Anxiety can make us question what physical sensations are “real” versus “in our heads.” With mental and physical illness so closely tied, they often fuel each other and become inseparable.
Note: An abbreviated version of this article first appeared on MindBodyGreen (read it here). This expanded article offers an in-depth look at the role of anxiety in physical illness.
In September 2020, I was adapting to the new COVID reality. Living mostly in isolation, I managed our three young boys in online learning while my husband spent long hours working as a doctor at a local hospital. There didn’t seem to be any light on the horizon. Like many Americans, I was dealing with the physical and mental consequences of chronic stress and anxiety.
The garage gym became my only sanctuary.
To manage our physical and mental health during the pandemic, we pieced together some gym equipment. Exercise was the only way I actively managed my anxiety. Working out provided a break from my mom-turned-teacher responsibilities. Plus, my bedroom was recently turned upside down during what I thought was to be a small, contained, five-week bathroom renovation. There was an abundance of stress in my household, and the garage was an escape.
Heart flutters turn into anxiety
On a September afternoon, I put my earbuds in and hopped on the stationary bike. That’s when the heart palpitations started. At the first pedal stroke my heart fluttered. It was like a fish flopping around in my chest but passed quickly. It was a blip and I needed to burn some calories, so I ignored it and pedaled on.
Ignoring a heart flutter is no small feat for someone who suffers from anxiety. Monitoring my body for signs of alarm was my anxiety’s full-time job. I was determined to push forward.
Then, there was another skip in my chest, as if my heart were pumping bubbles of air instead of blood. One heart palpitation is normal, no need for alarm. But I was starting to feel the palpitations with increasing frequency.
It scared me. A few palpitations, I could ignore. Several palpitations, my anxiety would not ignore. There was no going back. Cue the alarm bells. Flip the siren lights. My anxiety escalated. Little did I know it wouldn’t return to its baseline for a year.
How physical and mental illnesses blur
I disengaged from the bike, left on my cycling shoes, and click-clacked through the house until I found my husband, Andrew. He instructed me to lay down, checking my pulse. I was relieved to be married to a doctor with such calm composure, a stark contrast to my fluctuating levels of anxiety. He could feel the palpitations in the pulse on my wrist and had me rest until they stopped about five minutes later.
It may sound weird, but it was a relief to have him confirm that he felt the palpitations too. It’s not in my head! Anxiety is a sneaky little bitch in this regard. She’ll convince you something is wrong and in the next second, convince you that thinking something is wrong is paranoia and crazy talk.
“Probably stress,” he said.
These episodes continued to happen for over a week while I brushed them off as stress and anxiety. I noticed them again one morning while leaning over in the shower to shave my legs, but they stopped by the time I finished rinsing off. I walked through the house wrapped in a towel, dripping wet, to tell my husband about it. At this point, I was becoming scared, and my overall anxiety was escalating. But the palpitations had stopped, and I just sounded like a hypochondriac.
It was starting to be a pattern: my heart palpitations made me anxious. The anxiety increased the heart palpitations. The more flutters I felt, the more I thought something was wrong with my body. This fueled the anxiety, which fueled the monitoring of my body, which made me feel paranoid. Around and around I went in a vicious cycle between physical and mental symptoms.
When the physical symptoms became overwhelming
Later that morning, our dog, Scooby, threw up on the carpet. It was in my middle child’s bedroom, which was doubling as his classroom. As my son, Ike, continued to interact with his first-grade teacher, I could be seen in the background cleaning the carpet. Kneeling on all fours, my heart started to flutter again. It was uncomfortable this time, a stronger flutter and a slower recovery.
The anxious thoughts took over. I got up and walked to the laundry room to distract myself. For years, I used cognitive behavioral therapy (CBT) techniques to manage these anxious thoughts. One technique was to move around, another to throw my focus into a different activity. Walking to the laundry room for cleaning supplies was an attempt to distract from the anxiety, but the anxious thoughts were winning.
For more on the cognitive-behavioral approach to anxiety and how mindfulness can offer a better alternative, read this!
Don’t be anxious. Don’t be anxious. Don’t. You’re making it worse. You’re fine.
I was bossing myself around, but unable to comply. The next time I bent over to clean, my heart fluttered and raced again. This time it didn’t stop. My internal alarm bells escalated. It felt like something was wrong, but I kept second-guessing myself. Was this all my anxiety?
I sat down on our couch, heart racing as if I were doing an aerobics step class. Diagnosed with anxiety two decades ago, I’m no stranger to an elevated heart rate and tightness in my chest. I tried all the usual cognitive behavioral techniques to calm down, but the sensations persisted. Short of breath and thinking I might drop dead of a heart attack, I tried to keep my kindergartner on task as he “attended” class at the child-sized table just behind the couch.
It felt like my heart was racing and skipping periodic beats as I phoned my husband, breathless and teetering on panic. I worried about the entire Kindergarten class watching me pass out on Zoom and questioned if my oldest son would be able to call 911 like we had practiced in the past. My anxiety exploded.
Andrew, like me, assumed I was just having a panic attack, but the consistent flutter gave him pause. The only safe option was to go to the hospital. Despite having a nearby, supportive family, this wasn’t exactly easy during the pandemic, but I was lucky. Within thirty minutes both my mom and mother-in-law were in my family room. Still unvaccinated, I worried about exposing them to our germs, especially since my husband was treating COVID patients regularly.
I left the boys at their respective desks, masked up to protect “Gramsy.”
More physical symptoms, more anxiety, more doubts
On the drive, my heart continued to race and skip beats regularly. This only made my anxiety worse. My chest felt more constrained with each mile, and the thirty-minute drive felt suffocating. I could hardly talk, other than to say, “Something is really wrong.” My mom was forced to drop me at the Emergency Room curb due to COVID restrictions. As I walked up to the automatic glass doors, I knew she would be driving away, crying, feeling helpless.
Lightheaded from a racing heart, I couldn’t stand as I signed in. The lady behind the desk was kind, not at all the unsympathetic, overworked ER desk clerk portrayed in movies. She immediately got me a wheelchair and rubbed my back as I burst into tears.
“I’m just so anxious,” I tried to explain. I felt embarrassed that I might be responsible for my physical symptoms, still blaming it on my anxiety.
Due to COVID, there were few patients in the ER. The staff wheeled me into the triage area and immediately hooked up monitors. Questions were asked, blood was taken, and the monitors beeped on. As I laid there, my body started to calm down and I could feel my heart rate slowing down.
I started to doubt myself even more, and wondered what all anxious people consider from time to time. Is this all in my head? I sensed the nurses and doctor were growing skeptical as well. Not necessarily because they were unsympathetic, but because they see this all the time. Anxiety has a nasty way of making people think they’re dying. A lot of people enter the ER thinking they must be having a heart attack only to leave with the unfortunate and undeserved shame and embarrassment of an anxiety diagnosis.
After a while, I needed to go the bathroom and the nurse unplugged the monitors to set me free. I was shaky and weak from the stress of the ordeal. I again felt obligated to blame myself and my anxiety for the hospital visit. But after getting up off the bed and crouching down in the bathroom, I felt the flutters return. I was breathless again as I returned to the hospital bed. It was unmistakable.
Something was happening, and it wasn’t just my anxiety.
The doctor came in to discuss my blood tests. “Everything looks fine,” she shrugged.
I knew she was going to send me home without any answers, so I spoke up. At the risk of sounding “crazy” I told her about the trend I noticed. When I bent over, (to get on the bike, shave my legs, clean the carpet, go to the bathroom) my heart fluttered and I felt breathless. After a while, it would return to normal.
She looked puzzled and asked me to demonstrate. The monitors were left on as I crouched down towards the hospital’s beige, vinyl floor. On cue, my heart rate jumped as if I were running in place. The doctor promptly ended our experiment and had me lay back down. After a while, my heart rate was fine again.
The doctors continued to await more results, watch me on monitor, and consult with each other. What was happening to me was a mystery. There was a shift change, and the night doctor came in to discuss my plan of care. He reassured me everything looked fine in terms of immediate threat. They felt I could go home and follow up with a cardiologist in the future.
Ummm. Cue the worried, anxious mind.
I felt panicked at the thought of going home without an answer. Visions of me passing out while schooling the kids or having a heart attack while showering raced through my mind. Plus, I didn’t have a cardiologist. I was an otherwise healthy 40-year-old. My anxiety couldn’t handle one more stressor, especially a big one like this.
I was lucky the ER doctor displayed compassion, giving me a second option. I could be admitted to the hospital overnight, remain on a heart monitor, and consult with cardiology in the morning. The anxiety I felt regarding going home to battle this mystery on my own, far outweighed my anxiety regarding staying in a hospital full of COVID patients. I opted to stay for monitoring.
A physical diagnosis
Early the next morning, I had an echocardiogram and saw a cardiologist. Immediately, he suspected a diagnosis and had the nurse perform an experiment, what he referred to as a poor man’s table tilt test. A more formal table tilt test involves strapping a patient to a table and maneuvering their body through tilted positions to see how it affects heartrate and blood pressure.
I laid down for twenty minutes, sat up, and then immediately stood up, all while on monitor. Like before, I was fine until I stood up. The pressure built up in my chest, my breathing accelerated, and the heart monitor spiked. I talked like I was doing jumping jacks.
This proved the doctor’s suspicions. I was diagnosed with postural orthostatic tachycardia syndrome, or POTS. This syndrome causes an elevation in heart rate with big postural changes, like bending over and standing up. While we take the simple act of standing up for granted, a lot goes into coordinating this movement internally, including the maintenance of blood pressure and heart rate.
Generally, POTS affects blood flow when moving from a reclining to standing position. Common symptoms include lightheadedness, fainting, and an uncomfortable, rapid increase in heartbeat. As a “syndrome,” it involves multiple symptoms which all occur on a continuum. Thus, my POTS experience can be quite different from another patient’s.
“It’s not dangerous, just annoying and uncomfortable,” the doctor explained.
He put me on blood pressure medicine to prevent my heart rate from getting too high. I was given a list of lifestyle changes to decrease episodes, like staying hydrated, eating enough salt to keep my body in balance, and doing cardio. Perhaps most important of all, the cardiologist encouraged me to better manage my stress, which exacerbates both mental and physical illnesses.
No one knows for sure why I got POTS and there is no cure. For some, it occurs post-viral infection. My doctor anecdotally reported an increase in POTS patients as a result of COVID infections. For others, it occurs after a serious infection, pregnancy, or trauma. And for many, it is a mystery.
The interplay between physical illness and anxiety
It’s been almost a year since my POTS diagnosis and I’m feeling a lot better. With medication, my POTS is well controlled. However, the associated anxiety took quite a while to extinguish. The experience of an uncontrolled heart rate and chest flutters horribly exacerbated my already COVID-heightened anxiety.
My physical body had broken down and my mind felt like a raw nerve. For months, everything felt like a threat. Being left alone with the kids, working out in the garage, driving alone or with passengers all made me anxious in a way I never experienced prior to the diagnosis. The physical illness had fully exposed the mental illness.
In fact, POTS is frequently misdiagnosed as anxiety. It’s so hard to tease apart some of the obvious symptoms that many POTS sufferers go years without a proper diagnosis. And yet, my anxiety also helped me get diagnosed pretty quickly. Thankfully, I am extremely in tune with my body (probable due to my anxiety) and was able to make the connection between bending over and a racing heart.
I actually considered myself lucky in this regard. My time between onset and diagnosis was short partly because my symptoms came on so acutely. In a matter of one week, I went from having a couple heart flutters to a racing heart every time I stood up. In addition, I was lucky to go to a hospital that took it seriously enough to admit me so I could see a cardiologist. Otherwise, I would’ve suffered for a month or more while I waited for a new patient appointment. I was lucky the cardiologist I saw knew immediately how to confirm his suspicions and which medicine would control my symptoms.
Unfortunately, this is not where my discussion of POTS and anxiety gets tied up with a pretty bow.
Another diagnosis, more anxiety
A few nights after being discharged from the hospital, I crawled into bed and felt motion sick. It was as if the room were spinning, reminiscent of those nights in college when I had too much to drink. It was so bad I thought I was going to throw up and had to take anti-nausea medicine just to sleep. The next day it happened again. I was dizzy and motion sick despite standing still.
I assumed the dizziness that plagued me for days was either from the newly diagnosed POTS or the necessary blood pressure medication. It took pleading with the cardiologist and a trial of a different medication (which didn’t work, caused my POTS to flare, and ruined a family vacation), to realize it wasn’t the medicine. My primary care doctor attributed it to allergies, and I started a daily regimen of antihistamines to no avail.
Again, I questioned whether my stress and anxiety levels were to blame. Was this in my head?
The dizziness continued to wax and wane for months with no explanation. I endured multiple doctor appointments, an MRI of my head, a consult with an ENT (ear, nose and throat) doctor, a dizzying test of my inner ear known as a VNG (Videonystagmography), ongoing vestibular rehab therapy, a neurologist appointment, and finally a referral to a vestibular neurologist before getting a diagnosis.
I was finally diagnosed with vestibular migraines, and it all makes sense now.
Although I’m in a better spot than at onset, both the POTS and vestibular migraines truly exacerbated my anxiety. Before my medication was figured out, my heart rate would jump to 140 when I got up to use the bathroom in the middle of the night. Add in my intermittent, unexplained dizzy spells and it was a perfect storm. For an already anxious person, these episodes were terrifying. I was bracing for panic every time I got up.
As for most of us, the long-term stress of the pandemic had already taken a toll on my mental health, but the out-of-control heartrate and dizziness were the final straw. Instead of being anxious periodically, I was anxious always. The anxiety and POTS became intertwined, and the dizziness added confusion. For a while it was difficult to tell if my heart rate was elevated because I was anxious, experiencing a POTS episode, or having a dizzy spell.
That’s how I ended up with one illness fueling another. My always smoldering anxiety turned into a full-blown dumpster fire and stayed there for months. It was weeks before I could separate the POTS symptoms from the anxiety symptoms. The POTS symptoms were controlled with proper blood pressure medication. Yet, the pressure in my head and resulting motion sickness persevered. The resulting anxiety remained my biggest challenge and took months to return to its normal baseline.
This illustrates the weight of the mind-body connection and underscores the important role mental health plays in physical health.
For more on the the mind-body connection, read this!
Prioritizing mental health
I knew something had to change for me to better control my stress and anxiety. It was up to me to learn to deal with my anxiety in a way I hadn’t in the past. Going back to my counselor who focuses on mindfulness and the mind-body connection, I made major changes in my approach to mental health. I committed to creating a calmer life.
Every day I try to do something, even if just for five minutes, to calm my anxious mind. All the while, I’ve been chronicling my journey on this blog and working to create a community for others like me. The writing is cathartic. I’m still a work-in-progress but am so much better than before – mentally and physically.
The chaos of the storm has subsided and I’m excited for the next phase of reconstruction.
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Oh wow, this was such a fascinating read. I’m so sorry you went through all that. I bet a lot of other people can relate to being confused between anxiety-created symptoms and other symptoms. Your story really sheds light on the topic!!
Thank you for the support!