Physical Manifestations of Stress and Anxiety

Introduction to Physical Symptoms

The National Comprehensive Cancer Network (NCCN) defines distress as including a physical dimension alongside psychological, social, and spiritual components that interfere with coping ability 1, 2, 3
The American Society of Clinical Oncology guidelines document that stress, anxiety, and worry are related to important neuroendocrine changes that can affect patient outcomes 4, 6

Heightened anxiety is directly associated with increased adverse effects, more physical symptoms, and poorer physical functioning 4, 5, 6
Anxiety disorders present with multiple physical manifestations, including chest pain or discomfort 5, nausea or abdominal distress 7, sweating 6, paresthesias (numbness or tingling) 5, and chills or hot flushes 5

When evaluating patients with physical symptoms, clinicians must actively screen for underlying anxiety and stress 4, 1
The NCCN recommends screening for distress at every medical visit as a hallmark of patient-centered care, particularly with changes in disease status 7
Before attributing physical symptoms solely to anxiety, rule out medical causes first, including uncontrolled pain or fatigue 9, delirium from infection or electrolyte imbalance 9, thyroid disorders 9, medication side effects 6, and substance use or withdrawal 8, 9

Use validated instruments to quantify both symptom severity and functional impact, such as the GAD-7 for anxiety and the PHQ-9 for depression 8
The Hospital Anxiety and Depression Scale (HADS) is particularly useful in medically ill patients as it excludes somatic symptoms that may be confounded by medical illness; scores ≥8 on either subscale indicate caseness 8

First-line treatments for anxiety disorders with physical manifestations include SSRIs (such as sertraline) and cognitive behavioral therapy, with SSRIs associated with small to medium effect sizes compared with placebo for generalized anxiety disorder, social anxiety disorder, and panic disorder 8
For GAD-7 scores ≥10, conduct comprehensive diagnostic evaluation to confirm anxiety disorder diagnosis, rule out medical and substance-induced causes, initiate SSRI therapy or refer for cognitive behavioral therapy, and reassess regularly to determine treatment effectiveness 8, 9, 7

Do not dismiss physical symptoms as "just anxiety" without proper medical workup, as the relationship between anxiety and physical symptoms is bidirectional 8, 9, 4, 1
Do not overlook the common comorbidity between depression and anxiety, with approximately 31% of patients with an anxiety disorder also having major depressive disorder; prioritize treatment for the condition causing the greatest functional impairment 8