The body and the brain keep the score: a data-driven conceptual model linking trauma and postural tachycardia syndrome.

Postural tachycardia syndrome (POTS) is a common, often disabling disorder of autonomic nervous system regulation without a unifying etiological account. Converging evidence suggests infectious, physical, and emotional threats frequently precede onset. We propose a hypothesis-generating model in which POTS may, in some individuals, involve threat-induced, centrally maintained disruption of brain-body communication that may be responsive to neuroplasticity-based behavioral medicine. In this paper, we synthesized multidisciplinary literature and our team's data spanning (a) autonomic and central nervous system responses to threat and trauma, (b) neurological alterations associated with early life stress, (c) links between adverse childhood experiences and posttraumatic stress disorder with autonomic symptom burden, and (d) clinical developments targeting the threat system and autonomic regulation. These data suggest that chronic or overwhelming threat exposure is associated with sympathetic activation, reduced vagal tone, and neuroplastic alterations within cortico-limbic and brainstem networks that parallel POTS features (exaggerated tachycardia, autonomic rigidity, multisystem dysregulation). Preliminary data indicate individuals with higher trauma exposure and PTSD symptoms report greater autonomic symptom severity and poorer global health. Emerging imaging suggests a potentially important role for the periaqueductal gray (PAG), a midbrain hub for autonomic, cardiovascular, motor, and pain responses to threat, which may fail to reset after trauma, leaving the ANS in a sustained escape-mode (fight/flight/freeze) that increases POTS risk. Overall, these findings provide preliminary conceptual support for a unified hypothesis linking trauma, PAG-mediated threat responses, and sustained autonomic dysregulation in POTS, underscoring the importance of trauma-informed care. Behavioral interventions that target threat reduction and autonomic regulation such as rate variability biofeedback and neuroplasticity-oriented psychotherapies, may complement standard medical care. Prospective, longitudinal studies are needed to clarify causal pathways and identify responsive subgroups, and randomized clinical trials are required to establish the efficacy of nervous system-focused behavioral interventions.