POTS vs Anxiety: How to Tell Which Is Causing Your Symptoms

What's the Difference Between POTS and Anxiety?

POTS is defined by what your heart rate does when you stand: a rise of 30 or more beats per minute within 10 minutes (40 or more ages 12 to 19), with no drop in blood pressure and symptoms like lightheadedness, palpitations and shakiness that ease when you lie down (Vernino, 2021). Our team sees that rise as a compensation, the heart speeding up to protect blood flow to the brain. Anxiety starts with fear of something to come, such as a symptom, a test or standing up, and the body reacts to that fear.

A controlled study suggests the heart rate rise in POTS isn't anxiety in disguise. In that study, simulated standing raised heart rate by 39 beats per minute in people with POTS and by 19 in healthy controls. Anxiety scores were higher in the patients, but the researchers also ran sham versions that didn't pool blood, and their results suggest the heart rate rise is a physiological response that holds blood pressure up (Masuki, 2007). A formal psychiatric assessment of 21 people with POTS found that they didn't have more anxiety disorders, including panic disorder, than the general population, though they often seemed anxious (Raj, 2009).

Why Is POTS So Often Misdiagnosed as Anxiety?

In a survey of 4,835 people with POTS, the median wait for a diagnosis was 24 months (Shaw, 2019). Across 2 large surveys, about 3 in 4 people with POTS reported an earlier misdiagnosis, most often a psychological or psychiatric one (Tiotsop, 2026).

In our experience, anxiety often gets handed out as a brush-off diagnosis when nothing else explains the symptoms. Many people with POTS do have some anxiety, and it makes sense: when your body is going haywire, being scared of it is a normal reaction. That doesn't make anxiety the cause.

Can POTS Cause Anxiety or Panic Attacks?

It can contribute, and a small tilt-table study points the same way. In it, people with POTS reacted more strongly to unpleasant images while they were tilted upright and symptomatic, and the authors proposed that an overexcited autonomic system feeds anxious traits (Owens, 2018).

The patient in the video at the top of this page shows how a physical problem can drive anxiety. She'd been told anxiety caused her racing heart, lightheadedness and vision loss. Her symptoms came on with certain head positions, and Doppler ultrasound showed one of the arteries supplying the front of her head getting compressed in those positions. Feeling panicky when your brain is short on blood is a normal response, so treating the panic alone wasn't going to work.

Can Anxiety Make POTS Worse?

Yes, it can, and breathing is one route. Fear can speed up breathing, as it did in the case below, and blowing off carbon dioxide narrows the blood vessels in the brain and reduces its blood flow (Ainslie, 2009). For someone whose brain blood flow already drops when they stand, that adds to the problem.

In some people with POTS, though, the body moves first. In 11 people with POTS who felt short of breath upright, brain blood flow dropped about 17 seconds before their breathing sped up and their carbon dioxide fell (Del Pozzi, 2014). In one clinic sample, depressive symptoms and pain catastrophizing tracked with how bad people's autonomic symptoms were (Fisher, 2020). Our team sees how the loop can become a habit: when the physiology has kept the body on alert for a while, the alert state itself can be hard to break.

How to Tell If It's POTS or Anxiety

Our team looks for evidence, using 3 questions.

1. Does changing a behavior make the symptoms go away? If changing your breathing or your self-talk, or taking an anxiety medication, makes the POTS symptoms disappear, anxiety may be the main problem. If those help only partly, there's physiology left to find.
2. Which comes first? If you feel anxious and then the symptoms start, treat the anxiety. If the symptoms start and then you get anxious, as in "oh no, here it comes again," treat the physiology.
3. Can testing bring on the symptoms without the anxiety? Our team measures heart rate, blood pressure, breathing and brain blood flow as you change position. If the system breaks down in calm conditions, the anxiety probably isn't leading.

Our team once explained this in a legal deposition about a brain injury case, where an attorney argued the patient's racing heart was "all in her head." We asked him to imagine sprinting 400 meters for a million dollars, with one condition: bring his heart rate back to normal within 10 seconds. He laughed and said he couldn't. A heart rate that rises to meet a demand is a reflex. If an injury interrupts how blood circulates, or how the brain senses it, the heart can speed up to push more blood, and if the racing heart shows up without the anxiety, there's a reasonable chance anxiety isn't the leading cause.

Case Study: Fainting Spells That Looked Like Anxiety

What she came in with

A 46-year-old woman had gone 11 years without what she called seizures. In the 3 months before she came in, they'd returned and were speeding up. In her episodes she passed out, the way people do when they faint.

What we found

We ran a Valsalva test, bearing down to raise the pressure in the chest, followed by a tilt test, measuring blood pressure, brain blood flow and the carbon dioxide in her breath. Our team likes carbon dioxide to stay over 35. Hers rested at about 34, and after the Valsalva it fell to 18 to 21 and held there for a while. On the tilt table, blood flow to her brain dropped almost in half within the first minute at 70 degrees. Only after that did her breathing speed up, as she felt lightheaded and scared she'd have a seizure, which pushed her carbon dioxide lower still. We stopped the test in under 2 minutes, where it usually runs at least 10.

Her carbon dioxide was already low before she started to hyperventilate. The anxiety was real, and it came second.

What we did

We worked on how her body sensed and responded to pressure changes, then sent her home with a version of those exercises to do for a month.

Outcome and timeline

At the 1-month retest, the Valsalva no longer caused a big drop in carbon dioxide or brain blood flow, and she finished the full tilt test. Her brain blood flow never fell below 88% of her resting level, well within the range our team looks for. She'd had no seizures or fainting spells that month, and she felt calmer, handled stress better and was less reactive. This is one patient's result, and it can't predict anyone else's.

How Are POTS and Anxiety Treated When Both Are Present?

Match the plan to the problem. When anxiety leads, our team has seen treating it, through breathing work, changing self-talk or medication when it's needed, work remarkably well. Anxiety medication can also give short-term relief while you get your feet under you. The question our team asks is whether it addresses what's actually wrong: if a blood flow or reflex problem comes first, medication for anxiety won't fix it. Some of these drugs also change heart rate in POTS, which our page on SSRIs and POTS covers.

When the body leads, our team treats the physiology first, often with brain blood flow measured on a tilt table and transcranial Doppler, and also points people to support for the anxiety, because months of alarm can leave a habit behind. Some people find that once the physiology settles, everything else gets easier.

POTS vs Anxiety: FAQ

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