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The reply:

      We thank Bulbena et al for their interest in our paper on dysautonomia in the hypermobility syndrome (
      • Gazit Y
      • Nahir A.M
      • Grahame R
      • Jacob G
      Dysautonomia in the hypermobility syndrome.
      ). As they have pointed out, nine of the 13 somatic criteria for diagnosing a panic episode, as laid down in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM–IV) (

      American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (DSM-IV). 4th ed. Arlington, Virginia: American Psychiatric Press; 2000

      ), do, indeed, feature in the autonomic questionnaire we used. What they have omitted to mention is that our questionnaire contains 20 further questions over and above the nine they refer to, which do not form part of the DSM–IV criteria for panic attacks or other forms of psychiatric disease. None of our patients experienced “a discrete period of intense fear or discomfort in the absence of real danger” that forms “an essential feature” of the criteria for panic attack as defined in DSM–IV(

      American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (DSM-IV). 4th ed. Arlington, Virginia: American Psychiatric Press; 2000

      ), and none expressed phobic symptoms. The assertion by Bulbena et al that our patients' symptoms are psychogenic rather than dysautonomic in origin is highly contentious. Furthermore, it totally ignores the objective laboratory evidence of autonomic dysfunction demonstrated in 78% of the patients in our series presented in our paper.
      We would agree that the myriad constellation of varying symptoms described in dysautonomias does overlap with some of the criteria defining panic disorders. However, dysautonomia can never be diagnosed solely on symptoms because of their nonspecific nature. The most widely known dysautonomias are defined on the basis of relevant symptoms, plus objective hemodynamic abnormalities, together with (in some cases) coexisting neurological pathology. By contrast, panic disorders are based solely on criteria relating to symptoms. Moreover, there is no evidence of autonomic abnormalities in patients with panic attacks (as extensively studied by Stein et al) (
      • Stein M.B
      • Asmundson G
      Autonomic function in panic disorder cardiorespiratory and plasma catecholamine responsivity to multiple challenges of the autonomic nervous system.
      ). None of our patients had evidence of previous psychiatric illnesses (although 1 patient who had taken part in the questionnaire part of the study only had once been prescribed antidepressants). Our criteria for autonomic dysfunction were based on well-defined and widely accepted classification criteria for dysautonomia; e.g., postural orthostatic tachycardia syndrome (
      • Schondorf R
      • Low P
      Idiopathic postural orthostatic tachycardia syndrome an attenuated form of acute pandysautonomia?.
      ).

      References

        • Gazit Y
        • Nahir A.M
        • Grahame R
        • Jacob G
        Dysautonomia in the hypermobility syndrome.
        Am J Med. 2003; 115: 33-40
      1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (DSM-IV). 4th ed. Arlington, Virginia: American Psychiatric Press; 2000

        • Stein M.B
        • Asmundson G
        Autonomic function in panic disorder.
        Biol Psychiatry. 1994; 36: 548-558
        • Schondorf R
        • Low P
        Idiopathic postural orthostatic tachycardia syndrome.
        Neurology. 1993; 43: 132-137