When the Mind Won’t Stop

Using worry as a clinical clue to tell when anxiety is psychological vs. medical.

(Disclaimer: the below is for educational purposes only and does not constitute medical advice)

We’ve all been there: that sudden lurch in your chest, the unsettling flutter in your stomach, or a wave of inexplicable unease that washes over you. Is it stress? Too much coffee? Or something deeper, something saying “danger danger, seek attention immediately!”

Medical school and residency beat one lesson into me over and over: never assume anxiety lives purely in the head until you’ve ruled out the body. As a physician, I want to give you the lay of the land to help you understand when “just anxiety” might be a distress signal from your body, and a few tips that might help save you a trip to the hospital.

Medical Conditions That Directly Cause Anxiety Symptoms

In this first context, anxiety is not a separate psychological disorder but a direct symptom (a “medical mimic” or “secondary anxiety”) of an underlying physical illness. The illness itself creates the physiological state of anxiety.

The endocrine and hormonal system is one of the most common causes. Hyperthyroidism (overactive thyroid) is a classic example. Excess thyroid hormone speeds up the body’s metabolism, leading to symptoms that sound a whole lot like anxiety: a racing heart (palpitations), nervousness, trembling, sweating, irritability, and sleep disturbances.

A 2021 meta-analysis on Graves’ hyperthyroidism found that the pooled prevalence of anxiety disorders in newly diagnosed patients was 31%. That’s nearly one in three! Beyond the thyroid, adrenal gland disorders like Cushing’s syndrome (excess cortisol) or a pheochromocytoma (a rare tumor producing excess “fight-or-flight” hormones) can also directly trigger intense anxiety and panic. But don’t panic, I want to reiterate that this is VERY RARE. Even common hormonal fluctuations related to premenstrual syndrome and menopause can cause significant mood changes and anxiety.

Metabolic conditions are another frequent culprit. Hypoglycemia (low blood sugar), for instance, causes the body to release adrenaline to compensate, leading to shakiness, sweating, dizziness, and a fast heart rate that all feel like an anxiety attack. Similarly, electrolyte imbalances in sodium, potassium, or calcium can affect nerve and muscle function, leading to confusion and rapid heartbeat.

The cardiovascular system itself can be a source of anxiety. Arrhythmias, or irregular heartbeats, are tricky. The symptoms, well, sound (and feel) a whole lot like anxiety: racing heart, shortness of breath, sense of doom which both mimic and cause a state of panic. According to one paper, more than half of people with supraventricular tachycardia reported that they had been told by a physician that their symptoms were “in their head.” Postural Orthostatic Tachycardia Syndrome (POTS), a condition characterized by a rapid heart rate increase upon standing, also causes dizziness and palpitations often mistaken for anxiety.

Finally, substance-related causes are critical to consider. Withdrawal from substances like alcohol or anti-anxiety medications (benzodiazepines) can induce severe anxiety and agitation, while stimulants like caffeine or amphetamines are well-known causes of anxiety, agitation, and even panic. I’ve seen this quite a bit in my clinic: my patients, especially those with alcohol use disorder, wake up in the morning after drinking too much feeling anxious as a result of withdrawing from alcohol.

Anxiety Symptoms That Mimic Medical Conditions (Differential Diagnosis)

This second area is when a primary anxiety disorder, particularly a panic attack, produces intense physical (somatic) symptoms that mimic a life-threatening medical emergency. This is often described as the body’s “fight-or-flight” system acting as a false alarm.

The most common and frightening mimic is that of a heart attack. A panic attack can cause chest pain, a pounding, rapid heart (palpitations), shortness of breath, dizziness, sweating, and a sense of impending doom. Typically the chest pain for panic are described as sharp, stabbing, or intense pain localized in a small area, whereas chest pain from a myocardial infarction is often described as pressure, squeezing, fullness, heaviness, or a tight band around the chest and can radiate to the arm (usually left), neck, jaw, back, or stomach. MIs are tricky, as they can even show up as a dull ache or even be mistaken for indigestion or heartburn.

Panic symptoms can be challenging to distinguish from a heart attack (especially for someone without medical training), which is why medical evaluation (EKG, blood tests) is generally the gold standard for ruling out a cardiac event.

How common is this? Very. A 2020 systematic review and meta-analysis found that the pooled prevalence of panic disorder in patients with non-cardiac chest pain was 22.8%. This means that nearly 1 in 4 patients who come to the hospital for chest pain and are not having a heart attack meet the diagnostic criteria for panic disorder.

Medical Conditions That Lead to Anxiety (Co-morbidity)

This third category describes anxiety as a separate, co-morbid condition that is a common psychological response to the stress, burden, and biological changes of a chronic illness.

The link with cardiac conditions is very strong. Patients with coronary artery disease (CAD) or those who have had a myocardial infarction (heart attack) have high rates of anxiety. A 2018 meta-analysis found that the pooled prevalence of anxiety among these patients was 38%. That’s more than 1 in 3! Having fear of another event is so common that it is often described as “cardiac anxiety.” Yes, fear of the future is a hallmark of worry, a critical distinction which I will get into more later in the article.

On top of this, anxiety and heart disease can feed on each other; anxiety itself is an independent risk factor for developing heart disease and worsens the prognosis for existing heart disease.

Neurological conditions also show a high co-morbidity with anxiety. For example, one systematic review calculated a pooled odds ratio of 3.95, indicating that individuals with migraine are nearly 4x more likely to also have an anxiety disorder. Anxiety is also a common non-motor symptom in Parkinson’s Disease (often preceding motor symptoms by several years). A large 2016 meta-analysis found that about 31% of patients with Parkinson’s also have an anxiety disorder. I’ve seen this personally: a large number of patients with Parkinson’s have been referred to me or have joined my anxiety program over the years because of high anxiety. To round out the neurological category, conditions like epilepsy and Traumatic Brain Injury (TBI) are also strongly linked to anxiety, as the brain’s emotional regulation centers can be damaged.

Other chronic illnesses can be deeply intertwined with anxiety. Respiratory conditions like Asthma and Chronic Obstructive Pulmonary Disease (COPD) show high rates, as the physical sensation of being unable to breathe (dyspnea) is a powerful panic trigger (duh!). For COPD patients, panic disorder specifically is noted to be up to 10 times more common than in the general population. Gastrointestinal (GI) conditions like Irritable Bowel Syndrome (IBS) are also strongly linked, believed to be related to the “gut-brain axis.”

I know this one personally. In my book Unwinding Anxiety, I detailed how I was so anxious my senior year of college that I developed IBS. Ironically, I didn’t even know what IBS was at the time, and was in total denial that I could be anxious. Fortunately, my IBS resolved after I started a meditation practice in medical school. (And my personal experience set the stage for me specializing in anxiety as a psychiatrist.)

Lastly, chronic pain and autoimmune disorders like fibromyalgia and rheumatoid arthritis are associated with high levels of anxiety, driven by the stress of chronic pain and inflammation.

The Medication Plot Twist

Sometimes anxiety is iatrogenic (fancy term for doctor-caused). Corticosteroids, which we prescribe for everything from asthma to arthritis to poison ivy, reduce GABA, the brain’s main inhibitory neurotransmitter. Less GABA basically means less brake pedal on your central nervous system. While euphoria/hypomania is most common, anxiety, agitation, insomnia and irritability are frequently reported. The higher the dose, the more likely one of these symptoms shows up.

Albuterol, the rescue inhaler for asthma, causes nervousness and tremors in about 20% of patients. It acts on beta-2 receptors, which not only opens up your airways, but because your heart also has beta-2 receptors, it also literally activates your heart. So you can breathe better, but beta-2 as a side effect you get increased heart rate (tachycardia), palpitations and shakiness. Yup, feels like anxiety.

Thyroid replacement medication at too high a dose causes anxiety symptoms. ADHD stimulants cause anxiety (I see this a lot in my clinic). Over-the-counter decongestants can even cause anxiety by increasing serotonin and dopamine.

When the Mind Won’t Stop: How Worry Sets “Real” Anxiety Apart

How can someone with anxiety figure out when it is appropriate to go to their primary care doctor (or the ED) to get a complete workup. We doctors can’t order every test on every anxious patient.

The red flags that I look for are surprisingly straightforward: anxiety presenting late in life with no prior history. Anxiety that’s refractory to multiple evidence-based treatments. Anxiety that started after beginning a new medication. Anxiety accompanied by weight loss, tachycardia, hypertension, or other physical symptoms that don’t quite fit.

And, there’s one critical thing that I assess that can be a good (but not perfect) differentiator: WORRY.

Worry may be one of the most useful clues for distinguishing anxiety from its medical mimics. While panic, restlessness, or a racing heartbeat can all come from thyroid dysfunction, cardiac arrhythmias, or even low blood sugar, worry is different. It is a behavior, not a sensation. Worry is what the mind does in response to uncertainty: rehearsing, predicting, and trying to control what cannot be controlled. Two of the seven items on the gold-standard clinical anxiety assessment (GAD-7) specifically ask about worry (“Feeling nervous, anxious, or on edge” and “Not being able to stop or control worrying”), which shows how central it is to generalized anxiety.

Any good physician knows this distinction matters, which is why they take time to explore the details when someone presents with anxiety-like symptoms. They ask when the sensations began, how long they last, what brings them on, what makes them go away etc. They listen for patterns: does it happen only at rest, after caffeine, during exercise, or before a stressful meeting? Do symptoms wake the person from sleep or come on out of the blue? They ask about medications, recent illnesses, and whether anything helps, even temporarily. The goal is not just to collect data but to understand whether the symptoms follow the body’s physiology or the mind’s illogic (planning is logical, worry is not).

One simple way to check in with yourself to see if worry is driving your anxiety is to ask, “What’s happening right now—in my body or in my mind?” If you notice tension in your chest, a racing heart, or shallow breathing, that is the physiological side of anxiety. If you find yourself mentally spinning, replaying conversations, planning for every possible outcome, or trying to think your way out of discomfort, that is worry. The body feels; the mind worries.

And if worry is the main driver of your anxiety, don’t worry, it can be treated.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce worry and cultivate calm (www.goingbeyondanxiety.com).

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

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