doctor calculated the results, I recall all the times I had a heavy feeling. I described it in 2018 as almost a paralysis.
“Your heart rate did not jump. This is not a diagnosis of POTS,” my doctor explained. “What we are finding is you had an adrenergic response meaning your blood pressure jumped and you were symptomatic.”
Although I expected the blood pressure rise, I was surprised my heart rate stayed normal. The doctor explained that my results supported the evidence that when I am triggered, my body maintains the reaction. In other words, I get stuck in flight or flight.
I’M NEVER FUCKING STANDING AGAIN.
“So we’ve got three more tests,“ she said.
“Cool,” I lied.
Deep Breathing Test
When my specialist explained the deep breathing test, breathing in and out deeply for one minute with the help of a computer screen, I was like:
I TRAINED FOR THIS MY ENTIRE CHILDHOOD IN THE ASTHMA CLINIC. AND I PLAYED THE TUBA.
I was feeling pretty confident after surviving the tilt table. While my deep breathing performance was perfection and my heart rate was normal, my mast cells protested.
“I’m cold,” I interrupted the doctor’s explanation.
“Like suddenly cold?” she said.
“Yes,” I said.
She retrieved a blanket.
“My chest hurts,” I said, remembering that bronchospasms can often feel like a heart attack.
“This test is like blowing up a teeny, tiny balloon,” my doctor explained. “So, you know how much pressure you have to put on a teeny, tiny balloon?”
“Yeah, until my jaw pops out,” I replied.
Luckily, my jaw did not pop and my CSF blood patch did not blow, but honestly, this was my least favorite test because worried about my Ehlers-Danlos syndrome (EDS) complications. My results showed a slightly delayed sympathetic response, unlike my tilt table test. Perhaps, my body was starting to wear out from testing. This test triggered a wicked headache that built for 12 hours.
Quantitative Sudomotor Axon Reflex Test (QSART)
After the surviving the tilt table, a little electricity didn’t fluster me at all. Four small plastic cups were taped to forearm, foot, and leg to measure amounts of sweat, or sympathetic response, generated by a mild electrical current. Sympathetic nervous system
“It does feel a little prickly, but I think you’ll be fine,” my doctor said. “How are you feeling?”
“Prickly,” I said.
“Maybe that’s an understatement,” she said.
“Yep,” I said.
WHO THE HELL DESIGNED THESE TESTS?!
For me, this test was tolerable, not really any worse than a MCAS skin reaction. My sweat was slightly low in a few places. No surprise, as I often skip my deodorant stick with no repercussions.
As barbaric as these tests may sound, I am now very grateful I was able to access them.
My doctor diagnosed me with hyperadrenergic dysautonomia. Is it possible I had POTS, another type of dysautonomia, at one time? Very likely. The tests can inform treatment and further testing, but just like MCAS testing, the results can change over time and treatment still requires trial and error. I also tested negative for small fiber neuropathy (think tiny melon ball-like scoops of skin).
I’m looking forward to sharing my major improvements on new treatments– not beta blockers, which can exacerbate mast cell reactions. Aside from treatment, there’s a lot of value in a formal diagnosis for other providers to understand my body’s reactions and to support disability accommodations. For example, one doctor was so obsessed with my high blood pressure that she dismissed my CSF leak. Now I can explain my hyperadrenergic response.
After my long day of autonomic testing, my friend asked, “Do you want to go out and celebrate?”
“Yes,” I said, suffering from one of the worst migraines of my life.
TAKE THE DAMN PICTURE.
May 2021 Update
MCAS remission eliminated my dysautonomia symptoms completely. Dr. Weinstock estimates MCAS accounts for 1/3 of POTS cases. While autonomic testing helped me understand dysautonomia, pursuing MCAS treatment was a better use of my resources.