Persistent physical symptoms

Also called Medically unexplained symptoms, Functional disorders, Somatic symptom disorder

Real symptoms without a structural explanation. Not imaginary, not a diagnosis of exclusion done badly, and treatable.

What it is

Physical symptoms that are real, distressing and disabling, but for which investigations find no structural disease.

They are extremely common, accounting for a large share of general practice and specialist outpatient appointments, and they include chronic pain, fatigue, dizziness, bowel and bladder symptoms, and neurological symptoms such as non-epileptic seizures and functional weakness.

**The symptoms are not imagined and not deliberate.** The best current understanding is that the problem lies in how the nervous system processes and generates signals rather than in the organ itself, in the same way that software can malfunction on intact hardware. That framing is more accurate than the old idea of exclusion, and it is far more useful to people.

The historical term medically unexplained symptoms has been widely criticised, because it defines a condition by what clinicians have failed to find and implies nothing is wrong. Functional disorder or persistent physical symptoms is preferred.

Diagnosis should be positive rather than by exclusion. Functional neurological disorder, for example, has specific clinical signs, and it can be diagnosed with confidence rather than after every test comes back normal.

Treatment works: explanation, physiotherapy with a functional focus, psychological therapies, and pacing. Repeated investigation is itself harmful.

Signs you might notice

Physical symptoms that are persistent, real and disabling.

Investigations that are normal or show findings that do not explain the severity.

Symptoms that vary, sometimes markedly, with attention, distraction and circumstance.

Multiple symptoms across several body systems.

A history of repeated referrals to different specialties.

Distress, frustration, and often a conviction that something is being missed.

Not this, and needing investigation: new symptoms in an older person; weight loss; fever; night sweats; blood loss; progressive neurological deficit; or any change in an established pattern. A functional diagnosis does not protect anybody from developing disease, and new symptoms need assessing on their merits.

Urgent: anything that would be urgent in anybody else. Never let a functional label defer an emergency.

How it can affect day-to-day life

Being disbelieved is the central experience, and it comes from both directions: from clinicians who imply it is psychological, and from families and employers who see no diagnosis.

The word psychological does a lot of damage here. Stress and trauma are risk factors for some people and not for others, and a functional disorder can occur without any of that. Presenting it as a stress problem when the person does not feel stressed guarantees rejection of the diagnosis.

A clear positive explanation is the single most effective intervention. People who understand the mechanism do measurably better than those told nothing was found.

Repeated tests reinforce the belief that something is being missed, expose people to incidental findings, and are actively unhelpful once the diagnosis is secure.

Symptoms are often worse when attention is on them and better with distraction, which is a diagnostic feature rather than evidence of pretending, and explaining that carefully avoids enormous offence.

Specialist services exist, particularly for functional neurological disorder, and access is patchy.

Supporting someone well

Say clearly that the symptoms are real. Nothing useful happens until that is established.

Ask for a positive diagnosis and an explanation of the mechanism, not a list of what has been excluded.

Stop repeating investigations once the diagnosis is secure.

Ask for referral to a service experienced in functional disorders; for neurological symptoms, ask about a functional neurological disorder service.

Ask for physiotherapy with a functional focus, which is different from standard rehabilitation.

Ask for psychological therapy as a treatment for the symptoms, not as an implication about their cause.

Work on function and pacing rather than waiting for the symptoms to go.

Keep assessing new or changed symptoms normally; the label protects nobody from illness.

Use neurosymptoms.org, which is written by a neurologist and is the best patient resource available.

Where to get help

A GP practice, ideally seeing the same clinician consistently.

A functional neurological disorder service, or a pain or fatigue service, depending on the symptoms.

FND Hope UK and neurosymptoms.org for functional neurological symptoms.

Mind for support with the distress that accompanies it.