Treatment of Anxiety in Patients with Postural Orthostatic Tachycardia Syndrome (POTS)
For patients with POTS and anxiety, a combination of non-pharmacological approaches including cognitive behavioral therapy, sensory grounding techniques, and carefully selected medications that don't exacerbate orthostatic symptoms is recommended as first-line treatment. 1, 2
Understanding the Relationship Between POTS and Anxiety
- Anxiety is a common comorbidity in POTS patients that can both trigger and exacerbate orthostatic symptoms 2
- Many POTS patients experience physiological manifestations of anxiety (racing heart, tight chest) without recognizing the emotional component, a phenomenon described as "panic without panic" or alexithymia 1
- Anxiety can become a maintaining factor for POTS symptoms, creating a cycle that limits functional activities 1
Non-Pharmacological Management Approaches
Education and Cognitive Approaches
- Provide education about the physiological process of anxiety and its physical impact on the body, particularly how it interacts with POTS symptoms 1
- Teach patients to discriminate between POTS symptoms and anxiety symptoms, which can significantly decrease POTS-related functional impairment 3
- Implement cognitive behavioral therapy techniques including exposure therapy to feared situations that trigger orthostatic symptoms 3
Sensory Grounding Techniques
- Teach sensory grounding techniques to keep patients present in the moment and prevent dissociation during anxiety episodes 1
- Specific techniques include:
Physiological Management
- Implement breathing techniques and progressive muscle relaxation to manage acute anxiety symptoms 1
- Incorporate regular cardiovascular exercise, preferably in recumbent or semi-recumbent positions (rowing, swimming, recumbent cycling) 1, 4
- Start with short duration (5-10 minutes) of recumbent exercise at a level that allows speaking in full sentences 1
- Gradually increase exercise duration (approximately 2 additional minutes per day each week) 1
- Transition to upright exercise only as orthostatic tolerance improves 4
Pharmacological Management
Important Medication Considerations
- Avoid medications that inhibit norepinephrine reuptake, as these can worsen POTS symptoms 5
- Be cautious with medications that may cause hypotension in POTS patients 5
Medication Options
- Beta blockers may be considered for patients with hyperadrenergic POTS who have prominent anxiety symptoms 1, 6
- Ivabradine is reasonable for ongoing management in patients with symptomatic inappropriate sinus tachycardia, which may overlap with POTS 1
- For patients with severe anxiety, selective serotonin reuptake inhibitors (SSRIs) or neuromodulators may be considered, but should be initiated at low doses and titrated slowly 1
Integrated Approach for Optimal Management
- Implement a multisystemic approach that addresses both POTS and anxiety symptoms simultaneously 1
- Incorporate volume expansion strategies (2-3 liters of fluid daily and increased salt intake of 5-10g daily) as part of overall POTS management 5
- Use compression garments extending at least to the xiphoid process or with an abdominal binder to reduce venous pooling 5, 4
- Teach physical counter-pressure maneuvers for acute symptom management 5
- Consider psychological support with brain-gut behavioral therapies for patients with comorbid gastrointestinal symptoms 1
Monitoring and Follow-up
- Regularly assess for improvement in both anxiety symptoms and POTS symptoms 2
- Monitor for cognitive impairments, as POTS patients often experience difficulties with attention and short-term memory that may be exacerbated by anxiety 7
- Evaluate health-related quality of life in both physical and mental health domains to gauge treatment effectiveness 7