Is Dysautonomia “All in the Head”?
Postural Orthostatic Tachycardia Syndrome (POTS) is a recognized autonomic nervous system disorder that affects an estimated 1 to 3 million Americans. Its diagnosis is objective and requires, among other things, a 10-minute standing test or tilt-table test—where a sustained heart rate increase of at least 30 beats per minute in adults is documented without a significant drop in blood pressure. Despite this, patients often wait years before receiving an accurate diagnosis, with studies showing an average diagnostic delay of nearly five years after multiple physician visits.
The symptom burden is high, and the numbers are stark. POTS commonly co-occurs with migraines, irritable bowel syndrome, Ehlers-Danlos syndrome, fibromyalgia, and other chronic conditions. Symptoms such as lightheadedness, brain fog, fatigue, tachycardia, and palpitations that could frequently mimic anxiety or panic attacks, which can lead to misdiagnosis.
Adrenaline Dumping, Cerebral Blood Flow, and Comorbid Mental Health.
One mechanism that helps explain the overlap between dysautonomia and psychiatric symptoms is adrenaline dumping in response to reduced cerebral blood flow. In patients with POTS, when upright posture leads to inadequate blood flow to the brain, the body often compensates by releasing large amounts of catecholamines, including adrenaline.
This surge of adrenaline can cause symptoms such as tachycardia, palpitations, tremulousness, and heightened arousal, which closely resemble a panic attack. While these are physiologically driven by autonomic dysfunction, the repeated experience of adrenaline surges may contribute to psychological distress. Over time, some patients develop secondary anxiety, depression, or even post-traumatic stress disorder (PTSD), particularly when episodes are severe, unpredictable, or associated with fainting.
“Our collaboration with Dr. Stephanie Waggel, MD, MS, PMH-C
integrates psychiatric expertise with autonomic care.”
Recognizing this connection is essential. By understanding that adrenaline dumping is a physiologic response to cerebral hypoperfusion rather than “just anxiety,” clinicians can avoid dismissing patients while still acknowledging the real mental health burden that may develop alongside dysautonomia.
Where Psychiatry and Dysautonomia Intersect
The overlap between psychiatric and autonomic symptoms does not mean POTS is “just anxiety.” Instead, it highlights the need for multidisciplinary care. Many patients living with chronic autonomic illness experience secondary anxiety, depression, or sleep disturbance due to the uncertainty and limitations imposed by their condition.
This is where psychiatry plays a valuable role. Dr. Waggel recognizes when symptoms originate from autonomic dysfunction, when they are psychiatric in nature, and when both interact.
“Through Improve Medical Culture, Dr. Waggel offers mentorship and training for medical students.”
Together, we can better advocate for key elements of patient care, considering, for example:
- That the medication choices are carefully reviewed to avoid worsening orthostatic symptoms.
- That the “whole-person” is prioritized, validating both physical and psychological experiences, considering the person on a more holistic and integrated care.
- And ensuring that both health professionals and patients have access to the latest evidence, knowledge, and education to empower individuals with clarity and reduce stigma as a key to the plan of care.
Training the Next Generation
Through Improved Medical Culture, Dr. Waggel offers mentorship and training for medical students. This includes exposure to the complexities of dysautonomia, the psychiatric dimensions of chronic illness, and the importance of interdisciplinary, patient-centered care. Our team at Dikman Dysautonomia LLC contributes by sharing educational content on autonomic disorders, ensuring that tomorrow’s physicians are better equipped to distinguish between psychiatric and medical causes.
Key Takeaway
- POTS and psychiatric symptoms may overlap—but POTS has measurable physiological underpinnings, established diagnostic criteria, and clear treatment pathways.
- Effective care requires both autonomic and mental health expertise.
- By working together, autonomic specialists and psychiatrists can ensure that patients are not dismissed, but instead supported with comprehensive, multidisciplinary care.
References
Dysautonomia International. (n.d.). POTS: An overview. Retrieved from https://www.dysautonomiainternational.org/page.php?ID=30
Johns Hopkins Medicine. (n.d.). Postural orthostatic tachycardia syndrome (POTS). Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/postural-orthostatic-tachycardia-syndrome-pots
Johns Hopkins Medicine. (n.d.). Postural orthostatic tachycardia syndrome (POTS) program. Department of Physical Medicine and Rehabilitation. Retrieved from https://www.hopkinsmedicine.org/physical-medicine-rehabilitation/specialty-areas/pots
Johns Hopkins Medicine. (2025, February). Standing up to POTS. Johns Hopkins News. Retrieved from https://www.hopkinsmedicine.org/news/articles/2025/02/standing-up-to-pots
McCully, J. D., Thomas, T., & Taylor, S. (2022). “You look perfectly healthy to me”: Living with postural orthostatic tachycardia syndrome in adolescence. Journal of Pediatric Nursing, 62, e29–e36. https://doi.org/10.1016/j.pedn.2021.11.012
Raj, S. R. (2013). Postural tachycardia syndrome (POTS). Circulation, 127(23), 2336–2342. https://doi.org/10.1161/CIRCULATIONAHA.112.144501
Raj, S. R., Guzman, J. C., Harvey, P., Richer, L., Schondorf, R., Seifer, C., … & Sheldon, R. S. (2021). Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and related disorders of chronic orthostatic intolerance. Canadian Journal of Cardiology, 37(8), 1165–1182. https://doi.org/10.1016/j.cjca.2020.11.003
