A pain in the center of the chest. A heartbeat that skips. A burning sensation rising from the stomach. These are three of the most frightening sensations that anxiety can produce, and the three that most often lead people to the emergency room or to a cardiologist.
The test results are almost always negative. And then comes the phrase that those who hear it hate: "it's just anxiety." As if "just" meant it doesn't really hurt.
It really does hurt. The physical symptoms of anxiety are real, they have a precise physiological explanation, and understanding how they work is the first step to getting past them.
First of all: chest pain must always be evaluated
This point comes before anything else on this page.
Chest pain should never be attributed to anxiety by self-exclusion, and even less so by reading an article. If you have intense, unusual chest pain that radiates to the arm, neck, or jaw, accompanied by cold sweats, nausea, or shortness of breath, call emergency services. Don't wait, don't search online, don't try to breathe better.
Medical evaluation must be done even when the episode has passed and even if you suspect it's anxiety. Only afterward, with the test results in hand, does it make sense to work on the psychological level. And paradoxically, it's precisely that negative test result that makes the subsequent work effective: it removes the underlying doubt that would otherwise keep gnawing at you.
Why anxiety produces physical symptoms
Anxiety activates an alarm response designed to help us face danger. The heart speeds up to bring blood to the muscles, breathing becomes faster, digestion slows down because it isn't needed at that moment, and the muscles contract.
It's a perfect mechanism if there's a threat to flee from. It becomes a problem when it activates in the office, on the couch, or at three in the morning: all that preparation finds no outlet and keeps circulating in the body.
Then comes into playhyperventilation, which alone explains half of the symptoms. Breathing faster expels too much carbon dioxide, and the result is dizziness, tingling in the hands and lips, a sense of unreality, and in the most intense cases, stiffening of the hands.
Chest pain from anxiety
It has different origins, all benign, once everything else has been ruled out.
The most common is muscle tension: the intercostal muscles and those of the chest remain contracted for a long time, producing pain that can be sharp or feel like a weight. It typically changes with position or breathing, and often worsens if you press on it with a finger — something that pain of cardiac origin generally doesn't do.
Then there'shyperventilation, which gives a feeling of tightness and air hunger. And there's the gastriccomponent: reflux can cause a burning sensation behind the sternum that closely resembles cardiac pain.
This is not a guide for self-diagnosis. It's an explanation of what can happen after once a doctor has ruled out everything else.
Extrasystoles and palpitations
Extrasystoles are early heartbeats followed by a longer pause. They are perceived as a flutter, a skip, a jolt in the chest.
They are extremely common even in perfectly healthy hearts, and become more frequent with stress, lack of sleep, caffeine, alcohol, and nicotine. Those who experience them find them terrifying precisely because they come without warning.
But the real problem isn't the extrasystoles themselves: it's the attention that ends up being devoted to them. The more you listen to your own heartbeat, the more you notice it, and the more every normal irregularity becomes an event. Continuous monitoring — the finger on the pulse, the smartwatch checked ten times a day — is what keeps the cycle going.
Here too: palpitations should be reported to a doctor. Once evaluated, the psychological work concerns the relationship with the sensation, not the sensation itself.
Anxiety and gastroesophageal reflux
The link between the gut and the nervous system is documented and works in both directions.
Anxiety can promote reflux symptoms in several ways: it increases tension in the abdominal muscles, alters stomach motility, and with hyperventilation, there's a tendency to swallow air. In addition, a prolonged state of alertness lowers the threshold at which visceral sensations are perceived: the same stimulus, which previously went unnoticed, becomes bothersome.
And reflux in turn feeds anxiety, because the burning sensation behind the sternum resembles a cardiac symptom and reignites fear.
This means both need to be treated: the gastric part with a doctor, the anxious part with psychological support. Addressing only one of the two sides leaves the cycle intact.
The anxiety that oppresses
There's a sensation that many people describe with the same word: oppression. A weight on the chest, as if someone were sitting on it. Difficulty taking a full breath, the feeling of needing to yawn to manage it.
It has two components. The first is muscular: the accessory breathing muscles, those in the neck and shoulders, remain contracted and the rib cage moves less freely. The second is perceptual: in a state of alertness, attention is paid to breathing, and observed breathing stops being automatic. The more you try to breathe well, the less natural it feels.
This is also why the advice "take a deep breath" often makes things worse. What's needed is the opposite: exhale slowly and for a long time, letting the inhalation come on its own.
The cycle that maintains them all
The mechanism is always the same, whatever the symptom.
A normal bodily sensation is noticed. It's interpreted as a danger signal. Fear increases activation, which intensifies the sensation, which confirms the fear. At that point you start monitoring your body, and the monitoring increases the likelihood of noticing other sensations.
From there come repeated tests, multiple consultations, online searches for symptoms. Each of these things brings relief for a few hours and strengthens the cycle for weeks.
How to break free
Close the medical question once and for all. Get the tests your doctor recommends, and then stop. Repeating them doesn't add certainty: it uses it up.
Reduce monitoring. Fewer pulse checks, fewer online symptom searches, less smartwatch checking. At first anxiety rises, then it falls. It's the hardest step and the most decisive one.
Working on baseline activation. The Autogenic training is particularly recommended when the somatic component is prevalent, because it acts directly on the body and restores a sense of control that doesn't rely on obsessive checking.
Changing the interpretation. Don't try to convince yourself everything is fine, but learn to recognize the "sensation, catastrophe, fear" chain as it happens.
Take care of the basics. Sleep, caffeine, alcohol, exercise. They affect the threshold much more than it seems.
Frequently Asked Questions
How do I know if chest pain is anxiety or my heart?
It's not something to determine on your own, and it's exactly the kind of question a doctor needs to answer. There are some indicative signs — muscle-tension pain often changes with position and with finger pressure — but they aren't diagnostic criteria. When facing unusual chest pain, the reference is to call emergency services (112).
Are extrasystoles from anxiety dangerous?
Isolated extrasystoles in a healthy heart are not considered dangerous. But it's the cardiologist who determines whether the heart is healthy, not the article you're reading.
Can anxiety cause reflux?
It can promote it and can amplify how it's perceived. The two problems often coexist and reinforce each other, which is why treating only one of them works only halfway.
Why do symptoms get worse at night?
Because distractions are absent and attention turns inward. In the silence you notice your own heartbeat, and what would go unnoticed during the day becomes an alarm.
If the tests are normal, does that mean I'm making it up?
No. It means the symptom doesn't have an organic cause, not that it doesn't exist. Pain produced by tension-related muscle contraction is real pain, with a precise physical cause.
A journey in Florence or online
If you recognize yourself in this cycle, you can contact me for an initial introductory session. I receive in my office in Florence, at Via Tommaso Campanella 5, in the Campo di Marte – Coverciano area, and online.
You'll also find how to calm anxiety, how to understand if you suffer from anxiety and what to do during a panic attack.
After medical causes have been ruled out, these symptoms respond well to therapy: here's how psychological support for anxiety in Florence works.
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