When Anxiety Isn't Anxiety: Physical Conditions That Get Misdiagnosed

A woman walks into the ER with a racing heart, chest tightness, and a sense of doom she cannot shake. She is sent home with a printout about panic attacks and a recommendation to follow up with a therapist. Six months later, a more thorough provider checks her ferritin and finds it sitting at 8. Her body had been screaming about iron deficiency for months. Everyone treated her like she was screaming about nothing.

This is not a rare story. It is one of the most common patterns I see in my clients, especially women, and it has nothing to do with whether anxiety is real. Anxiety disorders are real, they are well-studied, and they deserve real treatment. But here is the thing I keep noticing in my Morris County NJ practice: when the underlying physical condition gets addressed, a meaningful number of people stop having "anxiety attacks" at all. Their nervous system was not broken. It was responding accurately to a body that was in trouble.

What a body in trouble actually feels like

The autonomic nervous system, the part of you that runs the show when you are not consciously thinking about it, is designed to respond to physiological distress with adrenaline, vasoconstriction, increased heart rate, and a heightened state of alertness. To you, that feels like racing heart, shortness of breath, dread, hyperawareness, restlessness, and a sense that something is wrong.

The catch is that adrenaline does not come with a label that says "this is from low iron" or "this is from blood sugar dropping." It just feels like panic. Without good information, both patients and providers can default to the most familiar explanation: it must be anxiety.

For some people, it is. For many people, it is something else, or it is anxiety stacked on top of something else that nobody has ruled out.

Physical conditions that commonly get misread as anxiety

This is not a diagnostic list. It is a list of things worth asking your provider about if you are dealing with what is being called anxiety and the standard treatments are not landing.

Iron deficiency, especially low ferritin. Heart pounding, breathlessness, fatigue, dread, restlessness. Extremely common in menstruating women, post-surgical patients, and anyone with heavy cycles. Ferritin under 30 is meaningful even if hemoglobin is "normal."

Thyroid dysfunction. Hyperthyroidism in particular produces racing heart, tremor, insomnia, irritability, and a constant wired feeling that looks identical to anxiety. Hypothyroidism can do its own version of this through sluggish metabolism and depression that gets called anxiety because the patient feels "off."

Blood sugar instability and reactive hypoglycemia. Shaky, sweaty, irritable, panicky episodes between meals or two to three hours after eating sugar. Often missed because fasting glucose looks fine.

Hormonal fluctuations. Perimenopausal estrogen swings produce real adrenaline surges, especially in the second half of the cycle and in the early morning hours. PMDD and luteal-phase mood shifts are a documented physiological pattern, not a personality flaw. I have written more about hormonal balance and what bodywork can and cannot do elsewhere, and the rename of PCOS to PMOS is partly an attempt to take this seriously.

POTS and dysautonomia. Heart races when standing. Adrenaline surges with no clear trigger. Brain fog, fatigue, lightheadedness. POTS is dramatically underdiagnosed, especially in women, and is often misread as anxiety for years before someone thinks to do a tilt-table test.

Histamine intolerance and MCAS. Flushing, racing heart, GI distress, headaches, and panic-feeling episodes after eating or in response to environmental triggers. Histamine is a chemical messenger your body uses for many things, including the fight-or-flight response. When it is dysregulated, you feel it.

Sleep apnea. Repeated nighttime oxygen drops keep the nervous system in a high-alert state. The result can be morning anxiety, daytime panic, and emotional volatility that gets blamed on stress when the real issue is that the person has not had restorative sleep in months.

Cardiovascular issues. Less common but real. Arrhythmias and certain heart conditions can produce panic-like episodes that have a physical cause that imaging or a Holter monitor can find.

Long COVID and post-viral dysautonomia. A growing category. Post-viral nervous system dysregulation produces a constellation of symptoms that include real anxiety-like physiology.

Hypermobility-related conditions. People with hypermobile Ehlers-Danlos and related connective tissue conditions often have POTS, MCAS, and dysautonomia stacked together. This trio is real and it is increasingly recognized, but it is still routinely missed.

The insomnia version of the same story

The same pattern shows up with insomnia. Someone cannot sleep, they get prescribed sleep medication or sent to CBT-I, and nothing really resolves because the underlying physical driver was never found.

A short, parallel list:

• Sleep apnea, which is the single most-missed driver of "insomnia" and "anxiety" both. People do not realize they are waking up dozens of times a night because their airway is collapsing.

• Restless legs syndrome, which is frequently iron-related and resolves with ferritin correction.

• Perimenopausal hormonal shifts, which produce 3 and 4 AM wake-ups with racing heart that nobody warned the patient about.

• Hyperthyroidism, which makes sleep feel impossible regardless of how tired the person is.

• Cortisol dysregulation, including the wired-but-tired pattern where cortisol crashes during the day and surges at night.

• Reactive hypoglycemia at night, which is a common driver of 2 to 3 AM wakeups paired with a hungry or panicky feeling.

• Histamine flares, which tend to be worse in the evening as histamine levels naturally rise.

Treating sleep as a primary problem when one of these is happening underneath is treating the smoke and ignoring the fire.

What to ask your provider

If you have been diagnosed with anxiety or insomnia and treatment is not working as well as you would expect, it is reasonable to ask for a more thorough physical workup. A reasonable starting panel includes complete blood count, ferritin (specifically, not just iron), thyroid panel including free T3 and free T4, fasting glucose and insulin, vitamin D, B12, and a basic metabolic panel. If symptoms include orthostatic features (worse when standing, better when lying down), ask about POTS evaluation. If symptoms include flushing, food reactions, or GI involvement, ask about histamine and MCAS. If sleep is a major piece, ask about a sleep study.

You are not being difficult by asking. You are being thorough. Patterns get missed when nobody is looking at the whole picture.

Where bodywork fits

Manual lymphatic drainage does not treat low ferritin, fix sleep apnea, or correct dysautonomia. But for people whose nervous systems have been running in a chronic high-alert state for months or years, gentle, sustained nervous system regulation is one of the few interventions that does not require a diagnosis to be helpful. MLD works through the parasympathetic system, which is the opposite of the fight-or-flight response. For clients dealing with chronic dysautonomia, hormonal volatility, or post-viral symptoms, regular sessions can be one piece of a much bigger picture of getting the body out of constant alarm mode.

I am not your doctor and I cannot diagnose anything. What I can do is notice patterns in the people who end up on my table, and one of the patterns I have noticed most clearly is this one: when the right physical condition gets identified and addressed, the "anxiety" often fades on its own.

The bottom line

Anxiety disorders are real. Insomnia disorders are real. Both deserve real treatment, and for many people, that treatment works. But "real" does not mean "the only explanation." If you are being told your symptoms are anxiety and you suspect something else is going on, you are allowed to keep asking. You are allowed to push for the bloodwork. You are allowed to want the whole picture.

Your body is not making this up. It is trying to tell you something. The question is whether the people around you are willing to listen.

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Morgan Larson, LMT, CMLDT

Owner, Firm and Flourish Lymphatic Therapies

Kinnelon, NJ | Serving Morris County