Episode 31 – POTS in Men

[Trigger warning: please note that this episode discusses depression, suicidal ideation, and suicidal attempts. If you are triggered by such discussions, you may wish to skip this episode. If you are triggered by discussions of suicide but would still like to read this transcript, please let me know by emailing volunteer@standinguptopots.org. I can remove the sections that discuss suicidal thoughts or behavior and send you a redacted transcript.]

00:01 Announcer: Welcome to the Standing up to POTS podcast, otherwise known as the POTScast. This podcast is dedicated to educating and empowering the community about postural orthostatic tachycardia syndrome, commonly referred to as POTS. This invisible illness impacts millions, and we are committed to explaining the basics, raising awareness, exploring the research, and empowering patients to not only survive, but thrive. This is the Standing Up to POTS podcast.

00:29 Jill (Host): Hello fellow POTS patients and marvelous people who care about POTS patients. I'm Jill Brook, and today we have an episode that is long overdue. We are going to discuss some research findings about the male experience in POTS, and I know that the males out there are probably thinking “about freaking time!” Well, I'm happy to announce that today we have two stellar researchers who have been investigating issues related to the male POTS experience, and they are here today to discuss their research and their findings, along with some practical tips that we can all use to try to improve life with POTS in boys and men. Our first guest is someone you know very well, Dr. Cathy Pederson, who is a neurobiology professor, a POTS researcher, POTS parent, and founder and president of Standing Up to POTS. And we also have her colleague, Dr. Brooke Wagner, who is a researcher, public sociologist, and associate professor in the Department of Sociology at Wittenberg University. Dr Wagner's academic work explores the social constructions of gender, sexuality, and deviance. She also has expertise in research methods and community-based research. And while Doctor Wagner, publications and academic presentations examine a range of topics, collectively, her work explores the impact of social definitions and how these culturally constructed ideas around identity shape one's lived experience. Her most recent research examines how chronic illness influences mental health, and it explores how a person's gender and their beliefs about gender shape their experience with chronic illness. So two incredible guests today, Dr. Pederson and Doctor Wagner, thank you so much for being here today.

02:26 Dr. Wagner: Thank you for having me. I'm happy to be here to talk to the POTScast community and to share the research that has kept me and Dr. Pederson so busy over the past six months.

02:35 Dr. Pederson: Thanks for having us, Jill.

02:37 Jill (Host): Yeah, I know we've been getting asked for a while now by many people to discuss the unique challenges of male POTS patients, and I'm so glad, Dr. Pederson, that you have the academic position and research skills to just say, “Yeah, that's important.” We don't need to wait for funding. We don't need to wait for anything. You can just go find the perfect colleague and get right to work and that’s such a value to our community. So, let's dig into it. Dr. Pederson, how did you collect the data for this study? [Transcriber’s note: you can read the article for this study here: https://jomh.org/articles/10.31083/jomh.2021.135]

03:14 Dr. Pederson: Yeah, this is actually a subset of data from a larger study that we've published on a couple of times. And you're right, I am lucky. I've had three wonderful partners - you were my first one, where we did a couple of papers together, and then Dr. Brookings who was at Wittenberg, and then Brooke Wagner. And so this is so funny, right? There's a "Brook” in each one – Jill Brook, Jeff Brookings, and now Brooke Wagner. So, it was meant to be. Anyway, we collected this data through the Standing Up to POTS website, through our social media campaigns, and we really had some help getting men from a men's group for POTS. So, for any of the guys that are listening, there are groups out there that are men only, where you can talk about how it feels to have POTS as a man. And so we got a lot of this data actually from that group. When we do these surveys, we construct a list of standardized validated instruments that measure a variety of psychological sorts of data for this one, and so one of those is depression. And we always look at that because I do a lot of work on quality of life and on suicide and suicidal thinking. And I ought to stop here and say that we should have a trigger warning while at the end of the show, especially when Dr. Wagner comes on, we're really going to be talking about gender roles and men and chronic illness. The part that I do a little bit earlier will be talking about depression and other psychological features, as well as suicidal behaviors, including suicidal thinking, making a plan, and making an attempt. So I just want to stop and say that we usually give a trigger warning at the beginning of some of these shows. The second thing that we were looking for here, we gave an instrument that looked at two different symptoms. One is perceived burdensomeness and that's the feeling that you’re a burden on your loved ones - family or friends - and instead of feeling like you're contributing to that family unit, you feel like you're a burden. And that same test also worked on something called thwarted belongingness, and that's the idea that you don’t feel part of a social group. You feel like you're on the outside sort of looking in. New in this study is another factor - it's called fearlessness about death. I've never looked at this before. This is part of Joiner's interpersonal theory of suicide to perceived burdensomeness, thwarted belongingness, and fearlessness about death are the three things that he talks about. [Transcriber’s note: Dr. Thomas Joiner is a well-known psychologist and researcher of suicidal behavior. In his 2005 book, Why People Die By Suicide, Dr. Joiner discussed that when individuals develop two separate mental states - thwarted belongingness and perceived burdensomeness – simultaneously and for long enough periods of time, they are more likely to engage in suicidal behavior.] But fearlessness about death is exactly what it sounds like. It's the idea that you have fear or you don't have fear about the idea of your own impending death. So we'll come back and talk about that more later. And then we give a suicide behavior questionnaire to just see where people are - if they're thinking about suicide, if they're feeling fine.

06:24 Jill (Host): Great, OK. So I guess first things first, Dr. Wagner who were the men in your sample? What do we know about them?

06:34 Dr. Wagner: Our sample was pulled from the larger study that Dr. Pederson was talking about that had 766 participants. Now we examined cases where the participants identified as male. Overall, our sample size was very small, so that's important to remember. In total we had 41 chronically ill men in our study. The age of our sample ranged from 18 to 75 years old, with an average age of 38.1 years old. The participants were all ill for at least one year and some were ill up to 34 years. On average, the men in our sample were ill for almost a decade - around 9.6 years. The total diagnoses for our sample ranged from one to six and comorbidity was also very common with patients averaging 2.3 diagnoses. Now, everyone in the sample was diagnosed with a chronic illness and most were diagnosed with POTS - that was at 92.7%, or 38 of the 41 participants. However, we had a few other chronic illnesses that were common amongst the sample - 19.5% of the sample also had chronic fatigue syndrome, 19.5% had mast cell activation syndrome. Just over 17% had orthostatic hypotension. Fourteen and a half percent had Ehlers Danlos Syndrome and 14 1/2 percent had vasovagal syncope.

08:07 Jill (Host): OK, so it sounds like they had the combination of things that we're used to seeing in this community. So, I guess almost for the big reveal, what was the main finding of the study?

08:24 Dr. Pederson: Like some of the previous work that I've published, we found that about 58% of men with POTS were at high risk or fell into the high-risk group for suicidal behavior. And so for our listeners who have been with us from the beginning of the podcast, that's not a big surprise. It was a small sample, as Dr. Wagner pointed out, but it seems to be representative of what we've seen in much larger samples in women. And suicidal behavior simply means that people were thinking about suicide, they were making a plan, maybe making a plan for suicide, and perhaps had a past attempt, or were contemplating making an attempt. The more exciting part of this, so that that part I think we've known for a while, we're showing it again in men, that men are similar to women in this way. But what I find really exciting is that Brooke and I were able to figure out predictive versus protective factors for suicide risk. And this is something that's absolutely brand new. So, if I'm chronically ill and the people around me who love me and are helping me out, make me feel bad every day for needing to do my laundry or do my grocery shopping or making my dinner, then that increases my perceived burdensomeness. But what this study showed is it also increases my risk of suicidal behavior. The second one that was predictive like that is fearlessness about death. This one I think makes sense. If I'm not fearful about death - so as my score goes up on this, I'm more fearless, right? I have less fear about death. The more likely I am to consider suicide as a viable option. So those were the predictive factors. And as those go up - perceived burdensomeness and fearlessness about death - then also the risk of suicidal behavior goes up. What's really, really exciting - and this is probably more Dr. Wagner than me, I don't know we're a good team, I think - were these protective factors. And we haven't seen this before, and I think we actually need to look at this in women and see if we see the same thing where we've got a higher number of people in our sample. But protective factors are those that decrease the risk of suicide. And so we saw that for age - as people got older, as these men got older, they did not fall in that high-risk group for suicide. What does that mean? That means that our younger folks, our younger men, are the ones that are at high risk. And as they move into their 30s and 40s and 50s, they have less risk of suicidal behavior. The other one that we found that was protective - and this goes against some of the literature - is something that we called “changes in health due to chronic illness” and we'll get into how Dr. Wagner constructed this in a little bit. But the idea is that the more symptoms these men had, the less suicidal behavior they marked on this survey. So, the higher the symptoms, the more visible, maybe we could say, their symptom load became, the less risk they had for suicide. Now, why I said that's contrary is there's a lot of data on physical illness and suicide and that data really says for people who have cancer and more visible illnesses that the higher the symptom load, the more suicidal they become. In the invisible illness community, it looks like the opposite. The higher the symptom load, the more protective that might be. So that's an interesting finding that we need to replicate in a bigger sample.

12:37 Jill (Host): That is fascinating and I remember finding that in our bigger study a couple years ago, and so that's really interesting that that was repeated here. I'm also glad to see that you found again that there's less suicidal behavior as patients get older because that tracks with what patients seem to tell me all the time, which is that it does get easier over time. Whether or not you actually find better treatments, just the coping skills or something about getting older seems to get better for people. So that's a really hopeful message. Dr. Wagner, do your findings suggest that the POTS experience is different for men than women, and if so, do your findings say anything about why?

13:26 Dr. Wagner: That's a great question. We learned that there are some areas of similarity, as Cathy has already discussed. For instance, the impact of perceived burdensomeness seems to affect both men and women who have POTS. And as we worked on this project, we began to ask ourselves what does perceived burdensomeness look like for men? Is it different than what women experience? You know, and we became interested in how gender impacts responses on these scales, and more specifically how expectations around masculinity impact men with chronic illness, like POTS. So here I should take a second and give a definition. So, what do I mean by “masculinity”? Well, masculinity refers to the culturally shared beliefs and ideas about what it means to be a man and how men are supposed to act. Common traits ascribed to men in the United States and Western world include things like being physically strong, being brave, being independent, stoic, and invulnerable. Now of course these ideas are impossible standards for anyone to live up to at all times. But for men with chronic illness it can be especially hard to meet these ideals. So we suspect that for some men not being able to be self-sufficient at all times due to chronic illness might further contribute to feelings of perceived burdensomeness. Additionally, valuing being brave or stoic might lead to increased attitudes around fearlessness towards death - another factor we found to increase risk of suicidal behavior. So while reviewing other research about men with chronic illness, we found several studies noting the psychological challenges men experience as they come to terms with their illness. One study encouraged men with chronic illness to adjust or renegotiate their understanding of what it means to be a man throughout their illness, especially as they encounter symptoms that diminish their physical health and autonomy. Holding on to rigid beliefs about what it means to be a man can lead to decreased mental health and physical health, according to some studies. To help decrease risk of suicidal behavior, some men with POTS may need to redefine their idea of masculinity based upon their new physical reality.

15:51 Jill (Host): Right! So this just reminds me yet again that there is plenty of misery to go around when it comes to chronic illness. Some of that misery comes from the illness itself, the biology going on, but then so much of the misery just comes from the social angle of it, and that is the part that always makes me sad, but it also makes me feel like we can do so much about it by, you know, doing some of the things you said - reframing it or by raising awareness. And if we could just get rid of the misery due to the social pressure that society puts on us, or we put on ourself, that that would actually be pretty significant. That's really interesting to me, and I know that with some of the men that we've had interviewed on this show that they have referred to the very things that you're talking about. Dr. Pederson, I believe you have been working on designing better survey tools for studying people with chronic illness. Can you tell us why our depression inventory is not as accurate for people in the chronic illness community?

17:06 Dr. Pederson: That's a great question, Jill. I started thinking about this several years ago when we started doing surveys. What we found was that people with POTS and other chronic illnesses seemed to be over diagnosed with depression, and the question is why is that? And when you look at the actual instruments that are out there for depression, especially the big popular ones, they use a lot of symptoms that are common for people with POTS. So, they call them ‘somatic symptoms’, which means body symptoms of depression, and so with depression, and I think our listeners maybe know this, you of course feel that real sadness and despair, emotionally, but a lot of times there's physical pain and there are physical effects that go with that as well. The problem is when you're trying to assess depression in someone that already has physical symptoms, that's where the waters really get muddy. And so there are a number of different questions on there that relate to things like sleep. Now, if you're depressed, sleep is an issue, but we know that many in the POTS community, and Jill and I did a study on this, I think we've done a POTScast on this, we know that like 98% of people with POTS don't sleep well. And so that's not a good assessment for the POTS community on whether they're depressed or not. Fatigue is another one. Energy concentration. Brain fog is really really common in our community, right? And so we're over diagnosing. Dr. Wagner actually had this idea to take some of these somatic symptoms off of the depression scale and create our own subscale that she called the ‘chronic illness inventory’. And we took six of these factors from the depression scale - these included agitation, concentration, energy, fatigue, irritability, and sleep, and use those to describe symptom load for our POTS patients. And so, we're going to talk more about what that is, but when I said changes in health due to illness, that's what I'm referring to as some of these items that we took off of that depression scale to make this chronic illness inventory. This is a real problem, though. It's a problem for the healthcare community, where they think “OK, maybe the job is done. I gave this depression scale. It's a validated instrument. It's used in many different populations. It says my patient is depressed. Job well done. I pat myself on the back and go home.” And of course, for that POTS patient, depression may not be the issue. In fact, I think a lot of our listeners were probably first diagnosed as depressed or as anxious largely for this problem, because these questionnaires have this overlap between bodily symptoms that we have as a result of our POTS, but they can also double as depression symptoms.

20:25 Jill (Host): Yeah. So it sounds like you said the depression, the anxiety, and maybe the deconditioning are kind of the three big things that POTS patients can get diagnosed with or accused of when that's not the problem, it's just that POTS symptoms have so much overlap with those things that to the untrained eye it looks like those things.

20:48 Dr. Pederson: That's exactly right.

20:50 Jill (Host): So I'm really glad you guys are working on creating better tools to pick these things apart. So for a really important question, how can practitioners help make male POTS patients have a better experience?

21:06 Dr. Wagner: Great question. Well, as I discussed a bit earlier, men with invisible chronic illnesses that are so physically demanding, like POTS, can suffer from mental health consequences by holding on to rigid beliefs around masculinity. So, these beliefs can cause a patient to be really hard on themselves for not being able to do something that they think they should be able to do. Or it might cause them to push themselves too hard, causing more harm in the long run. Or these beliefs might even cause someone to shut down and not reach out for help. So practitioners should be aware of these challenges and encourage men with POTS to get support and talk with a therapist and/or join a support group. Practitioners should be aware that men might be reluctant to share information that was not solicited and also hesitant about asking questions or advocating for what they need. So, removing barriers so that men can feel comfortable opening up and asking questions is essential for providers. Now, generally, men don't want to be seen as sick, and this is something that is shown across research for men that are chronically ill, but also men that do not have chronic illness. Men tend to not want to be seen in the role as a patient. Studies show that men will endure great pain and delay medical treatment, and this happens even more when that illness is associated with weakness. So not only does POTS affect one's physical health, making them weaker, it is an illness associated with women due to the higher rates in which women experience it. So, these are some challenging barriers to overcome, not to mention that POTS itself is rare and is not a well-known illness, which is a barrier in of itself. So, staying current on the newest research is important for practitioners, as is being an advocate for the illness. While with male patients practitioners might try using language that allows men to feel in control and autonomous as a way to help open lines of communication, as you work to build that trust and rapport with your patient. Research examining men’s experiences with other illnesses may be useful for helping us understand the experience men have with POTS as well. So, research about men with breast cancer. Note that these men experience additional barriers by having an illness associated so strongly with women. These men may ignore symptoms, which often leads to delayed medical treatment and some men with breast cancer note having negative psychological feelings like being shocked or feeling foolish for having what they consider a woman’s cancer. So we still need to do more research to better understand the experiences of men with POTS, but we can take away some lessons from these other illnesses with similar barriers. So for example, one way practitioners are overcoming barriers around stigma and awareness for men with breast cancer is by providing gender sensitive targeted approaches. So, this is providing information to target groups in gender sensitive ways. So in some cases providers have stopped using that pink ribbon imagery we typically think of when we think about breast cancer awareness and instead try to design something more gender inclusive. Or an emerging best practice is to create similar resources that are designed and specialized to target a particular group. So for example, creating targeted materials designed specifically for men with breast cancer and other materials designed for women with breast cancer. So as more research examining the differences for men and women with POTS comes in, we really might find the need to start creating more gender sensitive targeting for these groups. Finally providing psychological support for men with POTS is important. While many with POTS do not suffer from depression, we know that suicidal risk is increased in the community. Additionally, studies examining men with chronic illness note the psychological impact of such illnesses. So, practitioners working with men who have chronic illness and that are exhibiting suicidal behaviors should consider how a patient’s perceptions about masculinity can impact their experience with the illness. Additionally, how their perceptions of masculinity can impact their sense of self, and then how these beliefs may be impacting suicidal behaviors as well.

25:25 Jill (Host): Right, OK. And then maybe a really relevant question to all of us listening, how can we help our sons, our husbands, our fathers, our male friends who have POTS?

25:40 Dr. Pederson: Yeah, I think that's a excellent question. And, you know, as we've sort of been talking about POTS is sort of seen largely as a female disease or disorder. And it's really difficult for men, I think, to feel vulnerable because they're ill in the first place, as Dr. Wagner said. But secondly, to have this “female disease”, right, or female disorder, sort of makes it much worse. I think for a lot of men, and I know I get emails not infrequently from men who talk about this as being a female disorder and how traumatizing that can be for them. So I think as family members as friends as people who love a man with POTS, we need to understand that they do feel vulnerable, and nobody likes that. That's a human experience that we all try to avoid or cover up in lots of different ways, and I think men are more conditioned to hide vulnerability than women are. And so, if they're at a point where they can't get out of bed or they can't bathe themselves or stand in the shower, or whether, you know, whatever that symptom is that they happen to be having today, that vulnerability is compounded, I think, for men even more than it is for women. We need to think about those issues that are related to masculinity and where we can, try to foster a sense of independence, whether it's our teenage son, whether it's our husband, whether it's our father, whether it's our brother, whoever that guy is who is struggling with POTS or another chronic illness, let them do the things that they can do and maybe quietly do the things for them that they can't, right? To try to maintain that sense of dignity, I think is really, really important. Something I would say maybe is involve them in decision making. I know sometimes people with these chronic invisible illnesses are brain foggy, and they're not thinking right. But when they are thinking well, be sure that you involve them and don't just ask them and then move on, right, but really listen to their opinion because they do still matter in that family unit. And making them feel like that - that they matter - can actually decrease burdensomeness, decrease social isolation, and decrease the risk of suicide. And then the last one is avoid making that person that loved one feel guilt or shame for things that they cannot do. And this is one that I think a lot of times we do inadvertently when we're tired, when we're angry, when things haven't gone our way and something slips out of our mouth that we don't really mean that makes them feel bad. “I'm tired and I still have to do your laundry” or whatever, but we need to really work to avoid those kinds of comments, to serve with a smile, and again, to let them do what they can, what they want to be able to do, and contribute in that family. And then finally I guess is to really listen. If he's vulnerable with you and he really starts to share how he feels about that illness, listen and listen carefully and then believe him. Believe what he's telling you, believe how difficult it is for him to open up and be vulnerable in that way about an illness that very few people understand. And if we can validate their feelings, validate that we believe that they are ill, that no matter what the health care practitioners say, no matter what friends say, maybe extended family says, I'm with you. I believe you. I got you. And I think that is really the takeaway message is to really always try to be kind.

30:07 Jill (Host): Well, that's amazing advice. Yeah. You know, I am wondering in the eating disorder and the body dysmorphia space, there is some thinking that sometimes it can be helpful to call out the societal expectations that are making everybody miserable and that are impossible to live up to. It's almost OK to kind of resent those. I guess my question is, do gender stereotypes and gender expectations really serve us that well anymore? Is it OK to just treat them like some archaic old thing that you don't necessarily need? Or am I misreading that? I there is there like good evolutionary reasons they're there and we need to respect them, or can we just say these stupid things! Why are they making us miserable?

31:00 Dr. Wagner: [Laughs] I mean, that's a great question and something that a lot of academics debate historically, but I would argue that these are social constructs and maybe they grew for evolutionary purposes, but they really don't serve their function for us right now. We don't need to divide up what it means to be human into these two different tracks, right? You're strong or you're weak, you're brave or you're afraid. In fact, humans are all of these things at different points during their day and during their life. So, to even create these divides like what is masculine and what is feminine is ultimately dividing us from being a whole person, I would argue. So I would say, yeah, let's chuck these social constructs out the window.

31:50 Dr. Pederson: I love that idea. What if we could do that? What if we could call out those negative parts of the masculinity? What if we could say it's OK for a little boy, or for a man to be vulnerable. It's OK for them to show feelings. It's OK for them to not only feel like they're weak sometimes, but to also show that weakness. I think it could be very valuable. I love that idea, Jill. Let's call it out.

32:23 Jill (Host): OK, yeah, you know, 'cause it just makes me think when I was earlier on in my POTS journey and I was suddenly unable to keep up doing a lot of the female stereotypes, you know, POTS made it so that I didn't have the energy to wear high heels and I couldn't really shower or use a hair dryer and I didn't have the energy to wear makeup and I couldn't make dinner for my husband. And at the time it felt like the end of the world. And at the time it felt like I was letting people down and I was becoming a less valuable member of society. And now that a decade has passed, I almost have to laugh at that old me and think, Oh my goodness, I can't believe I was spending my time doing those things because life is better without them. [Laughs] But at the time it really did cause me a lot of anxiety to give up on those expectations, and I guess I just wonder if we could make it easier for other people to kind of give up on these invisible expectations so that it wasn't so hard to just be a person instead of a masculine or feminine person, 'cause I think, you know, some of my favorite men are not that masculine, they're just people. I sometimes I wonder, are we giving these these gender stereotypes too much power over us, and how can we make that stop? I don't know. Maybe that's a bigger question.

33:50 Dr. Wagner: It is a big question, definitely, but I think you're right. We are giving these stereotypes oftentimes too much power over us and it makes it more challenging for us to meet our goals and to get by in our everyday life. You know, Jill, I was listening to one of the podcasts from a while back and I remember you were telling a story about how you were thinking about what your life was going to be like in your 20s and how it was hard for you because you had this realization that that wasn't going to be your life. And I think these constructs of masculinity and femininity work the same way. We know we grow up and we have this idea of what I'm going to be as a woman or what I'm going to be as in a man. And when we're not able to fulfill those dreams or those, you know, ambitions, it can be very challenging for us and can create a lot of even psychological trauma as you are trying to negotiate who you are now in this new world and in this new place. So, being kind, as Dr. Pederson had said earlier, to those around us as they're trying to figure this out and making sure that as we're raising our children, not forcing them into these gender roles is a great place to start as well. So if you have children with POTS, regardless of their gender identity, being open and flexible with them and letting them figure out who they are without trying to force them into a masculine category or feminine category will probably benefit them greatly in the long run.

35:22 Jill (Host): That's great to know. So I know a final thought I wanted to just put out there is just reminding people that you keep finding that suicidal risk goes down with age, which implies that things get better. People stop thinking about suicide as they get older, they stop planning for it. It implies that if you can make it through those younger times, things get better. Is that right? And is there any other final thoughts we should leave people with?

35:59 Dr. Pederson: That's exactly right, and so I think that gives us some hope. And I know, going back to my daughter, when she was young, she got it at a younger age than most women do. And I thought, I don't know how she's ever going to make it to college. I don't know how she would live on campus. And she's doing those things now. And she was even 16 or 17 and I'm thinking I just don't see how we're going to make it. I've got this very bright child, but things are getting better. She got sick when she was ten. She's 19 now and she's so much better. Now, is she well? No. Is this the life that we envisioned for her when she was eight? No. But she's better than she was. She's on her feet, she's on her way to a career where she can sit, maybe recline, in order to do the work that she needs to do, and we need to hang in there. We need to hang in there as families. We need to hang in there as support systems. And we need to do what we need to do to make it to the next day, the next week, the next month, and the next year. I think that's exactly right. We've got to hang on, folks. Hang on.

37:14 Jill (Host): Well, Dr. Wagner and Dr. Pederson, thank you so much for joining us today and for all of the important work that you do. We are so glad to have your brainpower on Team POTS. And OK listeners, thank you for being here, too. Please remember this is never medical advice. Talk to your medical team about what's right for you, and please consider subscribing because it helps us get found by other people like you and we love people like you, so stay strong. Remember that you're not alone, and please join us again soon.

37:48 Announcer: You can find us wherever you get your podcasts or on our website, www.standinguptopots.org/podcast and I would add, if you have any ideas or topics you'd like to suggest, send them in. You can also engage with us on social media at the handle @standinguptopots. Thanks for listening and we hope you join us. This show is a production of Standing Up to POTS. © 2021 Standing Up to POTS. All rights reserved. [Transcriber’s note: For a copy of this transcript or the transcript for any other episode of the POTScast, or if there is something we can do to make these transcripts easier to follow, please email volunteer@standinguptopots.org]