POTS in Lyme Disease: Why You Feel Worse Standing

Start here: Learn how the nervous system is affected in Lyme disease in our autonomic dysfunction guide.

POTS (postural orthostatic tachycardia syndrome) in Lyme disease is a form of autonomic dysfunction that causes dizziness, rapid heart rate, brain fog, and fatigue—especially when standing. Many patients describe adrenaline surges, feeling worse upright, and symptoms that fluctuate from day to day.

While dizziness is common, this page focuses on POTS in Lyme disease—a specific pattern of autonomic dysfunction that helps explain why symptoms worsen when standing and improve when lying down.

POTS is part of a broader pattern of autonomic dysfunction in Lyme disease, where the nervous system has difficulty regulating heart rate, blood pressure, and circulation.

For a broader overview of symptoms, see our Lyme Disease Symptoms Guide.

What Is POTS in Lyme Disease?

POTS is a condition in which the body has difficulty maintaining stable circulation when upright. When standing, blood flow is not properly regulated, leading to a rapid increase in heart rate and symptoms such as lightheadedness, fatigue, and brain fog.

In Lyme disease, POTS may develop because of inflammation, nervous system disruption, or impaired autonomic regulation.

Published case series have described patients who developed orthostatic intolerance and POTS after Lyme disease, including fatigue, cognitive dysfunction, palpitations, lightheadedness, and near-syncope confirmed by tilt-table testing.

More recent studies suggest that autonomic symptoms are common in post-treatment Lyme disease, although only a subset of patients meet formal criteria for orthostatic tachycardia.

Common Symptoms of POTS in Lyme Disease

• Dizziness or lightheadedness when standing
• Rapid heart rate, especially when upright
• Fatigue and exercise intolerance
• Brain fog or difficulty concentrating
• Palpitations or internal trembling
• Symptoms that improve when lying down
• Near-fainting or fainting episodes
• Heat intolerance
• Weakness and shakiness

These symptoms often overlap with dizziness in Lyme disease, but the key pattern is worsening with standing.

Adrenaline Surges and Hyperadrenergic POTS

Some patients with POTS in Lyme disease describe sudden episodes of adrenaline surges—often referred to as “adrenaline dumps.” Learn more about adrenaline surges in POTS.

These episodes can include:

• Waking with a racing heart
• Sudden surges of adrenaline without a clear trigger
• Shakiness and internal trembling
• Anxiety-like symptoms
• Difficulty sleeping
• Feeling worse after exertion
• Episodes mistaken for panic attacks

These symptoms are not simply anxiety. They may reflect a hyperadrenergic form of POTS in which the autonomic nervous system becomes overactive.

This pattern is frequently misunderstood and may contribute to delayed Lyme disease diagnosis.

Dizziness in POTS and Lyme Disease

Dizziness is one of the most common symptoms in patients with POTS. Unlike classic vertigo, patients often describe lightheadedness, weakness, or a sensation of physical instability.

Symptoms typically worsen with standing, heat, walking, or exertion and improve with lying down.

Some patients also describe feeling disconnected, mentally foggy, or close to fainting when upright.

For a deeper dive into symptom patterns, see dizziness in Lyme disease.

Why POTS Is Often Missed

POTS is frequently overlooked because standard cardiac and neurologic tests may appear normal. Symptoms are often attributed to anxiety, stress, or deconditioning.

However, when symptoms consistently worsen with standing and improve with lying down, they may reflect an underlying autonomic disorder rather than a primary psychiatric condition.

Recognition of orthostatic intolerance may help explain fatigue, palpitations, cognitive dysfunction, exercise intolerance, and fluctuating symptoms that otherwise appear unrelated.

POTS vs Anxiety

POTS symptoms are often mistaken for anxiety because of overlapping features such as palpitations, shakiness, and a sense of internal distress.

Important clues suggesting autonomic dysfunction include:

• Symptoms triggered by standing rather than emotional stress
• Improvement with rest or lying down
• Presence of dizziness, cognitive dysfunction, and exercise intolerance
• Associated neurologic or circulatory symptoms

In some patients, what appears to be anxiety may instead reflect physiologic dysregulation.

POTS in Lyme disease may overlap with broader patterns seen in neurologic Lyme disease.

Clinical Takeaway

Pattern recognition matters. Symptoms that worsen when standing and improve when lying down suggest POTS.

POTS is increasingly recognized as part of the spectrum of autonomic dysfunction associated with Lyme disease.

Published case reports and more recent studies support an association between Lyme disease and orthostatic intolerance, although not all patients with autonomic symptoms meet formal criteria for POTS.

When dizziness, fatigue, palpitations, brain fog, and exercise intolerance occur together, a broader evaluation for autonomic dysfunction may be warranted.

Frequently Asked Questions

Can Lyme disease cause POTS?

Yes. Published case reports and series have described patients who developed POTS after Lyme disease, and more recent studies suggest autonomic symptoms are common in post-treatment Lyme disease.

Why do I feel worse when I stand up?

POTS causes abnormal regulation of circulation when upright, leading to dizziness, fatigue, palpitations, and rapid heart rate.

Can POTS feel like anxiety?

Yes. Palpitations and adrenaline surges may resemble anxiety, but symptoms that worsen with standing and improve when lying down suggest autonomic dysfunction.

Can POTS improve?

Many patients experience improvement with appropriate recognition and treatment of orthostatic intolerance and associated conditions.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

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