A reasonable proportion of the people I see at first do not describe themselves as anxious. They describe themselves as physically unwell. Persistent shoulder tension. Recurring headaches. Stomach problems that have been investigated more than once and never given a clear cause. A jaw that aches by the end of the day. A feeling of pressure in the chest that comes and goes. These are real symptoms, and they often end up being looked at carefully by GPs, gastroenterologists, physiotherapists, or dentists, with limited results. By the time the question of anxiety comes into the conversation, the person has often spent months or years working their way around the medical system without much resolution.

This pattern is sometimes called somatic anxiety, somatised anxiety, or, less clinically, the body keeping the score. Whatever the term, the underlying picture is that anxiety has expressed itself primarily through physical symptoms rather than through the mental experience of worry. The person may not feel particularly worried in the way they would describe worry. The body, however, is showing a different story.

Why some anxiety lives in the body

The threat response system is, fundamentally, a physical system. When it fires, the changes are physiological — heart rate, breathing, muscle tone, digestion, blood flow, hormone release. The mental experience of anxiety (worry, racing thoughts, foreboding) is partly a downstream consequence of the physical response, not a cause of it. In most people, the physical and the mental components are present together, and people learn to identify what they are feeling as anxiety because the two arrive in tandem. At its most intense, this physical surge is what produces a panic attack.

In some people, however, the mental side of the response is muted, suppressed, or simply less accessible than the physical side. The reasons vary. Some people grew up in environments where verbal expression of distress was not safe or useful, and learned early to keep it out of language. Some have a temperament that processes emotion physically more readily than cognitively. Some have been through periods of life where the demands made it necessary to override the mental signals, and the body absorbed what could not be acknowledged.

In each of these cases, the physical response continues to fire, but it is no longer easily readable as anxiety. It just shows up as headaches, or as gut symptoms, or as a chest that feels tight without an obvious reason. The medical investigations rule out the things that would be obviously medical. What is left is real and uncomfortable but does not fit the standard categories.

Why this matters for treatment

If you treat somatic anxiety as if it were a purely physical problem — better posture, gentler diet, more sleep — you usually get a small benefit and then the symptoms return. The physical work is not wrong, but it is incomplete. Treating somatic anxiety as if it were a purely mental problem — examining thoughts, challenging beliefs — is also usually incomplete, because the mental component of the anxiety is the part that is muted, and the cognitive techniques may not have much to grip onto.

The work that does produce change tends to bridge the two sides. The body is taken seriously as a source of information. The mental side is approached carefully, sometimes through the body rather than the other way round. Specific techniques drawn from CBT, alongside elements from compassion-focused therapy and mindfulness-based approaches, are used to slowly bring the system as a whole back into a more regulated state.

What this work looks like

Several specific pieces are usually involved.

Body awareness work. People with somatic anxiety often have a complicated relationship with their body — sometimes ignoring it for long stretches, sometimes hyper-attending to it during symptom flare-ups. Neither of these is full attention. Structured practices for noticing what the body is doing, throughout the day rather than just when something is wrong, often produces useful information that has been getting filtered out.

Tension and breath work. The body’s capacity to regulate itself is heavily influenced by the breath. People with chronic somatic anxiety often have shallow upper-chest breathing patterns that maintain a low-grade activation of the threat response. Diaphragmatic breathing, when it has been properly learned and practised consistently, can shift the baseline state of the nervous system over weeks. This is not a quick fix, but it is a foundational piece.

Cognitive work on what the symptoms mean. Once the symptoms have been read as anxiety rather than as evidence of an undiagnosed physical problem, the meaning of them changes, and the meaning is part of what maintains them. People with somatic anxiety often have a layer of secondary worry about the symptoms themselves — what if this is something the doctors missed, what if it is getting worse — and addressing this layer reduces the overall load.

Identification of triggers. The body usually responds to specific situations, even when the mind has not consciously registered them. Tracking the symptoms over a week or two, alongside what was happening before they appeared, often reveals patterns that were not visible from inside. Particular kinds of meeting, particular conversations, particular times of day, particular relational dynamics. Once the triggers are visible, they can be addressed directly.

Work on the mental side, brought in gradually. As the body settles, the mental component of the anxiety often becomes more accessible. People who said in the early sessions that they did not feel particularly worried often find, two months in, that there is a layer of worry that has been there for years and that they had simply stopped registering. This is a meaningful piece of the work, and the standard CBT techniques for generalised worry then become useful in a way they were not at the start. Disrupted sleep often becomes more manageable at this stage too, as the baseline level of physiological activation falls.

A note on health anxiety

There is some overlap between somatic anxiety and health anxiety, and the two can co-occur, but they are distinct. Somatic anxiety is anxiety expressing itself physically, with the person often not particularly worried about what the symptoms mean. Health anxiety is worry about having a serious illness, which often produces its own physical symptoms but is primarily driven by the cognitive layer. Treatment differs. The article on health anxiety in this series describes the latter in more detail.

When to seek help

If you have been investigated medically for persistent physical symptoms and the investigations have not produced a clear answer, if the symptoms have been present for several months, and if you can recognise some of what is described above in your own experience, structured CBT is worth considering. The symptoms are real, and the underlying anxiety is also real, even if it does not feel particularly mental. A free consultation is a sensible first step.