Manifestations of Anxiety Explaining Tachycardia and Hypertension in a Patient with POTS

Background: Postural orthostatic tachycardia syndrome (POTS) is characterized by autonomic dysfunction causing orthostatic intolerance. Psychiatrists should be aware of POTS because the symptoms exhibited by patients, such as tachycardia, tremulousness, fatigue, and abdominal pain, may be misinterpreted as a primary anxiety disorder, in particular panic disorder, or even as one of the somatoform disorders. Objective: The authors review literature on POTS and highlight a case of a 23-year-old female with hyperadrenergic POTS, admitted for a recurrent tachycardiac and hypertensive crisis. Method: The authors present a case report of history, diagnosis, and treatment. After being treated in the medical intensive care unit, the patient was referred to the internal medicine psychiatry service (med-psych) for management because members of her medical team hoped her symptoms would be better treated by managing her anxiety. Results: The patient had a history of multiple referrals for anxiety in spite of a known diagnosis of POTS. She also had serum catecholamines showing a normal norepinephrine while supine and comfortable, but highly elevated during a tachycardiac and hypertensive crisis. Conclusion: This case highlights the need for a broader understanding of POTS. Patients with this syndrome have a primary autonomic dysfunction driving their symptoms, though anxiety can be a component. In addition, serum catecholamines drawn while supine and comfortable may lead to inaccurate judgments as to the etiology of the patients’ tachycardia and should only be interpreted in conjunction with catecholamines drawn while upright or during an orthostatic crisis.