Before we call it anxiety

You ask for help with anxiety because that is the nearest available word. Your heart races. Your body trembles. You feel suddenly frightened, irritable or furious. Something has changed, and you want relief.

Yet you cannot identify what you are worrying about. The sensations seem to arrive first; the explanations follow.

“This feels as though it starts in my body.”

That observation deserves curiosity. It does not prove a medical cause, but neither should it be dismissed because the person is distressed. Crying during an appointment tells us that someone is upset. It does not explain why their heart races at home.

Anxiety describes an experience. It does not, by itself, establish its cause.

Anxiety has bodily effects, and physical conditions can produce anxiety. Some illnesses also create sensations resembling panic without fear being the initiating event. These processes can coexist. Panic itself can begin without a conscious anxious thought, so the absence of worry is a clue, not a diagnostic test. www.psychiatry.org

What, then, might deserve consideration before the explanation settles?

Heart rate and circulation are one starting point. Heart-rhythm disturbances, including supraventricular tachycardia and atrial fibrillation, can produce palpitations, breathlessness and dizziness. PoTS and other forms of dysautonomia can make standing, heat or meals physically difficult. Orthostatic hypotension, where blood pressure falls on standing, and vasovagal episodes can cause faintness, nausea and sweating. Dehydration can contribute to a fast pulse and reduced upright tolerance. nhs.uk

The pattern matters: a racing heart that starts and stops abruptly, symptoms linked to standing, or improvement on lying down may guide investigation. None is a diagnosis on its own.

Metabolic and nutritional conditions can also create an alarm-like state. Hypoglycaemia can trigger adrenaline release, causing shaking, sweating, palpitations and irritability; more severe lows can impair thinking. Hyperthyroidism can cause persistent nervousness, heat intolerance, tremor and a fast heartbeat. Iron-deficiency anaemia and B12 or folate deficiency can contribute to palpitations, breathlessness or weakness; B12 deficiency can also affect neurological and psychological functioning. Disturbances in electrolytes such as calcium or magnesium may cause tingling, cramps or tremor. support.endocrine.org

However, feeling “hangry” does not establish hypoglycaemia. Clinicians look for low glucose during compatible symptoms and improvement when glucose is restored. A bodily explanation needs evidence too. academic.oup.com

Hormonal changes can alter how the whole day feels. Perimenopause and menopause may bring hot flushes, palpitations, disrupted sleep and anxiety. PMS and PMDD can involve cyclical distress, irritability and reduced functioning; existing difficulties may also worsen premenstrually. Symptoms should be considered alongside their timing, rather than attributing every difficult week to hormones. Being under 45 does not exclude a menopausal transition or make assessment inappropriate. www.nhs.uk

Breathing difficulties can resemble, trigger or accompany panic. Asthma and other respiratory diseases can cause chest tightness and breathlessness. Inducible laryngeal obstruction involves temporary narrowing at the voice box, sometimes creating a frightening choking sensation. Breathing-pattern disorders, including hyperventilation, can produce dizziness, tingling, chest discomfort and air hunger. They may develop alongside illness, pain, stress or respiratory conditions. “Take a deep breath” is not a universal solution: repeatedly overbreathing can contribute to symptoms. camh.ca

Balance and neurological conditions deserve attention when the pattern suggests them. Vestibular migraine, benign paroxysmal positional vertigo and Ménière’s disease can cause dizziness, disorientation or nausea that subsequently generates fear. Some focal seizures, particularly involving temporal brain regions, can include sudden fear, unusual sensations or altered awareness. Repeated episodes following a similar brief sequence may warrant neurological assessment. These possibilities cannot be identified from the word “panic” alone. PMC

Allergic and mast-cell reactions can create another overlap. Flushing, itching, hives, abdominal symptoms, wheezing and circulatory changes may occur together. Anaphylaxis is an emergency. Mast-cell activation syndrome requires specific assessment; it cannot be diagnosed from anxiety, food reactions or improvement with antihistamines alone. Suspected dietary histamine intolerance is a separate, less clearly established explanation. www.aaaai.org

Sleep and digestive problems can contribute too. Obstructive sleep apnoea may cause repeated waking with gasping or choking, alongside daytime exhaustion. Reflux can produce chest or throat discomfort that is frightening. Pain and disrupted sleep may further reduce someone’s capacity to cope. Here, a physical symptom may provoke anxiety rather than directly reproduce an entire panic attack. nhs.uk

Medication and substance effects belong in the same enquiry. Caffeine, nicotine and recreational stimulants can contribute to arousal. Prescribed ADHD stimulants, salbutamol inhalers, decongestants such as pseudoephedrine and corticosteroids can produce relevant symptoms in some people. Antidepressants can initially increase agitation or anxiety; missed doses or withdrawal can also cause anxiety, dizziness and sweating. Alcohol or benzodiazepine withdrawal may be medically dangerous. NICE

Akathisia, often associated with antipsychotic medication, deserves particular recognition: an intensely uncomfortable inner restlessness and compulsion to move can be mistaken for worsening anxiety or agitation. A medication timeline may reveal something an anxiety questionnaire misses. Prescribed medicines should be reviewed with the prescriber, not abruptly stopped. Right Decisions

There are rarer endocrine causes, including phaeochromocytoma, an adrenal tumour that may produce episodes of headache, heavy sweating, palpitations and high blood pressure. These are considered when specific features justify it, rather than screened for in everyone who feels anxious. NHS

For neurodivergent people, the picture may be further complicated by sensory overload, difficulty recognising or communicating internal sensations, and the effort of managing bodily needs. Hypermobility and hEDS/HSD may be relevant because of associated pain and autonomic difficulties. Research supports an association between neurodivergence and hypermobility, but it does not establish one syndrome explaining every symptom. www.frontiersin.org

The practical question is whether assessment has considered the person’s bodily and environmental context. An overloaded person may need reduced sensory input. Someone with a medical condition may need treatment. Someone with panic may need psychological support. One person may need all three.

A broad differential should lead to focused assessment, not endless testing. These conditions are not equally likely, and this is not a checklist everyone must complete before accepting help for anxiety.

Useful questions include: Is this new? What happens first? How long does it last? Is it related to posture, meals, exertion, sleep, periods or medication changes? What has already been checked, and what remains unexplained?

Normal results narrow some possibilities; their meaning depends on what was measured and when. Equally, uncertainty does not prove that an undiscovered rare disease must be present. Anxiety can be diagnosed and treated while relevant medical questions are investigated.

Relief from a beta blocker does not settle the cause either. It may reduce palpitations while leaving their initiating problem unresolved. Propranolol can also mask warning signs of hypoglycaemia, making a prescriber review important when lows are suspected. www.medicines.org.uk

Therapy can help with fear, exhaustion and the effects on relationships throughout this process. It need not require someone to abandon questions about their body.

Before asking, “How can you manage your anxiety?”, there may be another question to ask:

“What are we calling anxiety, and have we adequately investigated what could be producing it?”

New severe chest pain, severe breathing difficulty, collapse, throat or tongue swelling, or sudden neurological symptoms need urgent assessment. Call 999 for suspected emergencies, even if previous episodes were labelled panic.