POTS: a racing heart, a dizzy head and a nervous system on alert.

Standing up should be nothing. In POTS it is an event. Understanding why the alarm fires so easily is the first step to turning it down.

This page is about understanding the condition and the role the brain and nervous system can play in it. It is not a diagnosis. Your own clinicians know your case.

What POTS is, and why diagnosis comes first

Postural orthostatic tachycardia syndrome, or POTS, is a disorder of the autonomic nervous system, the part that runs heart rate, blood pressure, digestion and temperature without you thinking about it. In POTS, standing up triggers an exaggerated rise in heart rate, by 30 beats per minute or more in adults, or to over 120, within ten minutes of standing, without a fall in blood pressure. The usual symptoms are dizziness, light-headedness, a pounding or racing heart, fatigue, shakiness, nausea, brain fog, and sometimes fainting.

POTS is diagnosed with a standing test or a tilt-table test, after other causes of a fast heart rate have been excluded: dehydration, anaemia, thyroid problems, heart rhythm disorders, medication effects and deconditioning after illness or bed rest.

Standard management includes fluids and salt, compression garments, a carefully graded exercise programme, and sometimes medication to steady heart rate or raise blood volume.

The neuroplastic contribution

Neuroplastic symptoms are real, physical symptoms produced by learned pathways in the brain and nervous system, a sensitized alarm system, rather than by ongoing damage or disease in the body. They are not imaginary and not "all in your head". Because the brain can change, they are reversible.

The ATNS Index of Neuroplastic Symptoms takes a strong position on POTS: neuroplastic symptoms are often a significant contributing factor and should be assessed. That is stronger than for many conditions in the index, and it reflects what POTS is. The autonomic nervous system is the body's alarm wiring. A racing heart, a surge of adrenaline, a dizzy, shaky, foggy feeling: these are the physical outputs of a threat response. In POTS, that response has become too easy to trigger.

Several things keep it that way:

• Each frightening episode of dizziness teaches the brain that standing is dangerous, so the next time you stand the alarm fires earlier and harder.
• Constant monitoring of heart rate, often with a wearable, keeps attention locked on the body, and attention amplifies sensation.
• Avoiding standing, exercise and outings deconditions the circulation and reinforces the sense of threat, a version of the fear-avoidance cycle.
• POTS overlaps heavily with other sensitized-system conditions in this index, including dysautonomia, ME/CFS and long COVID.

None of this means POTS is caused by anxiety. It means the same nervous system that produces the heart rate rise also learns, and what it has learned can be unlearned.

What the research shows

A review describing postural tachycardia syndrome as a heterogeneous and multifactorial disorder sets out several contributing mechanisms, from low blood volume and nerve changes in the legs to an overactive sympathetic response and deconditioning, and makes the point that many patients have symptoms well beyond standing intolerance. A review of the cognitive and psychological issues in POTS reports that somatic hypervigilance linked to anxiety and depression, and the behavioural amplification that follows, contribute to symptoms becoming chronic, and suggests mindfulness-based approaches may reduce hypervigilance and catastrophic interpretations of symptoms.

A 2023 paper on fear conditioning as a mechanism in POTS goes further. Its authors propose that somatic hypervigilance and anxiety can lead to a fear-conditioned surge of adrenaline on standing, and argue that seeing POTS this way opens the door to cognitive-behavioural approaches. This is a proposal, not a settled finding. The only direct treatment evidence we found is a single-patient case study of behavioural treatment: using exposure and symptom discrimination, the patient learned to tell POTS sensations apart from anxiety and her POTS-related impairment fell markedly. The authors note there are no established guidelines for psychological treatment of POTS.

The honest caveat is that no controlled trial has yet tested pain and symptom reprocessing specifically in POTS, and the physical mechanisms are real and deserve treatment. What the research does show is that how the brain interprets and responds to bodily signals is a major determinant of how disabling POTS becomes, which is exactly the lever a neuroplastic approach works on.

Signs the brain may be part of the picture

• Symptoms are triggered as much by anticipation of standing, crowds or heat as by the posture change itself.
• Dizziness and palpitations flare with stress, poor sleep or emotional upset and ease on calm days.
• You check your heart rate many times a day and feel worse after seeing a high number.
• Your symptoms spread well beyond standing: fatigue, brain fog, gut upset, pain and sensitivity to light or noise.

A solution that addresses it

Pain and symptom reprocessing is an approach aimed at the nervous system's role in symptoms like these. It includes education about neuroplastic symptoms, somatic tracking (noticing a racing heart or a wave of dizziness with calm curiosity rather than alarm), reducing fear and threat around standing and activity, a graded return to upright time and exercise, emotional awareness and expression, and acceptance and commitment skills. It is delivered by trained clinicians and increasingly through digital programs, and it is designed to run alongside your medical POTS plan, including graded exercise and pacing.

Cindra is a daily AI companion built around these approaches, with daily check-ins, short practices and plain-language lessons for people whose symptoms have a neuroplastic component. It supports your practice; it does not treat POTS or replace your cardiologist. If you would like that support, join the waitlist.

What to do next

1. Get a proper diagnosis with a standing or tilt test, and have your doctor exclude anaemia, thyroid disease, heart rhythm problems, dehydration and medication effects.
2. Put the standard measures in place: fluids, salt as advised, compression, and a graded, gentle exercise programme.
3. Ask your clinician whether neuroplastic symptoms are contributing. The index says they often are, so this is a fair question to raise.
4. Start learning how a sensitized alarm system works and practise daily, particularly around the moments you fear most.

Seek urgent care for chest pain, fainting with injury, fainting during exertion, a very irregular heartbeat, or breathlessness at rest. Those need assessment regardless of a POTS diagnosis. See the conditions index for related pages.

This article is for general education and is not medical advice, and it does not diagnose or treat any condition. Persistent symptoms deserve a proper medical assessment to rule out disease or injury before a neuroplastic explanation is considered. If your symptoms are new, changing, or come with red-flag signs such as fever, unexplained weight loss, numbness or weakness, chest pain, or loss of bladder or bowel control, see a clinician promptly.