The 'Evil Triad': MCAS, EDS & POTS | Dr. A Explains What You Need To Know

This one, nobody wants to have any of this, but sort of an interesting topic and it's getting much more common to talk about, and that's the quote unquote evil triad. Hey, I'm Dr. A. Welcome to the channel. This is a patient education channel for common medical problems that we get asked questions about. What usually happens is we do some videos and then that creates even more questions. So the evil triad in this case is looking at mast cell activation syndrome or MCAS, POTS or dysautonomia, and then hypermobility syndromes such as EDS, the family of Ehlers-Danlos and other hypermobility. Why would they be called an evil triad? Because they often run together. So that's what we want to get into in this particular video. But also, I just finished running a conference where I brought specialists in from all over the United States, and we talked largely about this triad and how to manage it clinically. But basically, somebody asked, I heard you refer to the Triad or the evil triad or whatever, and we might have been promoting the conference or something, or we might just been talking about mast cell or something like that. What are you talking about and how are they related? That's a question I want to answer here. So mast cell activation is one problem, and that is associated with histamine intolerance, mediator excess, so inflammatory mediator excess, and can be related to allergy, atopic phenomenon, and also just very unstable physiology. That goes on dysautonomia, which is a big picture category that includes things like Ehlers-Danlos syndrome, which is not one thing, and hypermobility syndromes, etc., are syndromes that usually—not always—but usually we're born with, and so we're much more mobile. Which you might think well, that'd be good if you're a ballerina, you know, or contortionist or something. And so these people often, for example, can do way more movement with their thumb than I can. They have much more flexibility. All of that's good, but if you imagine that you have a hypermobility syndrome that was genetic that you're born with, then you're going to tend to overuse joints. You're going to tend to hurt joints more easily, and in some cases of excessive hypermobility, you might dislocate joints more easily. And then dysautonomias. So POTS, which is one of the more common dysautonomias, basically what you're looking at is POTS is a description of the way the human body acts when it has a dysautonomia. So you have a positional change in blood pressure, and the autoregulatory mechanisms are not seeming to work correctly in dysautonomia. So people with dysautonomias will often have inappropriate responses to standing, inappropriate responses to sitting and lying down from their cardiac system. And the underlying problem is this idea of dysautonomia, which means your autonomic nervous system, which is supposed to automatically be correcting for you—it's the autonomic nervous system. System is the balance of sympathetic and parasympathetic nervous system. Those 2 sides are like yin and yang. They're not working together anymore. So it's like an imbalance. What this means— so for example, the autonomic nervous system is part of what helps your heart rate go up if you have to run away from an attacker. It's what helps you rest and digest, helps you relax, helps you do all the digestive stuff on the parasympathetic side. But also it helps if I have to stand up suddenly. It helps me to auto-regulate so my blood pressure doesn't drop too quickly. But What if I overregulate or I underregulate? That's dysautonomia that will go on there. So you might think, well, these are— you got something that's in the nervous system, you got something that's in the connective tissue system, the integumentary orthopedic system, so to speak. And then you got an immunologic problem, mast cell problems. How in the world would they all connect? And question that came up a lot at the conference a couple weeks ago, why do we have hypermobility in there when not all, but a lot of hypermobility is genetic? You're born with it. How could it be part of a grouping of syndromes? Well, what I want to do now that I've explained what all the 3 key players in the evil triad are is explain how they're connected. It can start anywhere with all 3 of them, and you don't have to have all 3. You could just have 2 of them. Very common to have dysautonomia and mast cell problems and maybe no, you know, hypermobility. But it's more and more common that we see people with hypermobility too. So let's answer first the question, hypermobility. Well, it's not that mast cell problems, for example, as part of the triad, gave you your genetic problem. It's that mast cell problems made what you were born with, the genetic tendency towards hypermobility, worse. Why? One of many reasons. That the immunologic changes that are inappropriate with mast cell problems have many chemical messengers that they send out. And one thing that they do directly affects my connective tissue. So if I already have connective tissue control and regulation problems, I'm going to become maybe more hypermobile. So I may have known I have EDS or hypermobility syndrome, but now that I have mast cell disorder, it's way worse. Doesn't seem to make sense, but it's an immunological chemical signaling connection. Now, if I work on my mast cell problem, will that make my EDS go away? No, not if it's genetic, but it might make it easier to control and easier to manage. So that's the connection there. What about the connection between mast cell problems and dysautonomias like POTS, et cetera? Well, again, you've got a nervous system problem seemingly, and an immune system problem, 2 different systems, but they both take marching orders from the immunochemistry in the body, among other things. And the direct connection between aggravating my mast cells and releasing these nasty mediators and my dysautonomia becoming worse is that the mediators that are released in mast cell activation syndrome, mast cell disease, whatever you like to call it, some of them spill over and they confuse my central nervous system, which is trying to keep the sympathetic and parasympathetic nervous systems, the yin and the yang of your autonomic nervous system, talking to each other and connected and responding appropriately. What really happens then is the more of the spillover of the inflammatory immunochemistry from mast cell problems I get, the further apart the communication is, and I get a literal dysautonomia, whether it's POTS or other type of disease disorder or whatever. Now, in the case of POTS dysautonomia, I have definitely seen people where either it completely goes away or it gets very, very, very low level when we get the mast cell disorder more under control. Now, if you think through what I just said, the common denominator in the triad is usually mast cell problems. And so if you've already been diagnosed, which commonly happens with POTS, and then you already knew you had Ehlers-Danlos or some sort of hypermobility syndrome, which you may not have connected to being aggravated by the POTS, but let's say you have those 2 diagnoses. A question that might want to cross your mind and your clinical team's mind is, if these are getting worse, we might want to look at broader diagnostics, take a look at mast cell activation syndrome, because often it's lurking in the background and I'm so symptomatic from my dysautonomia, whether it's POTS or some other dysautonomia, and my maybe some hypermobility, maybe not, that it's sort of overshadows the mast cell part of the problem. So I hope that answers the question, which we just wanted to keep to what is the triad and how they connect. I'm Dr. A. This is my channel where we answer these questions. Thank you. Thank you. Thank you so much. All the subscribers, both old and new, please keep liking, share, subscribe. We really picked up a lot of subscribers and it's great. And we do this to educate people and we have a whole bunch of content. Go to the main page, look at the playlist, look at all the stuff, and I'll see you all on the next video.