Can Health Anxiety Manifest Physical Symptoms?
Yes, health anxiety definitively manifests physical symptoms through direct physiological mechanisms, and these physical manifestations are well-documented across multiple clinical guidelines as core features of anxiety disorders.
Direct Physical Manifestations of Anxiety
Anxiety produces genuine physical symptoms through physiological pathways, not merely imagined complaints. The American Academy of Child and Adolescent Psychiatry guidelines explicitly recognize that anxiety can cause physical/physiological pathology secondary to anxiety symptoms 1.
Common Physical Symptoms Include:
- Cardiovascular: Racing heart rate, chest pain or discomfort, palpitations 1, 2
- Respiratory: Shortness of breath, feeling of choking 2
- Gastrointestinal: Nausea, abdominal distress 2
- Neurological: Dizziness, paresthesias (numbness or tingling), feeling lightheaded 2
- Thermoregulatory: Sweating, chills or hot flushes 2
- Musculoskeletal: Muscle tension, trembling 1, 3
- Systemic: Fatigue, restlessness, sleep disturbance 1, 3
The Physiological Mechanism
People can experience the physiological and somatic consequences of anxiety (racing heart, tight chest) without recognizing the experience emotionally 1. This phenomenon has been described as "panic without panic" or alexithymia 1. The fight-or-flight response activates the sympathetic nervous system, producing measurable physical changes regardless of whether the person consciously identifies as feeling anxious 1.
Clinical Impact and Outcomes
The American Society of Clinical Oncology guidelines document that heightened anxiety is directly associated with increased adverse effects, more physical symptoms, and poorer physical functioning 1, 2. This relationship affects morbidity and quality of life significantly 2.
Specific to Health Anxiety:
Health anxiety patients experience:
- Restlessness or feeling keyed up 3
- Easy fatigability 3
- Difficulty concentrating 3
- Irritability 3
- Muscle tension 3
- Sleep disturbance 3
These symptoms persist for at least 6 months and are disproportionate to actual medical risk 3.
Critical Diagnostic Considerations
The Bidirectional Relationship
The relationship between anxiety and physical symptoms is bidirectional 2. The American Academy of Child and Adolescent Psychiatry guidelines specify that anxiety can:
- Contribute to physical illness 1
- Result from physical illness 1
- Be a reaction to physical illness and/or treatment 1
Rule Out Medical Causes First
Before attributing physical symptoms to anxiety, you must rule out medical conditions 1, 2. Medical masqueraders include:
- Hyperthyroidism 1
- Cardiac arrhythmias and valvular disease 1
- Hypoglycemia 1
- Pheochromocytoma 1
- Caffeine excess 1
- Medication side effects 2
Laboratory testing (thyroid function, glucose) should be completed if suggested by signs and symptoms 1.
Assessment Approach
Use Validated Instruments
The Hospital Anxiety and Depression Scale (HADS) is particularly useful because it excludes somatic symptoms that may be confounded by medical illness; scores ≥8 on either subscale indicate caseness 1, 2. This prevents the circular problem of counting anxiety-induced physical symptoms as evidence against anxiety 1.
For generalized anxiety, the GAD-7 is recommended, with scores ≥10 indicating moderate anxiety requiring comprehensive evaluation 1, 2.
Management Strategy
First-Line Treatment
SSRIs (such as sertraline) and cognitive behavioral therapy are first-line treatments for anxiety disorders with physical manifestations 2. CBT has demonstrated large effect sizes (d = 1.01) specifically for health anxiety 4.
Addressing Physical Symptoms Directly
Occupational therapy guidelines recommend:
- Education about the physiological process of anxiety and its physical impact on the body 1
- Breathing techniques 1
- Progressive muscle relaxation 1
- Grounding strategies 1
- Regular cardiovascular exercise 1
Critical Pitfalls to Avoid
Do Not Dismiss Physical Symptoms
Do not dismiss physical symptoms as "just anxiety" without proper medical workup 2. This is the most dangerous error in clinical practice. The bidirectional relationship means that:
- Real medical conditions can coexist with anxiety 1
- Anxiety itself produces measurable physiological changes 1, 2
- Missing a medical diagnosis while attributing symptoms to anxiety can lead to serious morbidity and mortality 2
Screen for Comorbid Depression
Approximately 31% of patients with anxiety disorders also have major depressive disorder 2, 3. Always screen for both conditions using validated instruments 2.
Recognize Hypersensitivity
Many patients with anxiety report hypersensitivity to touch, light, sound, and movement 1. This sensory over-responsiveness can become a maintaining factor, resulting in avoidant behaviors that limit functional activities 1.
Long-Term Considerations
Health anxiety accounts independently for high disability and service use 5. People with health anxiety are more likely to be high-frequency attenders to general practice (OR = 2.0) and specialist medical services (OR = 2.4) 5. It is important to recognize and treat health anxiety, even when coexisting with other conditions, to prevent high disability burden and excessive service use 5.