Medically Unexplained symptoms
About this leaflet
We all have physical symptoms – painful or
uncomfortable feelings in the body – at different times in our
lives. Usually they get better on their own, without any treatment.
If they don't, we might ask a doctor about them. Usually a
physical cause can be found - but sometimes it can't, even when blood tests and x-rays or scans have been
Symptoms like this are common. They can
be called “medically unexplained symptoms”, because they are not
due to a physical illness in the body. However, they
can be explained, but to do this, we need to think about
causes that are not just physical.
This leaflet is for anyone with physical
symptoms without an obvious physical cause. It also explains what
you can do to help yourself and what treatments are available.
We hope the leaflet will also be helpful if
you are a relative, friend or carer of someone with such
What is a symptom?
We have all sorts of aches, pains and odd
sensations in our bodies. Most of the time we know that these
are part of our everyday life, that they will go away on their own,
and we ignore them. If these changes are more painful or
uncomfortable, or unusual, we know they may be signs of an illness
– and we call them symptoms.
How often can doctors not explain physical
- About 1 in 4 people who see their GP have
- In a neurological outpatient setting, it is 1
in 3 patients or more’ *
Medically unexplained symptoms are really frustrating
- The tests for your symptoms are all normal - but you still have
- An important part of getting better is understanding what the
problem is – and neither you nor your doctor know.
- It can feel as though other people think that your problems are
imaginary, or that you are making them up.
What sort of symptoms can be medically
The commonest ones include:
- pains in the muscles or joints
- back pain
- feeling faint
- chest pain
- heart palpitations
- stomach problems - pain, feeling bloated, diarrhoea and
These aren’t the only medically unexplained
symptoms. Other problems include collapsing, fits,
breathlessness, weakness, paralysis, numbness and tingling.
What causes medically unexplained
When something in our body doesn’t feel right,
there usually is a bodily or 'physical' cause - stomach
problems may be due to an infection, or palpitations may be due to
a heart problem.
What if there is no physical explanation for
your physical symptoms? We can often understand and explain
such symptoms when we look at how our thoughts, feelings and
stresses can affect our bodies.
But – to say that a bodily symptom is not just
physical is not the same as saying they are all in the
mind. Medically unexplained symptoms aren't “all in the mind”,
but neither are they all in the body. To understand them we
have to think about how the mind and the body work
How are the mind and body linked?
We often think of our minds and bodies as two
separate things. In fact, they work together and affect each
Research shows that there is two way
communication between our brains and bodies. This happens
- Signals travel down the nerves from the brain to the body ...
and back again from the body to the brain.
- Natural chemicals, called 'hormones', circulate in
the bloodstream. Some are produced by the brain and
affect the body ….. and some are made in the body and affect
the brain and the way we feel.
Every day, thoughts, feelings and stresses
play a part in making changes in our bodies - for example:
- when we feel embarrassed, we blush
- feeling worried or frightened can cause an uncomfortable
feeling of "butterflies in the stomach"
- when we get upset we feel our throat tighten – “a lump in the
We also know that the way we think and feel
can make us physically ill. For example:
- feeling low or stressed makes any pain we have feel worse
- long-term stress can make us more likely to have high blood
pressure or a heart attack.
A disease in the body can affect the way we
think and feel.
Ways of thinking about the mind and the
There are different ways of thinking about how
the mind and the body are linked that can help us to understand
medically unexplained symptoms.
- Like a computer - hardware and
You can think of the brain and nerves as like
the computer that sits on a desk. But the electrical messages that
run through the nervous system are like computer programmes or
Let's look at what can happen when someone
loses the use of an arm or a leg. It can be problem with the
hardware. The brain or nerves can be damaged by a stroke or an
injury, so the messages can't get to or from the arms and
legs. However, you can get the same symptoms without any
damage to the brain and the nerves. There seems to be a
software problem. The brain and the nerves are intact but,
because the software is not running properly, they are not
controlling the limbs properly.
These “software” problems can happen when you
are under a lot of stress. Stress seems to interfere with
messaging (or “software”) of the brain and nerves. A simple
example is when someone collapses or faints when they are
under stress, like a computer “crashing”.
Chronic pain can be like this. There doesn't
seem to be physical damage that would cause pain, but something has
gone wrong with the “software” so that the brain is still getting
Another similar way of thinking about the
cause of symptoms is like a car or piano being out of tune.
All of the parts are there, but they aren’t working properly.
How does feeling stressed cause physical
Over thousands of years, we have evolved a way
of responding to stress that gets our body ready for physical
action. This was useful when life was more dangerous.
If a cave man (or woman) was attacked by a tiger, it was important
that they were able to fight the tiger or run away. This is
sometimes called the “fight or flight response”.
How does this work? Our
mind recognises the danger. The brain then sends signals to
the body via the nerves and chemicals in the blood stream,
particularly adrenaline. These signals get the body ready for
action. We breathe more quickly to get more oxygen into our
blood stream. Our heart pumps faster and harder to get blood
to our muscles. Our muscles become tense so that they are
ready for action.
We still have lots of
stresses. Nowadays, though, we don't need to
physically react to most of these stresses. For example, we
may feel under stress if we take an exam, give a talk to colleagues
at work, or if we need to be somewhere in hurry and our bus is
late. Our body’s stress response gets going and our body gets
ready for physical action - but there is nowhere for the energy to
This kind of stress response can give you:
- rapid heartbeat and palpitations
- chest tightness and breathlessness
- dizziness, faintness and feeling light headed
- feeling strange or “spaced out”
- shakiness and tremor
- indigestion, feeling sick, diarrhoea
- dry mouth
- tightness in the throat
- numbness and tingling
- headache, muscle tension and neck stiffness
- sweating and feeling hot or cold.
These physical symptoms of stress can feel
very uncomfortable, especially if we don’t know why they are
happening. They can make us feel ill. This worry can
cause even more stress and bodily symptoms, making us feel even
worse … and so on. This is more likely to happen if stress
goes on for a long time, as when we have money or job worries, or
We usually feel pain when there is damage to
the body. However, we can feel long-term or chronic pain, even
when there doesn’t seem to be a problem with the nerves. For
example, pain can be caused by an injury, but chronic pain
continues after the injury has healed. It can be very frustrating
to feel pain when there is no injury or bodily illness to account
for it. We may be also be worried that people won’t believe
how much pain we are in.
We think that chronic pain happens when intact
nerves and areas of the brain that signal pain just seem to work
wrong. (see the section above about “hardware and
Pain can make us feel miserable and depressed,
especially when it goes on for a long time. In turn, feeling
depressed lowers our pain threshold and makes the pain feel
worse. A vicious circle of pain and depression can occur where
each makes the other worse.
How does worry make symptoms worse?
It is natural to worry about our health when
we have symptoms that we don’t understand. And some of us just
worry more about our health than others. This can make us more
likely to have medically unexplained symptoms. This can happen
for a number of reasons:
- If family or friends have had serious illnesses, we may be
concerned that we will become ill too.
- We may carry our childhood experience of
illness into our adult life. For example, if our parents
worried a lot about their (or our) health when we were children, we
may be more likely to see a doctor about symptoms that someone else
- If we have already had an illness, this can make us more likely
to notice ordinary feelings in our body and misinterpret them as
signs of further illness. For example, someone who has had a
heart attack may be on the look-out for symptoms that might suggest
another heart problem.
How can being ill with anxiety or depression cause
Anxiety or depression obviously affect our
mood, but they can also cause physical symptoms. We may recognise
the physical symptoms, but find it harder to see that we are
anxious or depressed. So we tend to think that these symptoms are
due to a physical cause – when there is none.
Most people who go to their GP with anxiety or
depression begin by talking about bodily symptoms.
We have seen how the body’s stress reaction
can cause a lot of bodily symptoms. When we are ill with
anxiety, the body’s stress reaction is switched on when it is not
needed. Some of the bodily symptoms that come with anxiety are
described in the section above “How does feeling stressed cause
When we are ill with depression, not only does
it make us feel low or sad, but it also affects the body and causes
symptoms such as:
- loss of appetite
- loss of weight
- low energy
- general aches and pains.
Can I have a physical illness and medically
It is common for people to have a physical
illness, but also to have physical symptoms that are not fully
explained by that illness. This can happen for a number of
A physical illness can causes emotional stress
– which then creates physical symptoms of its own (see “How does
feeling stressed cause physical symptoms?” above).
For example, someone with an illness such as
asthma or emphysema can find it hard to breath at times. This
can be frightening, which triggers the stress reaction described
above. This makes them breathe faster and their chest feels
tight. A vicious circle is set up whereby breathlessness and
stress each make each other worse. The breathlessness is then
out of proportion to the illness that triggered it in the first
Similarly, someone who is anxious about their
heart may experience palpitations or chest tightness that are due
to stress and not heart disease.
A painful physical illness can make us feel
depressed. This lowers our pain threshold and makes the
experience of pain worse. A vicious circle can be set up, as
described in the section on “Chronic Pain” above.
If we know that we have a physical illness we
may be more alert for bodily symptoms that could indicate that our
health is getting worse. We might find that sensations that
we would otherwise ignore, such as aches or pains, become symptoms
that we worry about.
Is there a diagnosis for my symptoms?
We can give a name or a “diagnosis” for
- they occur together in a particular pattern in many people,
- when they share a similar cause.
Diagnoses for certain patterns of medically
unexplained symptoms include:
- Irritable bowel syndrome – troubling stomach
- Fibromyalgia – widespread bodily pain
- Non-epileptic attack disorder – in epilepsy,
fits are caused by problems with the electrical activity of the
brain. In non-epileptic attack disorder, someone has fits
that look like epileptic fits, but the electrical activity of the
brain is normal.
Examples of diagnoses that may be made because
of possible causes of these symptoms include:
- Somatisation disorder and somatoform
disorder – where stress is thought to be a major cause of
the symptoms, especially when the symptoms go on for a long time or
are particularly severe.
- Dissociative disorder (also called 'conversion
disorder' or 'dissociative-conversion disorder') – where it is
thought that symptoms that look like they are caused by a disease
of the nervous system (e.g. fits, paralysis, loss of memory),
but are in fact caused by stress.
- Health anxiety (sometimes called
hypochondriasis) - where someone worries a lot that their symptoms
mean they have a serious physical illness, despite reassurance that
they are not physically ill.
- Body dysmorphic disorder – where someone
is overly concerned about an aspect of their appearance, which
causes them considerable distress or gets in the way of everyday
Other diagnoses can be given for medically
unexplained symptoms, but it is common to use a general term to
describe the symptoms, such as “medically unexplained
symptoms”. Another common term is “functional” - the symptoms
are due to a problem in the way the body is functioning, even
though the structure of the body is normal.
What tests should I have for my symptoms?
You may wonder if you should have
investigations for your symptoms, such as a blood test or a
scan. Your doctor can discuss with you what investigations you
need for the symptoms you have, and when enough tests have been
done, to look for anything important.
It is often unhelpful to have investigations
that are unlikely to show anything:
- Tests may be painful and carry a risk of harm.
- Unnecessary investigations that don’t show anything are often
not reassuring. They can make someone worry even more that
there is something still to be found and that more tests are
What can I do to help myself?
Are there any stressful things going on in your life that might
be affecting how you feel? Can you talk to someone about
these? Can you get any help or advice to manage the
situation? By reducing stress you might find that your
symptoms feel better too.
Make your life
If you feel generally healthier, you may find
that your symptoms bother you less. Try to eat healthily and
cut down on smoking and alcohol. Try to get enough sleep and
have a regular sleep routine that you stick to.
Exercise can help to strengthen muscles and
generally make us more fit. However, don’t overdo it, or this
might just make you feel more tired and unwell - build up
Find time to
Relaxation often can help you to manage your
symptoms. This might be making time for you to do something
that you enjoy or that distracts you from your problems. You
might also find learning some relaxation techniques
helpful. There are many self-help books and websites
for reassurance and information about your symptoms
If you find that you spend a lot of time
worrying about your symptoms, try to remember that repeatedly
looking for reassurance or information can be
unhelpful. Reassurance often doesn’t last long and the worry
quickly comes back. Similarly, spending too much time looking
for information about your symptoms – such as on TV, in books or on
the internet – can make you more convinced that there must be a
physical illness to account for your symptoms.
When might I need treatment for my
If you find that an explanation of the cause
of your symptoms and self-help aren’t effective, your doctor might
suggest other treatments.
Your doctor might refer you to a psychiatrist
or psychologist who has experience of helping people with medically
unexplained symptoms. Often they will ask you about your
symptoms, as well as your life in general, to help understand how
the two can be linked. This can also help to decide what
treatments might suit you best.
Antidepressants are used to treat a range
of problems, not just depression, and can help treat medically
unexplained symptoms in a number of ways.
- Sometimes, the symptoms are part of anxiety or depression. In which case, the
symptoms will improve if the depression or anxiety is successfully
treated with antidepressants.
- A vicious circle can be set up between symptoms, such as pain
and depression. Antidepressants can help break this vicious circle
and both the depression and the symptoms can improve.
- Some antidepressants act as pain-killers and may be prescribed
for chronic pain, even when someone is not depressed.
- Antidepressants can help to treat a range of medically
unexplained symptoms, even when someone is not depressed. We
are not sure exactly how they do this, but the evidence shows that
they do work.
Before you start an antidepressant, you should
discuss the possible side-effects with your doctor. People
with medically unexplained symptoms may notice more side-effects
than others, partly because they may be looking out for bodily
symptoms. Knowing what to expect can help you to cope with any
side-effects. If you do get these, and you can put up with
them, they tend to improve after the first couple of weeks.
It is worth trying antidepressant treatment
for 2 to 3 months before deciding that it has not worked.
There are different types of talking therapies
that can help. The choice of therapy depends upon the sort of
problem and what therapies are available. These therapies
commonly help you to:
- recognise what seems to make your symptoms worse
- manage stresses that might contribute to the symptoms
- develop ways of coping with and living with the symptoms.
Some of the most commonly used talking
therapies to treat medically unexplained symptoms are described
behavioural therapy (CBT)
CBT can help you to
identify unhelpful thoughts about yourself and your health, which
can make symptoms worse. For example, someone may worry that,
because people in the family have been ill, they are bound to get
ill too. Or they may think that they need to have all
possible tests done in case something is missed. CBT helps
people to recognise and tackle these unhelpful thoughts and to
develop ways to change the way they think and behave, which can
improve their symptoms.
This can be particularly helpful when early
life experiences affect the way we think, feel and act. For
example, people who have experienced major difficulties as children
seem be more likely to have medically unexplained symptoms as an
adult. The therapy helps people to understand how and why
their symptoms occur, and to develop ways of coping.
therapy and solution-focussed therapy
These therapies help you identify and tackle
specific problems in your life that seem to be making the symptoms
Will I get better?
Most people who see a doctor with bodily
symptoms that are not due to physical illness are helped by talking
about how their symptoms are caused and what they can do to help
Some people have symptoms for a long time,
especially in the following circumstances:
- if they are under a lot of long-term stress;
- if they have had a lot of medical appointments and
investigations. It is not always easy to understand that
there may not be a single physical cause for the symptoms if
doctors have spent a long time looking for a physical illness.
Even if you have had symptoms for a long time,
there is much that can be done to help you live a better life and
to avoid unnecessary treatments or investigations.
- Assessment and management of
medically unexplained symptoms (2008) Hatcher S and Arroll
B. British Medical Journal 336: 1124-1128.
- Efficacy of treatment for somatoform
disorders: a review of randomized controlled trials (2007)
Kroenke K. Psychosomatic Medicine 69:881-888.
- Functional somatic syndromes
(2007) Page L and Wessely S. In: Handbook of Liaison
Psychiatry, editors: Lloyd GG and Guthrie E. Cambridge
- Medically unexplained symptoms,
somatisation and bodily distress. Developing better clinical
services (2011) Editors: Creed F,
Henninsen P, Fink P. Cambridge University Press.
- * The epidemiology of chronic
syndromes that are frequently unexplained: do they have common
associated factors? International Journal of
Epidemiology, Volume 35, Issue 2, 1 April 2006, Pages 468–476,
V R, McBeth J, Zakrzewska JM, Lunt M, Macfarlane G J
Functional and dissociative
neurological symptoms: a patient’s guide
This website has been compiled by neurologists
and gives detailed information about neurological symptoms (such as
weakness, numbness or blackouts) which are not due to neurological
Improving physical and mental health: medically unexplained
This website has been compiled by medical
royal colleges to provide links to resources for supporting the
physical health of people with mental health problems and the
mental health of people with physical health problems. It
includes a section on medically unexplained symptoms.
This website is compiled by health
professionals for patients. It gives information about
attacks which look similar to epileptic seizures, but which are not
due to the abnormal electrical activity in the brain that causes
This leaflet was produced by the Royal College of Psychiatrists
Public Education Editorial Board and the Faculty of Liaison
Series Editor: Dr Philip Timms
Authors: Dr Jim Bolton & Dr D Attard
This leaflet reflects the best available evidence available at
the time of writing.
Illustration: © Lo Cole: http://www.locole.co.uk
© November 2015. Due for review: November 2018
Royal College of Psychiatrists.
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