When Every Test Is Normal, and You Are Still Unwell
What this condition actually is
The names have changed several times and the old ones did damage.
You may have heard somatisation, psychosomatic, medically unexplained symptoms, or — still, in Indian hospitals, said within earshot of patients — hysteria. Current classifications use somatic symptom disorder and bodily distress disorder.
Here is the change that matters most, and it is not a technicality.
The older idea was: symptoms with no medical explanation. Tests normal, therefore psychiatric. The diagnosis was made by exclusion — a diagnosis of what was left over.
The current definition does not work that way. It is defined by what is present, not by what is absent. Specifically: distressing physical symptoms, plus excessive thoughts, feelings and behaviour around them — persistent anxiety about their seriousness, disproportionate time and energy spent on them, a life increasingly organised around them.
Which means two things people are rarely told:
You can have a real, diagnosed disease and also have this. A person with genuine diabetes, genuine arthritis, or a genuine cardiac problem can also develop a level of preoccupation and distress that has become a separate problem needing separate treatment. One does not disprove the other.
Nobody is saying your tests were wrong or your doctors missed something. This is not a claim that there is a hidden illness. Nor is it a claim that you are inventing one.
So it is all in my head?
No. And I want to spend a moment on this, because it is the sentence that ends treatment before it starts.
Everything you feel is in your head, in the strict sense — pain, touch, temperature, nausea are all constructed by the brain from signals coming in. That is true of a broken bone as much as of anything on this page. The brain does not passively receive sensation; it interprets, filters and amplifies it.
In some people, and for reasons that include genetics, prolonged stress, previous illness, and periods of intense fear, that system becomes turned up. Signals that would ordinarily be filtered out get through. Ordinary sensations get amplified into significant ones. Attention locks onto the body and, once attention is on a sensation, the sensation genuinely intensifies — this is measurable, not a manner of speaking.
The result is real pain from a body that is functioning normally. The nerve is doing its job. The volume control is set wrong.
That is not imagination, and it is not weakness. It is also, importantly, not permanent.
What it looks like in India
The presentations here have their own character, and international articles will not describe them.
Pain — head, back, abdomen, whole body. Frequently described as moving.
Burning sensations — in the feet, in the eyes, in the stomach, in the chest. Sometimes described as heat rising through the body.
Gas and acidity. The commonest idiom of distress in this country. Gas that moves, gas that rises to the head, gas that causes giddiness. Enormous quantities of antacids get consumed for what is not an acid problem.
Weakness and giddiness — a body that will not do what it used to, without any weakness on examination.
Palpitations and breathlessness — overlapping heavily with anxiety and panic, and covered further on the anxiety page.
Tingling, numbness, “current” sensations.
Concerns about semen loss. I include this deliberately, without any mockery, because it is a recognised presentation in Indian psychiatry; it is common among young men, and it is met almost everywhere with either ridicule or a chemist selling something. Men present with weakness, poor concentration, anxiety and physical complaints, attributed to loss of semen through nocturnal emission or masturbation. The underlying distress is genuine; it is usually accompanied by anxiety or depression, and it responds to treatment. If this is your worry, it is a legitimate reason to see a psychiatrist, and you will not be laughed at here.
Functional neurological symptoms. Weakness, difficulty walking, tremor, or episodes that look like seizures but are not epilepsy. These are among the most badly treated presentations in Indian hospitals. The patient is frequently labelled dramatic, told to stop it, and occasionally shouted at in casualty. These episodes are not under the person’s control, and they are not faking. They have a recognised name, a recognised mechanism, and specific treatment. Anyone who has been treated with contempt for this deserves better and should seek a psychiatric opinion rather than accepting the verdict.
Why the medical system makes it worse
Not through anybody’s bad intent. Through a completely reasonable process that produces a bad outcome.
You have a symptom. The doctor, correctly, investigates. The test is normal. You feel relief — for a few days.
Then the symptom returns. And now there is a new thought: the test missed it. So another doctor, another test, perhaps a bigger one. Normal again. Relief again, shorter this time.
Each cycle does three things. It teaches your brain that this symptom is dangerous enough to warrant investigation. It fixes attention more tightly on the body. And it shortens the half-life of reassurance until eventually a normal report brings no relief at all, only the conviction that nobody is looking properly.
Meanwhile real harm accumulates: procedures with genuine risks, medicines that pile up, painkillers that become a problem of their own, money that runs into lakhs, and — for the person — years.
And then somebody says there is nothing wrong with you, meaning your organs are healthy, and the patient hears you are making this up, and the relationship breaks, and they go to the twelfth doctor.
If you recognise this cycle: it is not your fault and it is not your doctors’ fault. It is a trap that the system and the illness build together.
What is often underneath
Not always, but very often:
Depression. Which in India frequently arrives wearing a body’s clothes. Low mood may not be reported at all; body pain and weakness are what gets described.
Anxiety. Producing genuine physical symptoms and then generating fear about them.
Past experience. A serious illness or death in the family, a frightening medical episode, sometimes childhood adversity or trauma.
Life circumstances that cannot be said out loud. I put this carefully, because it is easy to make it sound like an accusation. But there are situations — a marriage that cannot be discussed, a debt, caring for a difficult in-law, a job with no exit — where distress has no acceptable outlet, and the body becomes the only permitted language. In many Indian households, “my stomach hurts” gets a response and “I am unhappy in this house” does not.
That is not manipulation. It is usually completely outside the person’s awareness, and pointing at it clumsily is one of the fastest ways to lose a patient.
A story from the consulting room
The following is a composite — assembled from patterns I have seen many times. It is not any one patient, and all details have been changed.
The woman with the cloth bag.
She had stopped going to functions, because what if the pain started. She had stopped cooking on bad days, so her daughter-in-law had taken it over, and that had become its own quiet grievance in the house. She spent, by her own estimate, three or four hours a day thinking about her stomach.
Her gastroenterologist had done what a good gastroenterologist does. He had found nothing, twice, and had told her — kindly — to relax. She had understood this to mean he had given up on her.
The first thing that changed was the explanation. I drew her the volume-control idea on a piece of paper. She did not accept it that day. She came back a fortnight later and said her son had explained it to her again at home and she had thought about it, and she wanted to know why nobody had told her this in nine years.
We agreed on monthly appointments regardless of symptoms. We agreed no new investigation unless something changed. She was, on assessment, clearly depressed — sleeping badly, no interest in anything, a mood she had never once mentioned to any of the eleven doctors because nobody asked and it did not seem like a medical matter.
Treatment was ordinary: an antidepressant, some CBT work, and a plan to slowly resume cooking two days a week.
At about five months she told me the pain was still there but she had been to a wedding.
At around a year she said something I have quoted to patients ever since: “It still comes. But it is not the main thing in my day any more.”
That is what recovery looks like in this condition. Not a cure. A demotion.
For families
Believe the pain. You do not have to understand it. Saying “there is nothing wrong with you” is heard as an accusation of lying, and it costs you the ability to help.
Stop asking about the symptoms. How is your stomach today? asked four times a day, out of love, keeps attention locked exactly where it must not be. Ask about her day instead.
Do not fund endless testing. Wanting to do something is natural, and paying for the sixth scan feels like caring. It is one of the most reliable ways to make this worse.
Encourage activity, gently, without a lecture. Not rest. Not “just push through it” either. Small, regular, negotiated.
Do not accuse anybody of drama. Whatever you have concluded privately during nine years of this — saying it aloud ends the possibility of treatment.
Watch for what she is not saying. Sometimes the body is carrying something that has no other permitted route in the house. Nobody needs to be blamed for that. It is worth being curious about.
Frequently Asked Questions.
Am I imagining this?
No. The symptoms are real and physically felt. The problem lies in how signals are processed and amplified, not in whether you are experiencing them.
Does this mean the doctors missed a disease?
It does not mean that, and it also does not rule it out forever. Good practice is to remain open to genuinely new or changing symptoms while stopping the repeated re-testing of the old ones.
Why is a psychiatrist treating my pain?
Because psychiatry has effective tools for pain that is generated and amplified in the nervous system — including medicines that act on pain pathways. It is not a comment on whether your pain is real.
Is this hysteria?
That word should be retired. It was used to dismiss people, mostly women, for a very long time. The conditions it referred to are real, recognised and treatable.
Will I be told to stop my other medicines?
Not without discussion, and not by a psychiatrist acting alone. Often part of the work is simplifying an accumulated list of medicines, done carefully and with the other doctors involved.
How long does treatment take?
Months rather than weeks. Improvement is usually gradual and shows up first as doing more, and only later as feeling less.
Sources
- Indian Psychiatric Society — Clinical Practice Guidelines
- World Health Organization — ICD-11, bodily distress disorder
- DSM-5-TR — somatic symptom and related disorders
- National Institute for Health and Care Excellence (NICE) — guidance on medically unexplained symptoms in primary care