Introduction

Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system resulting in an inappropriate increase in heart rate, which mostly occurs when going from lying down/sitting to standing.¹,³ It can result in a number of debilitating physical symptoms, affecting multiple different body systems such as dizziness, palpitations and syncopal episodes (fainting).¹,⁴ These combined with other symptoms such as brain fog, fatigue and headaches can affect a person’s ability to engage in normal day-to-day activities, which can have a profound effect on their psychological well-being.¹,³ 

Understanding the psychological impact of POTS

POTS is a chronic health condition, meaning that it is something a person is likely to have in the long term, and often follows a relapsing and remitting course.²,⁴ It is common for those suffering with POTS to experience concomitant mental health disorders, most notably anxiety and/or depression.¹,⁴ Generalised anxiety disorder (GAD) is characterised by excessive worry and fear about many different aspects or activities.² Depression is defined as a pervasive low mood, anhedonia (loss of pleasure in things normally found enjoyable), as well as hopelessness and despair.³ A lot of the physical symptoms found in anxiety and depression can also be experienced in POTS, worsening their experience and compounding a person’s distress.¹,³,⁴ This follows the trend found in those suffering from other chronic health conditions, with one study showing that 87% of POTS patients exhibited clinician-rated mild-moderate major depressive disorder.¹ 

Anxiety in POTS patients

When people become anxious, the body releases hormones which prepares it for encountering a potentially dangerous situation.² ⁵ This is why people experience the physical symptoms of anxiety - shortness of breath, palpitations, dizziness - which are very similar to what is seen in POTS.² ⁵  Unfortunately, this body system is quite primitive and cannot differentiate between a real and perceived threat, which can keep the person stuck in ‘fight/flight/freeze’ mode.² ⁵ It is worth mentioning that people with POTS also seem to be particularly sensitive to the effects of this system, and the system which counterbalances it isn’t always functioning properly.³

POTS can cause anxiety for a number of reasons.² ⁴ The initial noticing of symptoms without knowing the cause of them leads to uncertainty, which is one of the most commonly recognised triggers for anxiety.³ Then, the diagnosis of a chronic condition with no definitive path to recovery can lead to worries about managing day-to-day life, and also how the future will look.³ ⁴ People with POTS often find they have to make big changes in their lives, which can be scary and unsettling.³ There may be worries around being able to work, how they will manage their finances, and also how it will impact their relationships now and in the future. Social situations which could trigger symptoms in front of others, and a fear of stigma and rejection, can lead to people isolating themselves from groups they had previously engaged with.³ Exercise is often a particularly pervasive trigger for those with POTS, as in the short term, it can lead to a worsening of physical symptoms such as breathlessness and fatigue.² ³ Both an avoidance of situations and a lack of exercise can then lead to anxiety deteriorating further.² ³

Depression in POTS patients

There is a big crossover between developing depression and experiencing POTS.¹ ³ It is also important to note that depression and anxiety do not have to exist in isolation.³ ⁴ It is not uncommon for people to experience both of these mental health conditions concurrently when dealing with a chronic illness.³ ⁴ The constant worry about the future and the feeling of being stuck can contribute to low mood and anhedonia (lack of interest and/or pleasure in things that would normally interest a person).³

Factors which also lead to the development of depression include becoming isolated from normal social groups and a person having to make significant changes to their lifestyle.¹ ³ An example might be that a person is a keen runner, and mainly socialises with their running group, which they now feel unable to do, due to the physical symptoms of POTS. The lack of exercise could lead to their mental health deteriorating further, with more time spent in rumination and depressive thoughts. There is an added sense of hopelessness with having a chronic illness, which also contributes to the development of depression, as there is no clear end to the symptoms.⁴ It is not like developing a urinary tract infection, for which a person can just take antibiotics, knowing that in a few days the distressing experience will pass. There is more of a tendency for people to feel stuck in their condition.³ Similarly to anxiety, the physical symptoms of POTS - fatigue, brain fog, and headaches - are also commonly found in depression, making the experience doubly worse.¹ ³

Coping strategies for managing anxiety and depression in POTS

There are a number of helpful ways to manage the mental health disorders surrounding living with a chronic health condition like POTS.² ³ ⁵ 

Firstly, the person can learn to calm the body and mind down, and bring it out of ‘fight/flight/freeze’ mode by using different techniques, including: 

• Meditation and breathing techniques to slow the heart rate and calm the nervous system down² ⁵
• Mindfulness-based techniques and other relaxation activities to step out of spiralling and catastrophic thought processes² ⁵

Other options which are helpful for both anxiety and depression are:

• Engaging in regular and manageable exercise, slowly building up the intensity over time and taking rest when needed ² ⁵
• Being open with friends and family when it feels safe to do so can really help decrease anxiety around social situations and provide a good support network through more difficult times² ⁵
• Seeing a trained psychotherapist/counsellor to help you with the emotions surrounding a POTS diagnosis² ⁵
• Accessing online and in-person support groups, such as those at potsuk.org and thedysautonomiaproject.org
• Seeking advice from your doctor about possible medication options, which could help, such as selective serotonin reuptake inhibitors (SSRIs) and beta blockers² ⁵
• Letting your workplace know what you are going through, and if there are any changes you may need as a result of your Diagnosis² ⁵
• Keeping a diary of what your triggers are, eg alcohol, or stressful events, can help you make lifestyle changes and feel more in control of your health² ⁵

Summary 

In conclusion, POTS can have a huge impact on a person’s quality of life, resulting in a deterioration in psychological health.¹ ³ It is very common for people to experience mental health conditions such as depression and anxiety as a result of this diagnosis, and it is an important part of managing the condition.¹ ³ People who have POTS will likely benefit from mindfulness and relaxation techniques, engaging in regular, manageable exercise, and seeking advice from trained healthcare professionals such as counsellors and their GP. ² ⁵ 

FAQs

What is postural orthostatic tachycardia syndrome (POTS)?

POTS is a syndrome resulting from an abnormally high increase in heart rate when going from sitting to standing.¹ ⁴

What is the cause of POTS?

There is no clear reason why people develop POTS, but risk factors include stressful life events and following an illness/infection. ² It is a disorder of the nervous system.² The part which helps slow your heart rate down doesn’t function properly, and the part which speeds your heart rate up is very sensitive, leading to an imbalance in functioning.²

What are the symptoms of POTS? ⁴

The symptoms of POTS are varied and not limited to dizziness, headache, fatigue, brain fog, palpitations, shortness of breath, chest pain and exercise intolerance.¹ 

How do I get diagnosed with POTS?

You can get diagnosed with POTS by contacting your local GP, who will likely arrange some investigations such as blood tests, an ECG (electrocardiogram) and take your blood pressure and heart rate both sitting down and standing up.²

What else could my symptoms be?

The symptoms of POTS are varied and could be indicative of other, more serious health conditions, which require urgent intervention. ⁵ If you have any concerns or your symptoms deteriorate, do not hesitate to seek urgent medical advice. ⁵ 

Is there a cure for POTS?

POTS is a chronic health condition, meaning there is no definitive cure for it, although for some people, the symptoms will go away without treatment.² Most experience a relapsing/remitting course of the illness.² However, there are techniques and medications which can help with managing the symptoms of POTS.²

Is it common for people with POTS to experience mental health problems? 

Yes, it is very common for people with POTS and other chronic health conditions to experience concomitant mental health conditions such as depression and anxiety.¹ ³

What should I do if my mental health deteriorates?

If your mental health deteriorates and you find yourself having suicidal thoughts, you should seek urgent advice.⁵ This could be in the form of your GP, local A&E or from an advice line such as the Samaritans (https://www.samaritans.org/how-we-can-help/contact-samaritan/)⁵