A patient of mine, a Garden City attorney in her mid-thirties, spent almost a year seeing her internist for what she assumed was a stomach problem. Bloating, nausea before big meetings, occasional chest tightness she was sure was cardiac. Every test came back normal. It wasn’t until her fourth visit, when her doctor gently asked how she was sleeping and whether anything had been stressful lately, that anxiety entered the conversation at all. By the time she got to my office, she’d spent thousands of dollars and months of worry chasing a physical explanation for something her body had been trying to tell her from a different angle the entire time.
This is more common than most people realize, and it’s one of the reasons anxiety goes untreated for so long. We tend to picture anxiety as a mental experience: racing thoughts, worry, dread. But anxiety is fundamentally a physical event before it’s a psychological one, and for a large number of people, particularly high-functioning professionals across Nassau County who are used to pushing through discomfort, the physical symptoms show up loudly while the anxious thoughts stay quiet enough to miss entirely.
How Anxiety Manifests Physically
Gastrointestinal symptoms. Nausea, stomach cramping, diarrhea, or a stomach that simply won’t settle before something stressful. The gut and the nervous system are directly connected through what researchers call the gut-brain axis, which is part of why anxiety so often lands in the stomach first.
Cardiovascular symptoms. A racing heart, chest tightness, or a sensation of pressure that mimics cardiac symptoms closely enough that many people, understandably, go to an emergency room before they ever consider anxiety as the cause. Research on emergency department visits for non-cardiac chest pain has found that a substantial share of these cases involve an underlying panic attack rather than a cardiac event.
Muscular tension and pain. Jaw clenching, tension headaches, and a tight neck and shoulders that don’t resolve with massage or stretching because the tension is being generated continuously by an activated nervous system, not a single physical injury.
Fatigue that sleep doesn’t fix. A specific kind of exhaustion that comes from a body that has been in a low-grade state of alert for weeks or months, even when the person isn’t consciously aware of feeling anxious.
Sleep disruption. Difficulty falling asleep, waking at 3 a.m. with a racing mind, or sleep that technically happens but doesn’t feel restorative.
All of this traces back to the same biological system: the hypothalamic-pituitary-adrenal axis, which governs how the body releases cortisol and manages the stress response. Recent research reviewing this system’s role in anxiety has found that when it stays activated too long, the effects extend well beyond mood, touching sleep, digestion, and cardiovascular symptoms alike.
Why This Gets Missed
Part of the reason this connection gets missed is cultural. Long Island’s professional population, particularly commuters into Manhattan from towns like Mineola, Merrick, and Rockville Centre, often operates in fields that reward pushing through discomfort rather than naming it. Physical symptoms get treated as inconvenient obstacles to work around, not information. It’s also simply easier, and often less frightening, to consider a physical explanation than an emotional one. A stomach problem feels solvable. Admitting you’re anxious can feel like admitting something is wrong with you, rather than something happening to you.
There’s also a generational piece to this on Long Island specifically. Many patients grew up in households where physical complaints were taken seriously and emotional ones were quietly waved off, so a stomach ache gets a doctor’s visit while a racing mind at 2 a.m. gets told to “just relax.” By adulthood, the physical channel is often the only one that feels legitimate to raise, even when it’s not the one actually driving the distress.
The Loop That Makes It Worse
For a meaningful number of patients, this doesn’t stop at “anxiety causes a physical symptom.” Once someone notices a symptom, particularly one involving the heart or breathing, a second layer of anxiety often develops specifically about the symptom itself. A racing heart becomes something to monitor obsessively. A stomach cramp becomes evidence that something more serious is being missed. This creates a loop: anxiety produces a physical sensation, the sensation itself becomes frightening, and that fear produces more of the original physiological arousal, which intensifies the sensation. This pattern, often called the catastrophic misinterpretation of bodily sensations, has been studied extensively as a core mechanism in panic and health anxiety, with research consistently finding that people prone to this loop interpret ordinary physical sensations as far more dangerous than they actually are. Patients often describe this as feeling like their body has turned against them, when what’s actually happened is that normal anxious physiology has been layered with a second, symptom-focused anxiety on top of it.
Research on interoception, the sense of what’s happening inside your own body, has also found that people with higher health anxiety tend to be less accurate, not more, at reading their own internal signals, and more prone to interpreting ambiguous sensations as threatening. That combination, a nervous system generating real sensations and a perceptual bias toward reading them as dangerous, is part of why this loop can feel so convincing from the inside even when nothing medically dangerous is happening.
Breaking this particular loop is often where treatment has to start, because as long as a patient is actively afraid of their own heartbeat or stomach, standard anxiety-reduction techniques tend to get overwhelmed by the more immediate fear of the symptom itself.
What This Looks Like in Treatment
When a patient comes in describing physical symptoms first, the work often starts with education: helping someone understand that their body isn’t malfunctioning, it’s responding accurately to a nervous system that has learned to treat ordinary life as more dangerous than it actually is. From there, we use Cognitive Behavioral Therapy to address the anxious thought patterns feeding the physical response, along with somatic awareness work that helps patients recognize early physical warning signs before they escalate, often by tracking the specific sequence of thought, sensation, and behavior that shows up in a given episode. For patients caught in the symptom-fear loop described above, we work specifically on reducing symptom monitoring and reinterpreting physical sensations accurately, which is different from simply telling someone to stop worrying and requires structured practice.
For patients whose anxiety is rooted in longer-standing patterns, Psychodynamic Therapy and Dynamic Experiential Learning help address what the nervous system is actually protecting against, often something that predates the current stressor by years. Not every patient needs or wants this deeper layer of work; some find real, lasting relief through the practical and somatic tools alone, and that’s a legitimate outcome, not a partial one.
A 2024 review in Current Neuropharmacology examined the gut-brain axis specifically in anxiety disorders, PTSD, and OCD, and found consistent evidence that microbiome-immune-brain signaling contributes to symptom production in these conditions, part of the biological basis for why anxiety so often produces genuine physical distress rather than merely psychological worry.
A Composite Case
Consider a Rockville Centre father in his forties who came to therapy after a cardiologist cleared him twice for chest tightness that appeared almost exclusively during his commute home. Once we started working together, it became clear the tightness correlated precisely with the moment his train pulled into the station and he began mentally transitioning into managing his household’s evening chaos, a pattern common among the high-functioning professionals we see across Nassau County. His body had learned to brace before his mind had consciously registered anything to brace against. Treating the anxiety directly, rather than continuing to investigate it as a cardiac issue, resolved a symptom that four months of testing hadn’t touched.
What Getting Better Actually Looks Like
Recovery from anxiety-driven physical symptoms rarely happens as a single moment of realization. More often, it looks like a gradual loosening: the chest tightness on the train shows up less often, and when it does, it passes faster and provokes less fear. The stomach issues become less frequent and less alarming when they do occur, because the underlying anxiety driving them has actual outlets now instead of only a physical one. Patients often notice the change first in how they respond to a symptom rather than in the symptom disappearing entirely; a racing heart used to mean a spiral of catastrophic thinking, and now it means noticing the sensation, naming it accurately, and letting it pass. That shift, from fear of the body to a working relationship with it, is usually the clearest sign that treatment is taking hold.
When to Take This Seriously
Physical symptoms should always be medically evaluated first. This isn’t a suggestion to assume everything is anxiety. The relevant question comes after the tests come back normal and the symptoms persist, at which point it’s worth asking whether anxiety, not another undiscovered physical cause, is the actual driver.
Distinguishing Anxiety From an Undiagnosed Medical Issue
Patients often ask how to tell the difference, and there’s no single clean answer, but a few patterns tend to hold. Anxiety-driven physical symptoms often fluctuate with context: worse before a specific stressor, easier on a relaxed weekend, absent on vacation. A symptom that shows up regardless of circumstance, that’s progressively worsening rather than fluctuating, or that comes with other red-flag signs your physician would flag, deserves continued medical attention regardless of how anxious you also happen to be. It’s entirely possible, and common, to have both a real medical issue and an anxiety response layered on top of it, which is one more reason this isn’t about choosing one explanation over the other.
Frequently Asked Questions
Can anxiety really cause chest pain?
Yes. Anxiety activates the same fight-or-flight response that increases heart rate and can create sensations of chest tightness or pressure. Any new or severe chest pain should still be evaluated medically first.
Why didn’t my doctor mention anxiety sooner?
Primary care visits are often short, and physical symptoms are typically investigated as physical issues first, which is appropriate. The conversation about anxiety often only happens once other causes are ruled out.
Is this the same as a panic attack?
Not necessarily. Panic attacks are acute and intense. The pattern described here is often a more chronic, lower-grade physical anxiety that doesn’t spike as dramatically but persists longer.
Getting Help in Nassau County: If physical symptoms have been cleared medically and keep coming back, it may be worth having a different kind of conversation. Contact Us → to talk about what you’ve been experiencing.
References: MacKay, M., Yang, B.H., Dursun, S.M., & Baker, G.B. (2024). The Gut-Brain Axis and the Microbiome in Anxiety Disorders, Post-Traumatic Stress Disorder and Obsessive-Compulsive Disorder. Current Neuropharmacology, 22(5), 866-883.
Clark, D.M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.
Petersen, S., Van Staeyen, K., Vögele, C., von Leupoldt, A., & Van den Bergh, O. (2015). Interoception and symptom reporting: disentangling accuracy and bias. Frontiers in Psychology, 6, 732.
Foldes-Busque, G., Denis, I., Poitras, J., Fleet, R.P., Archambault, P., & Dionne, C.E. (2019). A closer look at the relationships between panic attacks, emergency department visits and non-cardiac chest pain. Journal of Health Psychology, 24(6), 717-725.
Ariño-Braña, P., Zareba, M.R., Ibáñez Montolio, M., Visser, M., & Picó-Pérez, M. (2025). Influence of the HPA Axis on Anxiety-Related Processes: An RDoC Overview Considering Their Neural Correlates. Current Psychiatry Reports, 27(10), 593-611.
Dr. Marc J. Shulman, Psy.D., Founder & Director, Long Island Psychology
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