Background and Purpose
The commonly used meaning of autonomic dysfunction (autonomic imbalance) can be said to encompass symptoms in which the autonomic nervous system is not properly controlled. In general, a chronic response to stress causes an abnormality of the autonomic nervous system. Due to the persistence of this state, an immune system reaction occurs, and the stage before being categorized as a specific disease may be referred to as a state of autonomic dysfunction. Since the autonomic nervous system affects the entire body, autonomic dysfunction also causes various symptoms to appear in various body organs, and when strong symptoms appear in a specific area, it itself may be given a different disease name.
Autonomic dysfunction is not commonly used in Western categorical diagnostic systems, and is mainly used in East Asian traditional medicine due to the similarity of theoretical concepts. In East Asia, autonomic dysfunction is used as a disease that contains the traditional concept of disease. In Japan, autonomic dysfunction is treated as a subclass of psychosomatic disease, in China, it is explained in connection with cardiac neurosis, and in Korea, autonomic dysfunction is explained as a dissonance between yin (陰) and yang (陽). Autonomic dysfunction, which means an imbalance between the sympathetic and parasympathetic nerves, reflects the traditional medicine’s integrative approach to mind and body and the perspective that disorders and diseases occur due to abnormalities in harmony and balance. In particular, stress-related autonomic dysfunction can be said to be a disease in which the perspective of oriental medicine, which emphasizes the connection between mind and body, can stand out. On the other hand, the Western medical community does not use the term autonomic dysfunction, and treats symptoms related to autonomic nervous system abnormalities as an independent disease. This can be said to be close to the view that autonomic dysfunction appears due to various causative diseases rather than stress.
Currently, in Korea, the scope of use for autonomic dysfunction is expanding as HRV test (手陽明經經絡技能檢査) is used as an oriental medical device. However, there has been little research conducted by categorizing it as a specific diagnosis, and it has been difficult to establish consistent standards for the definition of what is actually autonomic dysfunction, diagnosis criteria, and treatment.
Therefore, in this clinical practice guideline, we tried to derive the concept by organizing the literature on autonomic dysfunction. In the process, three issues were considered. The first is the cause of autonomic nervous system imbalance. In clinical settings, hyperactivity of the sympathetic nerve is often a problem as a disease. Autonomic imbalance can be understood as hyperactivity of the sympathetic nervous system due to stress response. The second is a typical physical symptom of autonomic dysfunction. Among the various body regions governed by the autonomic nervous system, the most prominently affected part is the circulatory system. Therefore, we tried to address the basic problems related to the circulatory system in autonomic dysfunction. The third is various mental symptoms caused by the failure of the autonomic nervous system. In particular, anxiety is the most common, and various other emotional and mental symptoms such as depression may appear. Considering these three factors, this clinical practice guideline defined autonomic dysfunction as ‘autonomic dysfunction caused by stress without any organic disorder’.
Subsequently, with the consent of the academic society members, somatoform autonomic dysfunction (F45.3) and vagus syncope (R55.0), which is a diagnosis related to autonomic dysfunction exists and empirical research results exist, was selected as the target disease to develop an evidence-based treatment guideline. In addition, among the disease concepts dealt with in traditional medicine, cardiac neurosis, which is considered to be related to autonomic nervous disorders and is actively being studied in Chinese medicine, was selected. Since these three diseases can be regarded as independent diseases, separate recommendations were developed. The definition of autonomic dysfunction and the selection process for the target disease were reviewed through several meetings with panelists specializing in Oriental Internal Medicine, Oriental Acupuncture and Oriental Medicine, and Oriental Rehabilitation Medicine, in addition to Oriental Neuropsychiatry. In addition, a consensus-based recommendation on autonomic dysfunction itself was developed through expert consensus so that it can be used in the clinical field of oriental medicine. This is to ensure that autonomic dysfunction is understood as a disease concept in oriental medicine and can contribute to its clinical use, and it is hoped that various discussions will be made based on this in the future.
Overview of disease
In this guideline, we tried to develop clinical practice guidelines for autonomic dysfunction by defining autonomic dysfunction as ‘autonomic dysfunction caused by stress without organic disorder.’ However, there has been little research conducted by categorizing this into a specific diagnosis. Therefore, this guideline has compiled the literature on related diseases to specifically organize the diagnosis and evaluation of autonomic dysfunction. Cardiac neurosis, somatoform autonomic dysfunction (F45.3), and vagus syncope (R55.0), which are categorical diagnoses related to autonomic dysfunction and have empirical research results, were summarized. After that, autonomic dysfunction was comprehensively summarized.
The first is ‘cardiac neurosis’ in China, a disease name that collectively refers to cardiovascular symptoms caused by autonomic nervous system dysfunction and accompanying psychoneurological symptoms. In other words, cardiac neurosis is a functional neurosis that deals with symptoms of abnormalities in the autonomic nervous system but focuses on cardiovascular symptoms, and since the study was very active in China, it was selected as the study subject of this guideline. Second, ‘somatoform autonomic dysfunction’ was selected because there is a specific diagnosis of somatoform autonomic dysfunction (F45.3) in the Korean Standard Disease Code (KCD-8) as a diagnosis related to autonomic dysfunction. However, there have been almost no studies on the disease, and it belongs to the subcategory of ‘somatoform disorder’ based on the DSM-IV standards, so studies on ‘somatoform disorder’ are included in this clinical practice guideline. The third is ‘vasovagal syncope (R55.0)’, which is a representative symptom of autonomic dysfunction. This is the most common type of syncope and is mediated by the vagus nerve reflex. Excessive stress causes blood vessels to dilate, blood pressure to drop, and temporary loss of consciousness.
In this guideline, the following diagnostic criteria are suggested by referring to the diagnostic criteria for cardiac neurosis in China and autonomic dysfunction in Japan.
A. Complaining of various symptoms due to autonomic dysfunction: Circulatory symptoms such as palpitations, chest tightness, chest pain, hyperventilation / difficulty breathing, psychological symptoms such as anxiety, irritability, depression, anger, symptoms related to the autonomic nervous system such as hypertension, fatigue, dizziness, headache, motion sickness, indigestion, nervous vomiting, stomach tightness, loss of appetite, sweating, sleep disorders
B. Discordance of autonomic dysfunction was confirmed by referring to the normal value for each age of the standardized test (heart rate variability test, HRV).
C. Not due to another medical condition and not better accounted for by a major mental disorder
– Excludes the following mental disorders: depressive disorder, anxiety disorder, trauma- and stress-related disorder, and schizophrenia spectrum disorder.
D. Incongruity between yin and yang was confirmed by referring to oriental medical diagnostic tests: 8-gang dialectic (八綱辯證) tool, tongue diagnosis, pulsation, etc.
During the diagnosis process, abnormalities in the autonomic nervous system can be detected by referring to HRV. In addition, the results of various oriental medical diagnostic tests are interpreted from the perspective of yin and yang, and when the dissonance of yin and yang is broken, this result can be referred to the diagnosis of autonomic dysfunction.
Meanwhile, autonomic dysfunction can cause a variety of symptoms due to the nature of the disease, making differential diagnosis from other diseases important. Symptoms must not be due to organic disorders or other medical conditions, and mental disorders that may exhibit similar symptoms (depressive disorder, anxiety disorder, trauma- and stress-related disorder, schizophrenia spectrum disorder) are excluded because related standard clinical practice guidelines exist. In addition, arrhythmia, orthostatic vertigo, and orthostatic hypotension, which are one of the symptoms of autonomic dysfunction, were already covered as major diseases in other standard clinical practice guidelines of Korean medicine (vertigo), so they were excluded from this diagnosis.
After diagnosis of autonomic dysfunction, a detailed diagnosis of related diseases can be made according to the following criteria.
The diagnostic criteria for cardiac neurosis focus on circulatory symptoms, such as palpitations, chest tightness, and pain. It is mainly based on exclusive diagnosis, excluding the corresponding organic acute, infectious, allergic and other related diseases, and then diagnosing in combination with clinical symptoms.
The diagnostic criteria for somatoform disorder focus on complaints of physical symptoms without organic abnormalities. Somatoform autonomic dysfunction, a subcategory of somatoform disorder, focuses on symptoms of organs or systems controlled by the autonomic nervous system. In order to be diagnosed with somatoform autonomic dysfunction, signs of autonomic nervous excitement must appear in at least two of the following: cardiovascular, respiratory, esophagus and stomach, lower gastrointestinal tract, and genitourinary system.
The diagnosis of vasovagal syncope can be made using a medical history, physical examination including blood pressure measurement, and electrocardiogram. It is recommended to obtain a detailed history of current and previous episodes of loss of consciousness from the patient and, if present, from an eyewitness at the time of loss of consciousness. Diagnosis can be made by combining physical examination results, such as blood pressure measurements in the supine position and standing, and 12-lead electrocardiogram results. In addition, headup tilt test is a diagnostic test technique that can be used to evaluate syncope.
