“What if it’s something serious?!”

My experience of health and illness anxiety in adolescents has gradually moved me away from thinking of it as a primarily cognitive problem.

This was not where I started. My clinical training pointed clearly in a different direction, and for good reason. The cognitive model of health anxiety is a genuinely compelling one. The account offered in texts like the Oxford Guide to Cognitive Behavioural Therapy, and in the broader clinical literature, makes a strong case: that what we are dealing with is a pattern of misinterpretation, in which neutral or ambiguous bodily sensations are read as evidence of serious illness. The model is internally coherent, it maps onto what patients describe, and it has generated treatments with a reasonable evidence base behind them.

I did not arrive at scepticism quickly, and I do not hold it lightly. But something kept not quite fitting. Not in a way that was easy to name at first. More a recurring sense, sitting with these young people, that the framework was leaving something out. That the work being asked of me, if I followed the model faithfully, was somehow not reaching the part of the problem that felt most alive in the room.

What I find myself sitting with instead is a young person who seems to be using their body as a way of approaching a question they cannot quite think about directly. The symptoms are not random. Nor are they just mistakes. They are being used as evidence for something that already sits, quietly, in the background of their experience. Not a fully formed belief, and not something they would necessarily say out loud, but a kind of expectancy that something inside them may not be entirely right. The body becomes the place where that question can be asked again and again.

Over time, I’ve also become struck by how often these young people come from families that, on the surface, function well. There is usually care. Often a great deal of it. Things get done. Appointments are attended. The adolescent is, in many ways, well held. And yet, emotionally, there can be a particular atmosphere. A tendency towards keeping things manageable. Towards smoothing rather than dwelling. Feelings are not absent, but they do not always have much room to unfold in their more uncertain or disorganised forms.

Anxiety, in these settings, is not always spoken. It is felt more as a kind of background pressure. Sometimes it sits more visibly with a parent, sometimes less so, but it often feels as though it belongs to the system rather than any one individual.

The young person, often quite perceptive, seems to register this. Not consciously, and not as a deliberate role, but gradually they begin to occupy a position within the family where they are attending to something that is otherwise left unarticulated. I have come to think of this, tentatively, as a kind of monitoring function. They become the one who notices, who checks, who keeps an eye on what might be going wrong. But the monitoring does not take place in the realm of thought.

These are often young people whose thinking is relatively organised. They can be articulate, reasonable, even insightful about others. It is when attention turns inward, particularly towards the body, that something shifts. A sensation can be returned to, inspected, tested in a way that a feeling cannot. And so the question begins to change. Less “what am I feeling?” and more “what is wrong with me?”

It has gradually become harder for me to see this as simple misinterpretation. The symptom gives form to something otherwise difficult to hold in mind. It allows vulnerability to be expressed in a way that feels legitimate and shareable. It draws others in, often quite powerfully, into cycles of concern and care.

I find myself wondering whether what we are seeing is not just anxiety about illness, but a particular way of organising experience. An adolescent, sensitive to internal disturbance, within a family system that tends towards regulation over exploration, comes to use the body as the most available place to locate and manage uncertainty. The symptom, in that sense, is not incidental. It is a solution.