Are We Diagnosing POTS Too Often in Anxious Young Women?

Postural Orthostatic Tachycardia Syndrome (POTS) has received growing attention in the last decade, particularly among young women presenting with persistent fatigue, palpitations, lightheadedness, and an array of unexplained somatic symptoms. At the same time, anxiety disorders and heightened somatic focus are also widespread in this group. The clinical question now confronting many practitioners is not only diagnostic but philosophical:

Are we overdiagnosing POTS in anxious young women, or are we finally shedding light on a neglected dysautonomic condition?

Let’s explore this issue through a critical, evidence-informed lens tailored for clinicians and medical students alike.

What Exactly Is POTS?

POTS is a subtype of dysautonomia defined by a sustained rise in heart rate of ≥30 beats per minute in adults (or ≥40 bpm in adolescents) within 10 minutes of standing, without a corresponding drop in blood pressure.

Symptoms are diverse and may include:

• Lightheadedness or dizziness
  
  
• Fatigue and low stamina
  
  
• Palpitations
  
  
• Cognitive clouding or “brain fog”
  
  
• GI complaints
  
  
• Intolerance to standing or exertion
  
  
• Episodes of near-syncope or syncope
  

The condition most commonly affects females in their teens and twenties. It is frequently associated with other medical conditions such as Ehlers-Danlos Syndrome, autoimmune illnesses, mast cell activation, and in some cases, viral triggers including SARS-CoV-2 infection.

Why the Sudden Surge in POTS Diagnoses?

There’s no doubt that awareness has increased. More clinicians now recognize autonomic dysfunction as a legitimate clinical entity. Patient-led advocacy and online communities have helped educate both the public and medical professionals. Social media, for better or worse, has circulated symptom lists and self-assessment tools widely.

Moreover, the emergence of post-viral syndromes like Long COVID has pushed dysautonomia—including POTS—into mainstream medical discussions.

But with this growing recognition comes a dilemma: Are we truly identifying cases that were previously overlooked, or are we inadvertently labeling common symptoms with a complex diagnosis prematurely?

Diagnostic Challenges: POTS vs. Anxiety

Tachycardia, dizziness, and vague GI complaints can be seen in both POTS and anxiety disorders. This symptomatic overlap is where diagnostic clarity often starts to erode.

Anxiety can produce physical changes via hyperadrenergic responses—leading to tachycardia, tremors, and dizziness—that resemble autonomic instability. Panic disorder, in particular, can present with sudden heart rate spikes, shortness of breath, and presyncope.

So when a young woman walks into the clinic complaining of fatigue, palpitations, and feeling faint, the question becomes:

Is this an issue of misfiring autonomic control—or is it a manifestation of hypervigilance and stress-related somatization?

Evidence from the Literature: Are We Overdiagnosing?

Several studies have attempted to dissect the true overlap between psychiatric comorbidities and POTS-like presentations. The results, though not conclusive, are thought-provoking.

• A significant portion of patients diagnosed with POTS—between 30% to 40%—also fulfill criteria for anxiety or depressive disorders.
  
  
• Behavioral therapies such as CBT and physical reconditioning have yielded symptom improvement in subsets of patients initially labeled with POTS.
  
  
• Tilt-table testing, while often used to confirm diagnosis, may yield false positives in patients with high anxiety, due to heightened sympathetic tone during the procedure.
  

This isn’t to suggest that POTS is fabricated or purely psychological. But it underscores the clinical need for comprehensive evaluations and cautious interpretation of borderline findings.

Why Young Women? Gendered Nuance in Medicine

POTS disproportionately affects females, and biologically, this is not surprising. Hormonal differences, particularly the role of estrogen in vascular tone, may influence autonomic regulation. Structural factors, such as smaller cardiac size and lower baseline blood volume, may also play a role.

But beyond biology lies bias.

Young women with vague or multisystem complaints are often met with skepticism. They may be labeled as “just anxious” or conversely, quickly given a diagnosis like POTS to avoid diagnostic uncertainty. This creates two equally harmful paths:

• Overdiagnosis due to premature labeling
  
  
• Dismissal of genuine autonomic dysfunction as psychosomatic
  

Clinicians must be aware of both possibilities.

Red Flags for Misdiagnosis: When POTS Might Not Be the Culprit

Certain clinical features should raise doubt about the validity of a POTS diagnosis:

• Symptoms vary dramatically from day to day, or even hour to hour
  
  
• Orthostatic vitals are inconsistent or fail to meet POTS criteria on repeated measurement
  
  
• Heart rate increases are not sustained or reproducible
  
  
• History includes multiple medically unexplained syndromes
  
  
• Significant symptom relief follows psychiatric intervention or deconditioning reversal
  

In these cases, alternative diagnoses or functional overlays should be considered. Unnecessary use of the POTS label may shift focus away from effective interventions, such as psychotherapy or lifestyle modification.

Harm of Overdiagnosis: It’s More Than Semantics

Overdiagnosis carries consequences that are not benign. Several risks emerge when the POTS label is applied without meeting strict criteria:

1. Medicalization of Distress
   Patients may adopt a chronic illness identity and become trapped in a cycle of appointments, tests, and interventions, often with little symptom relief.
   
   
2. Missed Psychiatric Diagnosis
   Failing to recognize underlying anxiety can prevent patients from receiving proven treatments like CBT or pharmacotherapy, prolonging their suffering.
   
   
3. Polypharmacy and Side Effects
   Medications such as beta blockers or vasoconstrictors may be prescribed empirically. In patients without true autonomic pathology, these drugs can cause harm.
   
   
4. Reduced Functionality
   The diagnosis may discourage physical activity, perpetuating deconditioning—a factor that may be contributing to symptoms in the first place.
   

Is It Ever Psychogenic? The Concept of Functional POTS

Some clinicians have proposed the term "functional autonomic disorder" to describe patients with POTS-like symptoms but no clear structural or biochemical abnormality.

This model doesn't deny the symptoms—it reframes them. Just like functional gastrointestinal disorders or functional seizures, the suffering is real but not rooted in classic pathology.

In such cases:

• The autonomic system is responsive but hyper-reactive
  
  
• Stress, trauma, and learned bodily vigilance may reinforce the cycle
  
  
• Mind-body therapies such as pacing, mindfulness, and graded exposure can be transformative
  

This framework empowers patients by moving away from a disease-based identity and toward functional recovery.

So How Should We Approach These Patients?

The optimal clinical approach is one of cautious validation paired with rigorous assessment. Best practices include:

• Comprehensive autonomic testing (including repeat evaluations to confirm consistency)
  
  
• Detailed psychosocial history with attention to stressors, trauma, and personality traits like perfectionism
  
  
• Screening for nutritional deficiencies and comorbid medical conditions (e.g., anemia, thyroid dysfunction, B12 deficiency)
  
  
• Functional medicine considerations, including overlap with chronic fatigue syndrome, fibromyalgia, or central sensitization
  
  
• A collaborative discussion with the patient about the nature of their symptoms and the uncertainty involved in labeling
  

Most importantly, clinicians must avoid binary thinking. It is rarely “all in the mind” or “purely physical.” Nuance is essential.

Conclusion: Yes, We Might Be Overdiagnosing—But It’s Complicated

The increasing frequency of POTS diagnoses in anxious young women is not just a trend—it’s a reflection of evolving awareness, diagnostic complexity, and sometimes, confusion between psychiatric and autonomic phenomena.

While true POTS exists and can be disabling, many patients fall into a gray zone of functional dysregulation, somatization, or mixed etiologies. Mislabeling can cause real harm—delayed therapy, overmedication, and the entrenchment of a passive illness identity.

The clinical task, therefore, is to stay grounded in evidence without dismissing patient experiences. Empathy must coexist with diagnostic rigor. In the balance lies responsible, ethical, and effective care.