Sara Anderson, LPC

Maybe it’s not all in your head.

There is a bias in healthcare that too often suggests certain experiences by women might be a mental health issue. Especially if routine bloodwork looks fine, issues like fluttering in the chest, chronic pain, excessive worrying, changes in mood, or brain fog are too often referred for therapy when there might be a physiological cause.

This isn't a failure of healthcare. It's a failure of siloed thinking — the assumption that body and mind are separate systems that can be treated independently. They are not. And as a somatic and depth therapist of 25 years, I want to be sure that my clients and I have the whole picture.

Part of my job — the part that doesn't always get talked about — is knowing when to refer. Knowing when to say: before we go further, I want you to see your doctor. Not because I think you're imagining what you're feeling, or that it’s psychosomatic, but because I want to make sure we're treating the right thing.

Things worth ruling out.

These are not exhaustive. They are the ones I see most commonly missed or misread in the women I work with.

Parathyroid adenoma and hypercalcemia.

The parathyroid glands — four tiny glands behind the thyroid — regulate calcium in the body. When one develops a benign growth called an adenoma, calcium levels rise. And elevated calcium, even modestly, can produce symptoms that look exactly like anxiety, depression, cognitive fog, irritability, and in more significant cases, psychosis.

Here's what most people don't know: standard lab work checks calcium, but the threshold at which most physicians flag it as a problem is too high. My own surgeon told me that many doctors won't intervene until calcium is above 10.9. But research suggests that anything above 10.2 can produce significant mental health symptoms. A woman with calcium at 10.4 may be told her labs are normal — and sent home with an antidepressant — when what she actually has is a parathyroid adenoma that requires surgical removal.

I know this not just clinically. I know it personally. And I ask about calcium in ways that most therapists don't.

If you have never had your parathyroid hormone and calcium checked together — or if your calcium has been flagged as borderline and then dismissed — it is worth asking your doctor specifically about parathyroid function.

Thyroid disease.

Both hypothyroidism and hyperthyroidism can present with significant mental health symptoms. Hypothyroidism — an underactive thyroid — commonly produces depression, fatigue, cognitive slowing, weight changes, and emotional flatness that looks and feels exactly like clinical depression. Hyperthyroidism — an overactive thyroid — can produce anxiety, heart palpitations, irritability, and sleep disruption that looks and feels exactly like an anxiety disorder.

Thyroid function is routinely tested. But TSH alone — the standard screening marker — doesn't always tell the full story. Free T3 and Free T4, along with thyroid antibodies, give a more complete picture. If you have been told your thyroid is fine based on TSH alone, it may be worth asking for the fuller panel.

Perimenopause and menopause.

Not just the hot flashes. The neurological dimension.

Estrogen plays a significant regulatory role in serotonin, dopamine, and GABA — the neurotransmitters most directly involved in mood, anxiety, and sleep. As estrogen fluctuates and eventually declines, women can experience anxiety, depression, cognitive fog, sleep disruption, and emotional dysregulation that has a clear hormonal root. This is not weakness. It is physiology.

What concerns me is how often these symptoms get treated as purely psychological — addressed with therapy and antidepressants — without anyone connecting them to the hormonal transition happening simultaneously. I am not a hormone specialist. But I am someone who will ask about where you are in that transition and encourage you to have a full hormonal panel if you haven't.

Cardiac issues.

Anxiety and cardiac arrhythmia can feel identical from the inside. Heart palpitations, racing heart, shortness of breath, a sense of impending doom — these are classic anxiety symptoms and they are also classic cardiac symptoms. For women especially, cardiac issues are frequently underdiagnosed because the presentation is often atypical and because women's cardiac symptoms have historically been attributed to anxiety rather than investigated as cardiac events.

If you are experiencing physical symptoms alongside the emotional ones — particularly anything involving your heart rate or breathing — I will ask whether you have had a cardiac workup. Not because I think you're having a heart attack. Because I want to rule it out.

Autoimmune conditions.

Lupus, multiple sclerosis, rheumatoid arthritis, and other autoimmune conditions can produce significant neurological and psychiatric symptoms — including depression, anxiety, cognitive fog, and mood instability — sometimes before the primary condition is diagnosed. Women are disproportionately affected by autoimmune disease and disproportionately likely to have their symptoms attributed to mental health causes before the underlying condition is identified.

If you have a family history of autoimmune disease or unexplained physical symptoms alongside the emotional ones, it is worth mentioning to your doctor.

Nutritional deficiencies.

Vitamin B12, Vitamin D, iron, and magnesium deficiencies are common, inexpensive to test for, and significantly undertreated — and all of them can produce mental health symptoms including depression, anxiety, fatigue, cognitive fog, and irritability. These are not exotic or unlikely explanations. They are among the most commonly missed contributors to mood disorders in women, particularly in midlife when absorption and dietary patterns may have shifted.

A basic panel that includes these markers takes minutes to order and can change everything about how we approach the work.

What this means in practice.

When we begin working together, I may ask about your recent bloodwork. I may ask specific questions about physical symptoms that seem unrelated to what you came in for. I may encourage you to see your doctor.

For a long time I supervised psychiatrists and psychologists and I know the importance of treating the whole person, not just the presenting symptom. Many years ago, I referred a seven-year-old boy for neurological evaluation when his parents brought him to me because there was part of his story that needed further evaluation, and because assuming it was a mental health issue without ruling out a neurological one would have been a disservice to him. The neurologist told me he had never, in decades of practice, had a therapist be that thorough.

I believe that the women I work with deserve the same thoroughness.

Because your experience and your needs matter.