When the Body’s “Autopilot” Goes Off Course: Understanding POTS, Hypermobility, ADHD and the Complexity of Dysautonomia

“My heart races when I stand up.”

“I feel exhausted after a shower.”

“I get dizzy, however, all my tests are normal.”

“My body feels like it is constantly working too hard.”

These are experiences commonly described by people living with Postural Orthostatic Tachycardia Syndrome (POTS), a form of dysautonomia that is increasingly recognised in people with hypermobility conditions such as Hypermobile Ehlers-Danlos syndrome and Hypermobility Spectrum Disorder.

As a physiotherapist working with people with hypermobility, one of the most important lessons I have learnt is that these conditions rarely exist in isolation. The relationship between connective tissue, the autonomic nervous system, fatigue, pain, neurodivergence and medications can create a complex clinical picture that requires a much more individualised approach.

What is POTS?

Our autonomic nervous system is responsible for many processes we do not consciously control: regulating heart rate, blood pressure, digestion, temperature control and blood flow. When we stand up, gravity causes blood to shift towards our legs and abdomen. A healthy nervous system automatically responds by tightening blood vessels, increasing heart rate slightly and maintaining blood flow to the brain. In people with POTS, this automatic response does not work effectively.

Standing can trigger an excessive increase in heart rate, often accompanied by symptoms such as dizziness, light-headedness, fatigue, brain fog, exercise intolerance, palpitations, nausea or feeling faint. For many people, symptoms are worse with prolonged standing, heat, dehydration, illness, poor sleep or after exertion.

Why is POTS commonly seen with hypermobility?

The connection between hypermobility and dysautonomia is an area of growing research.

People with hEDS and HSD often have differences in connective tissue, which is found throughout the body, including blood vessel walls. One theory is that increased vascular elasticity may contribute to difficulties with blood pooling in the lower limbs when upright. If blood vessels do not constrict effectively, the body may compensate by increasing heart rate to maintain circulation to the brain and vital organs.

However, the relationship is not simply mechanical.

Many people with hypermobility also experience chronic pain, fatigue, deconditioning, gastrointestinal symptoms, altered sensory processing and immune-related symptoms, all of which can influence autonomic function. This is why two people with the same diagnosis may experience completely different symptoms. The medication conversation: when treatment can become complicated

One of the more challenging aspects of managing dysautonomia is understanding that medications can influence the autonomic nervous system. Medications are often prescribed for very valid reasons. For example, amitriptyline (a tricyclic antidepressant) is commonly used in low doses for chronic pain, migraine prevention, sleep difficulties and nerve-related pain.

However, amitriptyline also has anticholinergic effects, meaning it can influence parts of the autonomic nervous system involved in heart rate regulation, sweating, temperature control and blood pressure responses. For some individuals, these effects may worsen symptoms associated with dysautonomia, such as increased heart rate, dizziness, heat intolerance, constipation or difficulty regulating blood pressure. This does not mean amitriptyline is inappropriate or unsafe. Many people benefit significantly from it. Rather, it highlights an important clinical point:

In people with POTS or suspected dysautonomia, medications need to be considered as part of the bigger picture. A symptom such as fatigue, dizziness or brain fog may have multiple contributing factors—including the underlying condition, sleep, pain, autonomic dysfunction, hydration, activity levels and medication effects. Understanding this complexity helps clinicians avoid oversimplifying symptoms.

When ADHD enters the picture

The relationship between hypermobility, POTS and ADHD adds another layer of complexity. Research increasingly suggests an overlap between hypermobility-related disorders, autonomic dysfunction and neurodevelopmental conditions such as ADHD. For someone with ADHD, managing POTS can be particularly challenging.

ADHD can affect routines, consistency and self-monitoring. Remembering regular hydration, salt intake (when medically appropriate), pacing strategies, compression garments or a graded exercise program may require significant executive functioning. At the same time, some ADHD medications can influence heart rate and blood pressure, which means treatment decisions need to be individualised and monitored carefully in people experiencing autonomic symptoms.

This does not mean people with ADHD cannot use stimulant medication or that medications are automatically problematic. It means clinicians need to consider the whole person rather than viewing each symptom separately. A person is not simply a diagnosis of ADHD, a diagnosis of POTS or a diagnosis of hypermobility. They are a person whose nervous system, connective tissue, environment and treatment plan all interact.

Why physiotherapy matters in POTS and hypermobility

Physiotherapy is often an important part of multidisciplinary management for POTS and hypermobility.

However, rehabilitation needs to be carefully tailored. Traditional exercise advice of “just exercise more” can be unhelpful and sometimes discouraging for someone who becomes dizzy, exhausted or symptomatic with upright activity. Instead, rehabilitation often focuses on gradually improving cardiovascular tolerance, muscle strength, circulation and confidence with movement.

This may include:

• starting with positions that reduce symptoms, such as lying or seated exercise

• gradual progression towards upright activity

• strengthening the lower limbs and trunk to support circulation

• pacing strategies to avoid boom and bust cycles

• education about symptom responses and recovery.

The goal is not to push the nervous system into overload. The goal is to help the body develop greater resilience.

The importance of listening to the whole story

POTS in the context of hypermobility is a perfect example of why modern healthcare needs to move beyond single-system thinking.

A person may present with dizziness, but the cause may involve autonomic regulation, medication effects, hydration, sleep, pain, stress, deconditioning or hormonal factors.

A person may present with fatigue, but the answer may not simply be “exercise more”.

A person may present with brain fog, but the explanation may involve poor sleep, autonomic dysfunction, ADHD, pain or medication effects.

The answer is rarely one single factor.

Moving towards personalised care

For people living with hypermobility, POTS and neurodivergence, healthcare can sometimes feel like navigating a maze of disconnected symptoms. The future of care requires collaboration between doctors, physiotherapists, psychologists, occupational therapists and other healthcare professionals to understand how all these pieces fit together.

The most effective treatment plans are not built around a diagnosis alone. They are built around the individual. Because when the autonomic nervous system is struggling to regulate the body, the solution is not simply to “push harder”.

It is to understand the system, and help it work better.

References

Raj SR, Guzman JC, Harvey P, et al. Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS). Canadian Journal of Cardiology. 2022.

Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. Journal of Internal Medicine. 2019.

Grigoriou E, Boris JR, Dormans JP. Postural Orthostatic Tachycardia Syndrome (POTS): association with Ehlers-Danlos syndrome and hypermobility. Clinical Reviews in Bone and Mineral Metabolism. 2020.

Cederlöf M, Larsson H, Lichtenstein P, et al. Nationwide population-based cohort study of psychiatric disorders in individuals with Ehlers-Danlos syndrome or hypermobility syndrome. BMC Psychiatry. 2016.

Arnold LM, et al. Tricyclic antidepressants and autonomic side effects: clinical considerations in chronic pain management. Pain Medicine.

If you'd like personalised support with rebuilding physical capacity and movement after changes in your symptoms, Physiotherapist Blanche Leung consults at BJC Health. Book an appointment here