How are Generalized Anxiety Disorder (GAD) and Postural Orthostatic Tachycardia Syndrome (POTS) related?

From the Guidelines

Generalized Anxiety Disorder (GAD) and Postural Orthostatic Tachycardia Syndrome (POTS) frequently co-occur and can exacerbate each other through interconnected physiological mechanisms, with anxiety triggering the sympathetic "fight-or-flight" response, increasing heart rate and blood pressure, which can worsen POTS symptoms, as noted in studies such as 1. GAD involves chronic anxiety and excessive worry, while POTS is characterized by an abnormal increase in heart rate when standing upright, causing symptoms like dizziness, fatigue, and palpitations. The connection stems from the autonomic nervous system dysfunction present in both conditions. Conversely, POTS symptoms like racing heart and lightheadedness can trigger anxiety and panic. Some key points to consider in the relationship between GAD and POTS include:

• The pathophysiology of POTS is debated and likely heterogeneous, involving deconditioning, immune-mediated processes, excessive venous pooling, and a hyperadrenergic state, as discussed in 1.
• Treatment often requires addressing both conditions simultaneously, typically including beta-blockers like propranolol (10-40mg daily) or metoprolol (25-100mg daily) to manage heart rate, increased salt and fluid intake (2-3 liters daily with 3-5g sodium), compression garments, and gradual exercise programs for POTS, alongside cognitive behavioral therapy and sometimes SSRIs like sertraline (50-200mg daily) or escitalopram (10-20mg daily) for anxiety management, as suggested by studies such as 1 and 1.
• Physical therapy focusing on recumbent exercises and lifestyle modifications addressing sleep hygiene and stress management techniques are also beneficial for both conditions, as noted in 1.
• Screening for anxiety, such as using the GAD-7 scale, is recommended, especially in patients with cancer, as discussed in 1.
• Assessment of anxiety should identify signs and symptoms of anxiety, severity of symptoms, possible stressors, and underlying problems/causes, as outlined in 1. Overall, the management of GAD and POTS requires a comprehensive approach that addresses both the physiological and psychological aspects of these conditions, with a focus on improving symptoms, quality of life, and reducing morbidity and mortality, as emphasized in studies such as 1.

From the Research

Relationship Between GAD and POTS

• Generalized Anxiety Disorder (GAD) and Postural Orthostatic Tachycardia Syndrome (POTS) have been linked in various studies, with some patients experiencing symptoms of both conditions 2, 3.
• POTS is a multifaceted disorder of the autonomic nervous system, and many patients with POTS also report symptoms of anxiety, depression, and behavioral amplification, which can contribute to symptom chronicity 2.
• A case study on behavioral treatment for POTS found that cognitive behavioral therapy (CBT) can be effective in reducing POTS-related functional impairment and anxiety symptoms 3.
• GAD is a common disorder characterized by excessive, uncontrollable worry or anxiety, and it has been found to be associated with pronounced functional impairment and reduced quality of life 4.
• While there is no direct evidence on the relationship between GAD and POTS, studies suggest that patients with POTS may experience anxiety symptoms, and CBT may be an effective treatment for both conditions 3, 4.

Common Symptoms and Treatment

• Both GAD and POTS can present with symptoms of anxiety, and treatment for GAD, such as CBT and selective serotonin reuptake inhibitors (SSRIs), may also be effective for patients with POTS who experience anxiety symptoms 3, 4.
• Patients with POTS may also experience symptoms of orthostatic intolerance, such as dizziness, fatigue, and headache, which can be exacerbated by anxiety and stress 2, 5.
• Treatment for POTS typically involves a combination of lifestyle modifications, such as avoiding precipitating factors and increasing fluid intake, and pharmacotherapy, such as fludrocortisone and midodrine 2, 5.

Comorbidities and Associations

• POTS has been found to be associated with other conditions, such as mast cell activation disorder, which can present with symptoms of anxiety, allergic complaints, and gastrointestinal symptoms 6.
• Patients with POTS may also experience comorbidities, such as chronic fatigue, fibromyalgia, and sleep disturbances, which can exacerbate symptoms of anxiety and depression 2, 5.