Overview
A patient came to me last year having been in CBT for anxiety for three years. The therapy was good. The therapist was skilled. The patient had done substantial cognitive work and made meaningful progress on her anxious thinking patterns. m. with her heart racing, trembling for no clear reason, and feeling fundamentally unsettled in her body in a way no amount of cognitive work was reaching. We ran a comprehensive panel.
Her thyroid was significantly elevated. Her cortisol rhythm was disrupted. Her ferritin was below 30. Her blood sugar was running unstable.
Evidence summary
None of these had been previously assessed because her family physician's standard panel did not include the relevant markers, and because everyone — including the patient — had assumed the anxiety was psychological. After three months of integrative treatment addressing the biological dimensions, alongside continued therapy, the anxiety was significantly improved. Not because the therapy had been wrong. Because the therapy had been incomplete.
This article is about the hormonal and metabolic dimensions of anxiety — what they are, when they matter, and how to assess them.
Care considerations
It is for anyone whose anxiety has not fully responded to therapy alone and who suspects there may be a biological dimension they have not yet examined. Anxiety is a multi-system phenomenon Anxiety is not only a psychological condition. It is a state of the whole body — nervous system, endocrine system, immune system, metabolic system — and disruptions in any of these systems can produce or amplify anxiety symptoms.
A non-exhaustive list of biological factors that can drive or worsen anxiety: Thyroid dysfunction. Both hyperthyroidism and certain patterns of hypothyroidism can produce anxiety, palpitations, sleep disruption, and tremor that are clinically indistinguishable from primary anxiety disorder.
Next steps
Standard TSH-only screening misses many cases. A complete thyroid panel includes TSH, free T4, free T3, reverse T3, and thyroid antibodies (TPO and Tg). Cortisol dysregulation. Cortisol — the primary stress hormone — has a normal diurnal rhythm (high in the morning, low at night) and acute responses to stress. When this rhythm is disrupted, anxiety often follows.
The disruption may show as elevated baseline cortisol, blunted morning rise, or non-suppression at night. Salivary cortisol testing across the day captures this rhythm in ways a single blood draw cannot. Sex hormone fluctuations. Estrogen and progesterone affect mood substantially.