When It’s Not Anxiety: Understanding Autonomic Symptoms in POTS, hEDS, and Dysautonomia

For many people living with chronic illness, the most damaging experience is not the symptoms themselves. It is being told those symptoms are “just anxiety.”

While anxiety can absolutely coexist with medical conditions, it is not an adequate explanation for widespread, multisystem dysfunction. In conditions such as Postural Orthostatic Tachycardia Syndrome (POTS), hypermobile Ehlers–Danlos syndrome (hEDS), Mast Cell Activation Syndrome (MCAS), cervical instability, and related forms of dysautonomia, the autonomic nervous system is often the primary driver of symptoms.

Autonomic dysfunction is frequently mistaken for anxiety because both can involve changes in heart rate, breathing, temperature, and adrenaline. The difference is not subtle at a physiological level. One is driven by emotional processing. The other is driven by impaired nervous system regulation.

Understanding that distinction changes everything. Diagnosis improves. Treatment becomes more targeted. And patients stop being dismissed for symptoms their bodies are generating in very real, measurable ways.

When Symptoms Are Labeled “Just Anxiety”

Patients with dysautonomia are often told their symptoms are anxiety-based because the presentation does not fit neatly into one organ system. Symptoms may fluctuate. Testing may appear “normal.” Episodes may come on suddenly.

From the outside, this can look psychological.

From the inside, it feels anything but.

Autonomic dysfunction produces objective physiological changes that affect circulation, digestion, temperature regulation, breathing patterns, and sensory processing. These changes are not voluntary. They are not imagined. And they do not resolve through reassurance alone.

When clinicians lack training in autonomic physiology, anxiety becomes a default explanation rather than a differential diagnosis.

What the Autonomic Nervous System Controls

The autonomic nervous system regulates involuntary processes that keep the body stable in changing environments. This includes:

• Heart rate and blood pressure

• Blood vessel constriction and dilation

• Gastrointestinal motility and secretion

• Temperature regulation and sweating

• Bladder function

• Breathing patterns and CO₂ tolerance

• Hormonal and adrenal signaling

• Sensory gating and threat detection

• Sleep–wake cycling

When autonomic regulation is impaired, symptoms rarely stay confined to one system. Instead, they appear diffuse, episodic, and context-dependent, which is exactly why they are so often misunderstood.

Common Autonomic Symptoms Misdiagnosed as Anxiety

Below are symptoms frequently labeled as anxiety or panic despite having well-established autonomic mechanisms.

Temperature Intolerance

Sudden overheating, flushing, or cold sensitivity without environmental triggers reflects impaired vasoconstriction, vasodilation, and sweat regulation. This is a vascular control issue, not emotional dysregulation.

Gastrointestinal “Storms”

Nausea, bloating, early satiety, constipation, diarrhea, or alternating bowel patterns stem from disrupted enteric nervous system signaling. These symptoms often worsen with upright posture, stress on circulation, or autonomic overload.

Bladder Urgency or Retention

Autonomic imbalance can cause inappropriate detrusor activation or inhibition. Patients may experience constant urgency, incomplete emptying, or sudden retention without infection or structural findings.

Sensory Overload

Light, sound, motion, and visual complexity can provoke dizziness, nausea, or cognitive fatigue. This reflects altered sensory gating and vestibulo-autonomic integration rather than anxiety sensitivity.

Adrenaline Surges (“Adrenaline Dumps”)

Sudden tachycardia, tremors, internal shaking, sweating, or a sense of impending doom often occur while the patient feels emotionally calm. These episodes are driven by sympathetic overactivation and catecholamine release.

Blood Sugar–Like Symptoms in Non-Diabetic Patients

Autonomic dysfunction can alter cortisol, epinephrine, and insulin signaling, producing shakiness, weakness, sweating, and lightheadedness that mimic hypoglycemia.

Pupillary Changes

Unpredictable dilation or constriction of pupils reflects disrupted sympathetic–parasympathetic balance and often contributes to headaches, eye strain, and visual discomfort.

Air Hunger

A persistent need to sigh or take deep breaths is commonly related to dysfunctional breathing patterns, altered CO₂ tolerance, and vagal dysregulation. It is uncomfortable and alarming, but not anxiety-driven.

Asymmetric Blood Flow or Temperature Changes

Cold hands with a warm core, one-sided flushing, or uneven temperature changes indicate impaired peripheral vascular control.

Sleep Disturbance

Nighttime tachycardia, frequent awakenings, vivid dreams, and unrefreshing sleep reflect failure of parasympathetic dominance during rest cycles.

Why Autonomic Symptoms Feel Random — But Aren’t

Autonomic symptoms are often described as unpredictable because the triggers are not always obvious. Posture, hydration status, temperature, sleep debt, hormonal shifts, inflammation, sensory load, and mechanical instability can all influence autonomic output.

When these variables are not accounted for, symptoms appear to come “out of nowhere.” In reality, they follow physiological rules that are simply overlooked in traditional care models.

Conditions Commonly Linked to Autonomic Dysfunction

Autonomic symptoms may be primary or secondary to several overlapping conditions, including:

• Postural Orthostatic Tachycardia Syndrome (POTS)

• Hypermobile Ehlers–Danlos syndrome (hEDS)

• Mast Cell Activation Syndrome (MCAS)

• Cervical or craniocervical instability

• Venous outflow obstruction

• Hormonal and hypothalamic dysregulation

These conditions frequently coexist, amplifying symptom complexity and making reductionist explanations particularly harmful.

How Physical Therapy Approaches Dysautonomia Differently

From a rehabilitation perspective, treating dysautonomia is not about pushing conditioning or “powering through.” It requires respecting nervous system readiness.

Effective physical therapy approaches often include:

• Breath training to improve CO₂ tolerance and vagal tone

• Positional progression to safely reintroduce orthostatic stress

• Autonomic pacing rather than symptom-driven exertion

• Rib cage and pelvic mechanics to support respiration and circulation

• Nervous system regulation strategies to reduce sympathetic dominance

When applied correctly, physical therapy becomes a tool for restoring regulation rather than triggering flares.

Why Accurate Diagnosis and Language Matter

Mislabeling autonomic dysfunction as anxiety has consequences. It delays diagnosis, leads to inappropriate treatment, erodes patient trust, and allows symptoms to worsen through deconditioning and unmanaged instability.

Recognizing autonomic symptoms for what they are does not invalidate mental health. It clarifies physiology. And clarity is what allows patients to receive care that actually matches their biology.

Conclusion

Autonomic dysfunction is not anxiety in disguise. It is a complex, multisystem physiological condition that deserves informed, nuanced care.

When clinicians understand autonomic regulation, symptom patterns stop looking random. When patients are believed, treatment becomes possible. And when the nervous system is addressed directly, people finally begin to stabilize.

The more we replace dismissal with understanding, the fewer patients will be told that their lived experience is “all in their head.”

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References

Cleveland Clinic. (n.d.). Dysautonomia. https://my.clevelandclinic.org/health/diseases/6004-dysautonomia

Dysautonomia International. (n.d.). Dysautonomia information and patient resources. https://www.dysautonomiainternational.org

Ehlers-Danlos Society. (n.d.). Dysautonomia and Ehlers-Danlos syndromes. https://www.ehlers-danlos.com

Johns Hopkins Medicine. (n.d.). Postural orthostatic tachycardia syndrome (POTS). https://www.hopkinsmedicine.org/health/conditions-and-diseases/postural-orthostatic-tachycardia-syndrome-pots

National Institute of Neurological Disorders and Stroke. (n.d.). Autonomic disorders. https://www.ninds.nih.gov/health-information/disorders/autonomic-disorders

Raj, S. R. (2013). Postural tachycardia syndrome (POTS). Circulation, 127(23), 2336–2342. https://doi.org/10.1161/CIRCULATIONAHA.112.144501

Vanderbilt Autonomic Dysfunction Center. (n.d.). Postural orthostatic tachycardia syndrome. https://www.vumc.org/autonomic-dysfunction-center/postural-orthostatic-tachycardia-syndrome

Disclaimer:

This article is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and individualized care.