Are we seeing more stress-related physical symptoms during the COVID pandemic?

Observations from my practice and some approaches to managing this

The simple answer is yes. Stress related symptoms are common during “normal” times so in this period of heightened global uncertainty, it is not surprising that General Practitioners such as myself are seeing more patients presenting with symptoms that don’t have a clearly defined physical cause.

By physical cause, we mean that as far as we can tell through careful history and examination and appropriate testing, there isn’t an obvious disease process such as cancer, inflammation or a fracture at the root of the symptoms. Over the last few weeks, we’ve seen more cases of migraine, irritable bowel with normal investigations and unexplained rashes and skin problems. The other presentations that are interesting are those such as eczema and skin problems such as psoriasis which typically don’t affect the patient under normal circumstances.

I’ve certainly has conversations with people who have experienced flare ups of skin conditions that that had not bothered them for years. One patient had a particularly spectacular flare up of psoriasis with a forty year gap between presentations. The last presentation being at the time of his A-Levels in the late 1970s

The interesting question here is why should these sorts of things flare up now? When I spoke to the individual concerned, the current pandemic had brought up feelings of anxiety relating to his job and future and this was similar to the stresses he had experienced during his time at sixth form. It was as if the body had remembered the stress response and churned it out again.

There are many conditions that are thought to have stress-related components. The following list from the PPD Association gives a comprehensive summary (1). So if you are having new symptoms that seem to have started in the last couple of months, what should you do? See below for some thoughts

Firstly any new symptom that is not resolving within reasonable timeframe such as couple of weeks should have a medical evaluation to rule out a physical disease process. Clearly if you feel unwell, then seek help as soon as possible. Any COVID-19 sounding symptom should be managed according to the current guidance which can be found online (2).

Your local GP remains open although there are changes to the operating procedures of all practices. A recent article in the Guardian (3) found that 75% of consultations are now being conducted over the telephone or via video or email. This seems to be working well. Some people will still need to be seen face to face and practices have put in place measures to keep things as safe as possible. This may mean coming to the surgery early on in the day and both doctors’ and patients’ wearing PPE. The hospitals have postponed a lot of routine work but they are still carrying out urgent appointments and essential investigations.

Download the hidden stress test and complete it. This can be found on the PPD website (4). It is not uncommon to find that stressors are not immediately obvious. A person may know that something is stressful intellectually but not be able to connect with the feeling tone of the experience. Interestingly often when people do get in touch with the feelings and “feel” them, the physical symptoms will often resolve. Being stressed about something doesn’t always imply that you are not coping with it.

Once you have the test completed, look carefully at the sources of stress and see if there is anything that you can do to reduce the stress or perhaps alter the way that you are reacting to it. Be gentle with yourself. A spirit of curiosity and self-compassion is helpful. Reduce your expectations of yourself if possible. You do not have to do everything perfectly.

Make time to connect with others. Humans are social creatures and it can be really helpful to talk to others about what is going on –  “A problem shared is a problem halved”. This may be in person or virtually. The Smart Brief article below has some helpful suggestions and science (5).

Spend time in nature. Having our “time outside” curtailed in the initial stages of the lockdown made going outside for a “walk” a much bigger thing. It forced us to slow down and explore new routes out of the house. We noticed many things about our local area that we had never actually seen before. This article from the Guardian enthuses the benefits of immersing ourselves in nature which in itself is stress-relievng (6).


A Foray into Mind-Body Medicine Part 4

In this final blog, I’m going to explain how I incorporate this approach into my NHS work within General Practice. On a typical day, we will see quite a few patients with probable stress illness. They may present with headaches, back pain, or other related conditions. The first step is a thorough history and examination with appropriate investigations as directed by the story and the various clinical guidelines that we use within the NHS.

The patient’s story is so important in this work. It’s crucial to find out when the problem started, what was going on in their life at the time as well as any beliefs or worries that they may have about its causation. There are certain “clues” in the history as to a possible “mind-body” cause. For example, did the symptoms start at a particularly stressful time in the person’s life? Are there specific triggers to the problem? A common story is say back pain that only happens at work remitting completely when the person is back home. Vigorous movements in the gym are completely pain-free and then the pain re-exerts itself when the individual is resting or perhaps thinking about future problems.

Not all life stressors are conscious and maybe perceived as normal to the person. Also people can be reluctant to admit to stress because of the perception of being seen as “not coping”. In actual fact, stress is a normal part of life and not something that just happens to the odd few people. The Hidden Stress Inventory available on the PPD Association website is a useful download.

It’s imperative to keep the mind open when stress illness is suspected and investigate appropriately to rule out any physical disease processes such as cancer, inflammatory conditions or fractures. This might be through the use of imaging, blood testing or electrophysiological testing. Even when the tests are normal and I’m fairly confident we are dealing with stress illness, I never quite close my mind completely and I will re-investigate patients if the symptoms change in a way that might suggest a physical disease process is evolving.

I tend to have a higher suspicion for physical illness in older patients, with symptoms that are progressively worsening and in people that physically look unwell. Unintentional weight loss / unexplained lumps and bumps on the body and non healing ulcers or skin lesions must also be checked out carefully.

It’s really important when discussing stress illness to reiterate that the SYMPTOMS ARE REAL. They are not imaginary or part of some psychiatric problem or weird conversion symptom. They are so common as to affect us all at some point. I can remember having really quite severe dental pain a few years back. As a child I was rather fond of sweets and amassed a number of fillings by the time I was a teenager. I’ve mended my ways somewhat since becoming an adult but dental pain tends to provoke a really over the top reaction in me and I worry unnecessarily about my teeth falling out.

On this occasion, off I trotted to the dentist and had an examination and X-rays and all looked fine. On hearing this, the pain disappeared. Now when it comes back, I tend to ask myself what’s bothering me and look at my thought processes. I also remind myself that I have regular dental checks and they have all been fine. Then, if the pain persists, I might at that point consider visiting the dentist.

When I see patients, if I suspect a mind-body problem I will usually share my thoughts quite early on. I then explain, if tests are needed that we will review the situation once the investigations are back. Sometimes people do not want to consider an emotional cause for their symptoms. This is okay and it’s important not to force one’s opinions on them. Again beliefs are important here and sometimes discussing emotions and stress can make people feel vulnerable. They might worry that they are being slotted into some sort of mental health box. This is not the case.

It interesting that when a patient starts to look at their emotions and make sense of them by feeling them or say journalling about them, their symptoms may initially get worse or move to another part of the body. Dr Sarno called this the Symptom Imperative and it is actually a good diagnostic test for mind-body syndrome as physical diseases do not typically behave in this way. Becoming aware of emotions can feel threatening initially (presumably this is why they were unconsciously repressed in the first place) and so the body-mind kicks back by producing more symptoms. Thankfully noticing this process adds weight to the case for stress related symptoms and can be very reassuring to the patient as the chances of recovery are high.

One of the main issues with this work in NHS General Practice is the lack of time. Typically we will consult in 12 minute appointments and so this work may take 2-3 appointments to even introduce the concept. There is a shortage of appointments within the system and so it can be quite frustrating. We have the advantage of having known many of our patients over several years and so we tend to know what stresses and strains they are under.

I do a lot of signposting and with interested patients, I will signpost them to the websites I have mentioned in Blog 3. TMS Wiki has a free course curated by Alan Gordon LCSW (link below) which many have found helpful and in the last few years we have been gifted with the Curable App. This app is well worth signing up for and many of the US specialists I mentioned in the previous blog have contributed their knowledge as part of the Advisory Board.

It seems to me that other approaches for working with persistent pain and PPD type symptoms are becoming more acceptable to both doctors and patients. The opioid crisis has shown us that simply medicating symptoms with pharmacological agents does not consistently work and often causes more harm than good. We have to open our minds

Alan Gordon’s Pain Recovery Program

Curable App



A Foray into Mind-Body Medicine Part 3

In this blog I will cover the ongoing work of some of Dr Sarno’s colleagues who have continued his legacy. They have worked to develop his theories and make them available to a wider audience. There are many practitioners worldwide who are currently working with clients and patients in pain. Here in alphabetical order are four individuals whose work I am most familiar with. There are many others and I encourage you to research them.

Dr. David Clarke MD

Dr Clarke is Professor Emeritus of Gastroenterology at Oregon Health and Science University in Portland and President of the Psychophysiologic Disorders Association. A psychophysiological disorder (or PPD) is a clinical term for mind-body symptoms that are thought to be caused by learned neural pathways. A neural pathway is a neurological pathway that is created by the human body system in response to a particular need. For example we may have neural pathways for riding a bike or driving a car. Once we have leaned to do these things, they function automatically and we can do them without us having to think about them too much.

In PPD, these pathways are learnt as an adaption to previous stressors, traumas and repressed emotions. The process of PPD is likely to have begun life as a protective mechanism to help the individual navigate through life by keeping these stressors out of awareness. Over time, the symptoms become problematic and disruptive. Many medical diagnoses such as fibromyalgia, chronic pain symptoms and gastrointestinal symptoms such as irritable bowel syndrome are thought to have underlying PPD type processes and can be helped using a mind-body approach. It goes without saying that before a diagnosis of PPD is made, the patient must have undergone appropriate medical testing to rule out physical diseases such as cancer, inflammatory conditions and fractures. PPD is also known as Stress Illness and Mind-Body Syndrome and I’ll use the terms interchangeably.

The PPD website is a fantastic resource for both patients and interested professionals. I’d also recommend Dr Clarke’s book They Can’t Find Anything Wrong! 7 Keys to Understanding, Healing and Treating Stress Illness. He’s also co-authored a more recent book, Psychophysiologic Disorders with Dr Howard Schubiner and others.

Dr. David Hanscom

I first met Dr Hanscom in 2017 when he was speaking at the UK SIRPA conference (see below for details of what SIRPA is). He is a spinal surgeon specialising in complex spinal deformities. He is also managed to cure his own back pain using mind-body approaches. Based in Seattle, he is the author of two books, Back in Control and Do You Really Need Spine Surgery? In 2018, he ceased his surgical practice to help patients with mind-body approaches. He found in many cases, spinal surgery when there wasn’t a specific structural cause was unhelpful and harmful. His website and books are a very helpful resource for patients considering back surgery.

Georgie Oldfield MCSP

Georgie is my colleague here in the UK and I first met her in 2015 after reading Dr Sarno’s books. Thanks to Google and a helpful pointer from one of our American colleagues, I discovered that she was practicing in Huddersfield. Georgie is a physiotherapist and spent many years working within the NHS. In 2007, she went to New York to spend some time with Dr Sarno and subsequently set up SIRPA in 2010. SIRPA is the Stress Illness Recovery Practitioners Association. SIRPA works with both patients and clients in pain and also provides training to interested health professionals. Both the practitioner training and the patient recovery program are now online so that they are accessible to a greater number of people. Georgie also sees clients privately on an individual basis. In 2019, she became the first professional in the field to give a TED talk on this subject and the link is below. She’s also written a book which has also been translated into Spanish.

Dr Howard Schubiner MD

Over the years, Dr Schubiner has contributed to a number of important research studies in this field. Ongoing research is essential as this field develops to add credibility and provide scientific backing to the clinical observations. He is also a mindfulness practitioner and experienced teacher. He practices in Michigan, US. I absolutely love his YouTube clip explaining neural pathways. The link is below. There is an online Mind Body Healing Programme as well as two books, Unlearn Your Pain and Unlearn Your Anxiety.

For the fourth part of the blog, I’ll close by explaining how I have incorporated this work into my NHS GP practice.

A Foray into Mind-Body Medicine Part 2

So in this blog, I’m going to talk about the work of Dr John Sarno. Dr Sarno, (1923-2017) was Professor of Rehabilitation Medicine at New York University School of Medicine. He was a controversial figure in medicine as he went against the prevailing paradigm for treating chronic back pain. To his patients, he was a hero and many went onto live pain-free lives. I found out about him through a chance conversation with a medical colleague who suggested that I might find his books interesting. I went onto to purchase all three books; The Divided Mind, The Mind-Body Prescription and Healing Back Pain.

In many ways Dr Sarno was a typical doctor in appearance. He wore a while coat, had an imposing bedside manner and assessed patients using a typical medical “history and examination”. However his conclusions about what was causing the majority of his patients’ pain differed significantly from most of his contemporaries. He concluded that in most cases, patients with back pain had nothing physically wrong with their backs. Their pain was caused by repressed emotions, typically anger, which was deemed too threatening for the individual to express directly.

In a typically protective move, the body diverts the experience of anger into physical pain which is unconsciously expressed by the patient as a preferable option. The solution according to Dr Sarno, was to accept this fact and resume normal activity as soon as possible. Many patients recovered. Some needed more intensive psychotherapy to identify the emotions involved, feel them directly and then find some way of integrating them into their life story.

Sarno called this process of “pain being caused by emotions” – Tension Myositis Syndrome. This was later changed to Tension Myoneural Syndrome. This paid respect to the physiological process that Sarno believed was taking place. He hypothesised that physiological changes in the muscles and nerves of the body were taking place, driven by the presence of unconscious emotional conflicts. He also wondered if a process of oxygen deprivation was taking place at the level of muscles and nerves to cause the pain. To date, there hasn’t been significant evidence to prove this  “lack of oxygen hypothesis”.

Dr Sarno started developing his theories in the 1970s and 1980s. With the advent of MRIs, he noticed that patients’ syndromes didn’t always correspond with the “pathology” shown on the images. For example, a patient could have a scan which suggested a bulging lumbar disc on the right side, pressing on the sciatic nerve but have tingling and numbness in their left leg. This doesn’t fit a typical anatomical pattern. Other patients might have extensive osteoarthritis in their lumbar spines, but only get pain when they are under significant stress. This doesn’t fit with a bio-mechanical problem as the arthritis in the spine wouldn’t necessarily know that the person was visiting their Mother in Law! And why not have pain at any other time?

More recent studies such as the one by Waleed Brinjikji et al (1) demonstrated that 50% of pain-free 30 year olds have some evidence of disc degeneration on MRIs and 40% have evidence of a bulging disc. These numbers rise as people age and many of these people have no pain. Interestingly (as I’ve seen in my practice), once an asymptomatic patient becomes aware of these “changes” by viewing the MRI report, they can develop pain in the area of degeneration. This doesn’t make sense either unless you consider that the stress of knowing about this “abnormality” and the subsequent ruminations about what it might mean for their health going forward creates the symptom. This doesn’t mean that the pain is not real. It absolutely is. Sarno called these changes on spinal MRIs “normal abnormalities”. They are tied in with the process of ageing and are a normal part of life.

For me, as a doctor, Sarno’s theories made a lot of sense. I had experienced patients coming into my surgery complaining of severe back pain. After a chat, it became clear that something else was bothering them and expression of the emotion directly silenced the symptom and they left pain-free. Other patients who experienced bouts of back pain from time to time would experience relapses that corresponded with significant stressors in their lives such as losing a job or a family bereavement.

I remember a GP colleague, being incapacitated with back pain just as she was about to call a particular patient into her surgery. The patient was known to behave in an abusive way at times and was hyper-critical of the care provided. The doctor was incredibly conscientious and struggled to deal with this kind of behaviour. The pain was so severe that she had to end the surgery. This pattern doesn’t fit with a bio-mechanical cause as why would the pain have come on then and not at some other time?

Dr Sarno passed away in 2017 after a long career. His work continues thanks to the dedication of a number of health professionals who have developed his theories, published formal research and continued to train other interested health professionals

This is the subject of the next blog.

1) Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36, 811–6.

Other useful information

Youtube Dr Sarno Healing Back Pain audiobook

All The Rage (2016) film describing Dr Sarno’s work (pay per view)

Free TMS Wiki site with information about Tension Myositis Syndrome

A Foray into Mind – Body Medicine Part 1

My name is Dr Lizzie Croton. I am a UK GP. A few years ago, I became slightly disillusioned with some aspects of medicine. I was a diligent student, I learnt all the guidelines and could parrot them off with abandon if required. I felt that if I just applied them to the concerns that my patients brought to me, they would miraculously get better. Sadly this was not always the case. It seemed that blanketly applying the same guideline to each patient wasn’t always helpful. That’s not to say that guidelines cannot be helpful. In the right context, when it is clear what the pathology is, they can be very useful to provide structure and standardise treatment.

There were certain problems that I saw, chronic pain being the most common, that didn’t seem to be resolved by standard medical treatments. We could prescribe medication, we could perform imaging of the affected area or recommend certain body treatments such as physiotherapy. Sometimes this worked, but a lot of the time, it didn’t. I found myself becoming increasingly frustrated, as did my patients.

Around the same time, I saw a lady who had been diagnosed with fibromyalgia and was taking around eight medications, of which 6 were analgesic medications and the rest were antidepressants. We were talking one day and she mentioned cautiously that she had been thinking about stopping some of the medications as she didn’t feel they were helpful. I remember thinking that we had kind of come off the “map” as in those days, it seemed less common to stop prescribed drugs. Now de-prescribing is something that is becoming widely practised in medicine and for good reason. It provides flexibility, promotes patient choice and reduces the side effects of unnecessary medication.

I have to admit, I felt slightly anxious about allowing her to stop her medication. What if the pain got worse and we couldn’t handle it? I felt slightly out of control. We decided quite sensibly that we wouldn’t target them all at once and she could choose which one she wanted to stop first. So over a period of 4-6 months, we managed to stop 5 of the medications and she remained on 3. Her pain did increase initially, but interestingly she became more confident and better able to make decisions for herself. She started to make more informed choices about her healthcare and rather than just being a passive recipient of whatever medicine had to throw at her, she became a more empowered “patient” generally.

Seeing her change really interested me and completely defied my expectations. Clearly something positive had happened and I asked her about it one day. She felt that being given the choice to take matters into her own hands with professional backing had given her the control back and that had helped her to manage the increase in symptoms she experienced. Today she is well and working and generally enjoying life.

It was a couple of months later that a chance conversation with a friend introduced me to the work of US physician Dr John Sarno. His work is the subject of my next blog.

Details of individual patients have been changed to endure confidentiality. The above case study is an amalgamation of several patients. If you are taking prescribed medication, please do not stop it without consulting your doctor first.

Review of Psychophysiologic Disorders – Trauma Informed, Interprofessional Diagnosis and Treatment

Those who follow mind-body social media feeds will probably have noticed that a new book has recently been released. It’s called Psychophysiologic Disorders and has been edited by a number of leading clinicians in the field of of mind-body medicine.

I’ve just finished my first read-through of the text and and I’m very impressed with the depth of content and clinical wisdom that has gone into this piece of work. The authors hail from different backgrounds ; medicine, surgery, physiotherapy, psychotherapy and movement therapy are just a few of the disciplines represented. However they all describe different facets of the same process – How the body creates distressing symptoms that have no clear biomedical cause.

Although it looks like a professional textbook, I think there is a lot here that patients and clients experiencing PPD will find illuminating and helpful. It’s well -referenced, easy to pick up and read a chapter at a time. For me, the highlight was how so many different authors, from diverse fields could weave together a solution for those experiencing persistent, challenging medically unexplained symptoms.

It’s sat on my desk at work for the last month and I’ve shared the contents with interested patients. I hope that some of them have subsequently gone out and bought it.

I do believe that the medical paradigm for managing symptoms primarily with drugs is starting to change and we are starting to look more broadly at the “patient who has the disease” to paraphrase Sir William Osler. We are starting to consider their backgrounds, their traumas and their beliefs and coping styles. It’s certainly not easy, not least because of the time constraints within NHS systems these days. But we have to start somewhere and I applaud these authors for their work in this field and fully anticipate this book to become a seminal go-to reference for those seeking to understand more about PPD.

Tools that GP’s use to help them make decisions in consultations Information for patients

GP consultations in the UK are usually around 10-15 minutes long. This doesn’t give the doctor (or the patient) much time to decide what the problem is and what action (if any) should be taken to resolve it.

So, what tools does the doctor use to help him / her make decisions?

Firstly, the patient tells their “story”. What brought them here today? The doctor listens and will try to make sense of the story.

Western medicine has created a number of disease categories which are recognisable by the various “symptoms” and “signs” that the patient displays and/or complains of. For example, cough, fever, discoloured sputum and harsh breathing sounds in the base of the lung might suggest pneumonia. A sore throat with pussy spots on the tonsils and fever might suggest tonsillitis. These are all diagnostic categories.

So essentially, what the patient says and the signs that the doctor finds help him / her to slot the parent’s presentation into some sort of diagnostic category. It’s partly a pattern matching process but it is actually more complex than this because people do not often fit into neat categories. Some degree of clinical intuition or a “gut” feeling that something isn’t right can also be very helpful. I can think of several patients in my practice who presented with vague symptoms and an unremarkable examination but went on to have serious illness and I had almost a “sixth sense” that something wasn’t quite right.

To help standardise medical practice, there are a number of clinical “guidelines” that clinicians are encouraged to follow. The most commonly cited ones are NICE which stands for the National Institute for Heath and Care Excellence and SIGN – The Scottish Intercollegiate Guidelines Network UK GPs don’t have to be in Scotland to follow SIGN and I’m not aware of any geographical preference amongst my colleagues. Personally I find some of the SIGN guidelines easier to follow, but that’s just me and some conditions are covered by NICE and not SIGN and vice versa.

Clinical guidelines are assembled by panels of expert clinicians, service users and members of the public. They use results from clinical trials that are relevant to the condition and they also look at the cost implications of each treatment and how that fits in with the current health budget. Guidelines are reviewed within a given time period to keep them up to date. This means the recommendations may change and this may change the advice and treatment offered to the patient for a particular condition. You can find out more at

So as a doctor, firstly I am listening to what my patient says and taking into account what the examination findings show. This will give me some ideas as to what might be going on and help me to discuss my findings with the patient. If a guideline exists for whatever I think might be going on, then I’ll consult that particular reference to see what “treatment” or approach might help. All of this needs to be shared with the patient because at the end of the day, its their body and their life so they are not obliged to take my advice. There are situations where people might not be able to make sound decisions for a number of reasons, severe illness, severe mental health problems etc and so it is possible and sometimes appropriate to make decisions on behalf of people. This falls into the territory of the Mental Capacity Act and is outside the scope of this article

The role of doctors is changing from people who impart advice, to people who help patients make sense of the vast realms of data out there. Once hidden, medical knowledge is now freely available to anyone who wants to look at it. Google is the usual source of information and the patients I tend to see have often done copious research of their own before they come to visit me. I don’t really have an issue with Google or people googling their symptoms. What can be difficult though is the objectivity to make sense of what one is experiencing. As I said before, not everyone fits into a neat diagnostic box and people can have symptoms without any evidence of disease process going on. This is where the skills of another person with the help of other investigations, if needed, can be very beneficial.

Back to the subject of guidelines. I think guidelines can be useful to provide a sort of structure to medical diagnosis and treatment. They can save time in a time-pressured situation. The problem comes to my mind, when the guidelines become more important than the patient’s needs and wishes. This is the paradox. When clinical encounters are short on time, it can be tempting to slot signs and symptoms into a box, possibly prematurely rather than keeping an open mind, listening to the patient’s narrative and holding off a particular diagnosis until later when the picture is clearer. Many things can and do get better on their own and sometimes a firm diagnosis is not helpful or required. Of course, if the patient appears to have something life threatening, then this approach needs to go out of the window and the doctor needs to act now, as it were.

So in summary guidelines have their place. They are not rules and should not, to my mind, be taken as such. If you are seeing a doctor, be prepared for the guidelines to be consulted. Your views and opinions and knowledge are vital to the consultation process and so they are welcomed. One of the consequences of having so much data at our fingertips is that sometimes people will present to doctors with expectations that cannot be fulfilled. It may be that the current guidelines do not advocate that particular treatment or what the person is asking for is outside the scope of the doctor’s knowledge or experience. It’s important to listen, though and if possible suggest other sources of help.

Finally I’ll provide some websites that I use when seeing patients. is a pretty comprehensive source of information. NHS choices another old stalwart for medical information and provides an analysis of current medical headlines. If you want to see professional information, NICE Clinical Knowledge Summaries are useful.