"The tests are normal, but it still hurts": what therapy knows about psychosomatics

“All the tests are normal.” For many people that is the most confusing sentence they can hear. The pain is real, the fatigue is real, the digestion is not working — and the results say there is nothing there.

Then comes the part that wounds most: “So it must be in your head.” Hidden in that sentence is an accusation the speaker often does not even intend — as though “in your head” meant “made up”.

It does not. And this misunderstanding is exactly why many people with genuine physical distress circle between clinics for years, while treatment that would help them exists. In this piece I explain what psychosomatics is and is not, what actually happens in the body, and when therapy makes sense — and when it does not.

What psychosomatics is not

Let us start by ruling things out, because this is where most of the damage is done.

It is not faking. The symptom is physiologically real. Pain registers in the same brain regions whether the cause is injury or prolonged stress.

It is not a sign of weakness. A physical response to strain is not a matter of character. Many people with psychosomatic difficulties are markedly resilient — and that is often part of the story, because they endured for too long.

It is not a diagnosis by exclusion. “We found nothing, so it must be psychosomatic” is poor logic. A psychosomatic formulation rests on what is there — the pattern, the course, the triggers — not merely on what is absent.

It is not an excuse to stop investigating. Some illnesses are detected late. If the picture changes or new signs appear, renewed medical assessment is essential, even if the earlier psychosomatic formulation was correct.

What actually happens in the body

Three mechanisms that are reasonably well researched.

First: the stress system. Under threat the hypothalamic–pituitary–adrenal axis activates and cortisol output rises. This is useful in the short term. When the system does not switch off — because the threat is not a bear but an unresolved situation lasting months — the consequences appear in digestion, sleep, immune response and muscle tension.

Second: muscle tension we do not notice. Persistently raised tone in the shoulders, jaw and pelvic floor is common in people under prolonged strain. Because it is constant, it is not experienced as tension but as pain without a cause.

Third, and most interesting: how the brain constructs perception. Pain is not a signal travelling up a nerve from tissue to head. It is a prediction the brain assembles from bodily signals, prior experience and expectation. This is why it is possible to have severe pain without injury, and severe injury with little pain.

From which follows something counterintuitive: pain without a detected lesion is not less real — it arose differently. And precisely for that reason it can be influenced by routes that are not surgical.

Where this shows up most often

Some patterns I meet in practice, with the warning that none of them is automatically psychosomatic.

Digestion. Irritable bowel syndrome is the best-researched example of the gut–brain connection. It is a genuine disorder of function, not imagination, and psychological treatments have a demonstrated place in it.

Back and neck pain. In chronic pain without clear structural damage, the role of stress and expectation is well documented.

Headaches. Tension-type headache is often linked to muscle tension and strain.

Fatigue that sleep does not fix. Common in prolonged overload and in depression, where a physical symptom can be the first and only one.

Chest tightness and breathlessness. The classic presentation of anxiety, which people understandably attribute to the heart first — and it is right that this is ruled out first.

Skin. Flare-ups of eczema and psoriasis during periods of strain are common and documented.

Why the symptom appears just there

A question people often ask: why does my back hurt while my neighbour’s stomach does?

There is no confident answer, but there are sensible accounts. A symptom often appears where the body is already vulnerable — at the site of an old injury, in an organ with inherited sensitivity. Learned attention plays a part too: someone who grew up in a family that constantly monitored digestion will notice gut signals sooner.

What I advise against is symbolic interpretation. Claims like “shoulder pain means you carry too much responsibility” sound convincing and have no evidence behind them. Sometimes they are a useful metaphor; more often they steer people away from what would actually help.

What therapy can do here

Concretely, because general promises do not help.

It breaks the worry loop. With chronic symptoms the strongest maintaining factor is often fear of the symptom itself. Checking the body, avoiding movement and seeking further opinions all raise tension. Working on this loop is among the best-supported approaches for several conditions.

It addresses strain that persists. When the background is a situation that will not move — caring for a relative, untenable conditions at work, conflict at home — the body often settles only once the position shifts. Here therapy is in fact work on circumstances and boundaries.

It restores contact with bodily signals. Many people under long strain no longer register tension. Learning to recognise physical signs before they become pain is a measurable skill.

It lowers general arousal. Breathing and relaxation techniques are not magic, but they have a documented effect on the autonomic nervous system.

What therapy does not do: it does not replace medical care, does not treat inflammation and does not repair structural damage.

What a good doctor does and what a poor one does

Worth saying, because people often do not know what they may expect.

Good care says the results are normal and in the same breath explains that this does not mean there is nothing. It offers an account of how strain produces genuine physical symptoms, proposes a next step, and stays available if the picture changes.

Poor care ends with “there’s nothing” and a shrug. The person leaves feeling disbelieved, and because the pain remains, goes looking for the next opinion. That is how a cycle of investigations begins that lasts years and takes nobody anywhere.

If you have found yourself in the second case, it is worth asking outright: “If there is no physical cause, what do you suggest I do about these symptoms?” That question often moves the conversation.

One exercise worth trying

Not as treatment, but as a way of gathering information about yourself.

For two weeks record three things, one line a day: the intensity of the symptom from 0 to 10, what happened that day in one sentence, and how much you slept.

After two weeks, look for a pattern. Many people notice for the first time that the symptom is worst on Sunday evening or the day after a conflict, rather than after the greatest physical exertion. That is more useful information than another scan — and if you decide on treatment, it is an excellent starting point for a first session.

If there is no pattern, that is information too: then it is worth persisting with the medical route.

Where the limit of my work is

Since these are physical symptoms, the boundary matters particularly here.

I am not a doctor. I do not judge whether pain is caused by illness, and I never steer anyone away from investigations. When someone describes symptoms a doctor has not yet seen, my first suggestion is always the same: see a doctor first.

What I do is work with what builds up around a symptom — the fear, the avoidance, the tension, and the circumstances that maintain the strain. For many people that is exactly what is prolonging the symptom unnecessarily.

If you want to know how the system divides the professions, I have written about it in who may diagnose and who may prescribe.

What to remember

“In your head” does not mean “made up”. It means the nervous system is involved in producing the symptom — and because it is involved, it can be influenced.

Medical assessment always comes first and stays open. But when tests keep coming back clear while the symptom persists and tracks pressure, waiting for an investigation that will finally find something is pointless. At that point it is wiser to ask what is maintaining it.