The portal message lands while you are putting the groceries away. Bloodwork within normal limits. No acute abnormality on imaging. Follow up as needed.
You reread it looking for the part that explains why you could not stand up straight this morning.
All my tests are normal but I still have pain. It is a common thing to hear in a Fort Worth psychiatry office, after primary care, a scan, and a specialist whose workup came back clean.
Normal results rule things out. That is not the same as finding nothing wrong.
You are not a rare case. The CDC reported in 2023 that an estimated 20.9 percent of U.S. adults had chronic pain in 2021.
If you are in crisis or thinking about harming yourself, call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7, or reach our office at 817-659-7344 during business hours.
When all my tests are normal but I still have pain, what has actually been ruled out?
A test is a question, not a verdict. Each answers something specific and is silent about the rest.
NIAMS, the NIH institute for musculoskeletal conditions, says doctors order tests “to rule out a specific cause for your pain or to confirm a cause for your back pain,” and names what each can show.
- X-rays “only show bones”: fractures, aging changes, spinal alignment.
- CT shows the spinal canal and nearby tissues.
- MRI can show “damage or disease of the soft tissues,” including discs and nerve roots.
Not one of those is a measurement of pain.
A clean workup means the things those tests can detect were looked for and did not turn up. It does not mean every possibility was covered. Tests miss things, and some conditions need a test nobody has ordered, so ask what a given test does and does not rule out.
Normal MRI but still in pain: what the imaging research actually shows
A 2015 systematic review by Brinjikji and colleagues in the American Journal of Neuroradiology pooled 33 studies of 3,110 people with no back pain at all. Estimated disk degeneration on imaging rose from 37 percent at age 20 to 96 percent at age 80.
Read the direction: those were people without pain whose scans looked abnormal anyway. The authors concluded that “many imaging-based degenerative features are likely part of normal aging and unassociated with pain,” and that such findings “must be interpreted in the context of the patient’s clinical condition.”
An abnormal scan does not by itself explain your pain; a normal one does not by itself disprove it. Tissue and pain are two different measurements, and they disagree more often than people are told.
Pain that outlasts the injury
The International Association for the Study of Pain revised its definition of pain in 2020, the first revision since 1979. Two attached notes matter here. “Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.” And: “A person’s report of an experience as pain should be respected.”
Central sensitization explained, caveats included
IASP defines central sensitization as “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.” Nociception is the nervous system’s damage-detection signalling. In plain terms, the gain on a real signal can change, so ordinary input produces more pain.
The caveat comes from IASP itself: in a living patient, sensitization may only be inferred indirectly, from phenomena such as hyperalgesia or allodynia. Nijs and colleagues, in the Journal of Clinical Medicine in 2021, add that measuring those neurons in living humans is impossible. One can infer it at the bedside, where ordinarily painless touch hurts or a mildly painful one hurts more than it should.
IASP has also adopted a third descriptor, nociplastic pain, for pain arising from altered nociception without clear evidence of tissue damage or of disease in the somatosensory system, the wiring that carries touch, temperature, and pain. These are working frameworks, not settled science. Nijs and colleagues call studies of the 2021 nociplastic criteria “urgently needed,” and a 2026 review by Hauser and Kosek in the European Journal of Pain asks whether nociplasticity is a distinct category at all. The argument is over description, not over whether the pain is real.
Chronic pain, sleep, and mood run in both directions
NIMH puts the two-way part directly: depression can co-occur with chronic illnesses including chronic pain, and “depression can make these conditions worse and vice versa.”
Sleep is not a side issue either. In a 2013 review in The Journal of Pain, Finan, Goodin, and Smith reported that the closer-grained studies “tend to suggest that sleep disturbance is a stronger predictor of future pain than pain of sleep disturbance.” Tend to suggest, in a review rather than a trial. Treat sleep as its own problem, not a lever that fixes pain.
The CDC’s 2023 report found chronic pain in 39.0 percent of U.S. adults who had ever been told by a health professional that they had depression. That is chronic pain among people carrying a depression diagnosis, not the reverse, and which came first in your case, we cannot say.
Where this practice fits, and what we will not do
This practice addresses chronic pain primarily by treating the depression, anxiety, insomnia, and other psychiatric conditions that travel with it. As our service page says, we do not prescribe opioid medications for pain under any circumstances.
This Fort Worth office is not a general pain clinic, and we do not adjust another physician’s pain plan. Keep your primary care doctor, keep the specialist, and keep reporting new or changing symptoms. The CDC’s 2022 opioid prescribing guideline warns against patient “dismissal and abandonment.”
Some changes deserve a prompt call rather than wait-and-see: new weakness or numbness, loss of bladder or bowel control, unexplained weight loss, fever, pain that wakes you every night, or pain that suddenly changes character.
What a psychiatric evaluation adds when the pain itself is managed elsewhere
A full evaluation is where the parts nobody has had time to ask about come up: when the sleep broke, what happened to appetite and concentration.
NIMH lists “physical aches or pains, headaches, cramps, or digestive problems without a clear physical cause” among the symptoms of depression, diagnosed only when symptoms run most of the day, nearly every day, for at least two weeks. That item is there because depression can produce physical symptoms, not because unexplained pain is a sign of depression. If trauma sits in the history, PTSD care may fit better; if more than one adequate medication trial has failed, that is a treatment-resistant depression conversation.
The CDC’s 2022 guideline notes that patients with co-occurring pain and depression “might be especially likely to benefit from antidepressant medication.” The guideline’s word is might, and getting the diagnosis right comes first: some depression is part of bipolar disorder, and NIMH states that in bipolar disorder antidepressants “are not used alone because they can trigger a manic episode or rapid cycling.” Past highs, stretches of needing far less sleep, and odd reactions to earlier medications belong in the history. Say so if you have ever had one, even if nobody has used the word bipolar with you.
Bring a full medication list, including anything for pain, sleep, or migraine, and anything over the counter. Some pain medications interact with antidepressants: certain ones raise the risk of serotonin syndrome combined with an SSRI or SNRI, and opioids combined with sedatives carry risks of their own. That belongs in front of your prescribers, not sorted out alone.
We do not have good data on how often, or by how much, treating the depression moves the pain. Our part is treating the depression, anxiety, or insomnia we find: medication where it fits, psychotherapy, and sleep as its own target. Response varies, and we will say what we are and are not seeing.
Chronic pain and suicide risk: why we ask about it directly
The CDC’s 2023 report states that chronic pain “has been linked with depression, Alzheimer disease and related dementias, higher suicide risk, and substance use and misuse.”
The report says linked, and that is the whole of the claim. A CDC-authored analysis by Petrosky and colleagues in Annals of Internal Medicine in 2018 found evidence of chronic pain in 8.8 percent of 123,181 people who died by suicide between 2003 and 2014. Establishing a causal role, the authors said, was beyond the study’s scope.
What we do with a finding like that is ask about it directly, as part of a psychiatric evaluation, rather than wait for you to raise it. If today is one of the hard ones, call or text 988.
Frequently asked questions
Does a normal MRI mean my pain is not real?
No. IASP is explicit that nociception, the body’s damage-detection signalling, and pain are different things: pain “cannot be inferred solely from activity in sensory neurons,” and a person’s report of pain should be respected. Imaging asks about tissue, not pain.
Does having unexplained chronic pain and depression mean the pain is psychological?
The two are separate conditions that feed each other. NIMH states that depression can make a co-occurring chronic illness worse “and vice versa,” whichever one started it. Treating the depression is worth doing on its own terms, and it is no claim that depression caused your pain.
If my tests are normal, should I stop looking for a cause?
Keep looking, and keep your medical team on it. Tell your doctors about new or changing symptoms, and call promptly about new weakness or numbness, loss of bladder or bowel control, unexplained weight loss, or fever. Psychiatric care sits alongside that workup, not in place of it.
Will you prescribe anything for my pain?
Not opioids, and not the pain medications another doctor manages. We do prescribe for depression, anxiety, and insomnia, which is where our part sits. We may recommend changes to psychiatric medication, and we will explain why beforehand; never stop one on your own. The pain regimen another physician wrote stays as it is.
The bottom line
Normal labs and imaging mean the dangerous causes those tests can detect were looked for and did not turn up, good news that arrives feeling like bad news. It does not mean nothing is wrong. Researchers describe mechanisms that may account for pain outlasting the injury, central sensitization and nociplastic pain among them, though those frameworks are argued over and can only be inferred. Keep your workup going, and call promptly if anything new or fast-changing shows up. We work alongside it, and we do not prescribe opioid medications for pain under any circumstances.
Talk with us
If you are in Fort Worth or the surrounding North Texas area and what you have read here sounds familiar, we would be glad to talk it through with you. The Institute for Advanced Psychiatry is an outpatient practice at 6800 Harris Parkway, Suite 100, treating adults 18 and older. You can request an appointment or call 817-659-7344.
If you are in crisis or thinking about harming yourself, please do not wait for an appointment. Call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7, or go to your nearest emergency room.
Sources
- Rikard SM, Strahan AE, Schmit KM, Guy GP Jr. “Chronic Pain Among Adults – United States, 2019-2021.” MMWR Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. 2023;72(15):379-385. https://www.cdc.gov/mmwr/volumes/72/wr/mm7215a1.htm
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. “Back Pain: Diagnosis, Treatment, and Steps to Take.” Accessed 2026. https://www.niams.nih.gov/health-topics/back-pain/diagnosis-treatment-and-steps-to-take
- Brinjikji W, Luetmer PH, Comstock B, et al. “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.” American Journal of Neuroradiology. 2015;36(4):811-816. https://pmc.ncbi.nlm.nih.gov/articles/PMC4464797/
- International Association for the Study of Pain. “IASP Terminology.” Accessed 2026. https://www.iasp-pain.org/resources/terminology/
- International Association for the Study of Pain. “IASP Announces Revised Definition of Pain.” 2020. https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
- Nijs J, Lahousse A, Kapreli E, et al. “Nociplastic Pain Criteria or Recognition of Central Sensitization? Pain Phenotyping in the Past, Present and Future.” Journal of Clinical Medicine. 2021;10(15):3203. https://pmc.ncbi.nlm.nih.gov/articles/PMC8347369/
- Hauser W, Kosek E. “Nociplastic Pain: Facts, Controversies and Future Tasks.” European Journal of Pain. 2026. https://doi.org/10.1002/ejp.70175
- National Institute of Mental Health. “Depression.” Accessed 2026. https://www.nimh.nih.gov/health/publications/depression
- National Institute of Mental Health. “Mental Health Medications.” Accessed 2026. https://www.nimh.nih.gov/health/topics/mental-health-medications
- Finan PH, Goodin BR, Smith MT. “The association of sleep and pain: an update and a path forward.” The Journal of Pain. 2013;14(12):1539-1552. https://pmc.ncbi.nlm.nih.gov/articles/PMC4046588/
- Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. “CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022.” MMWR Recommendations and Reports. 2022;71(3):1-95. https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
- Petrosky E, Harpaz R, Fowler KA, Bohm MK, Helmick CG, Yuan K, Betz CJ. “Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System.” Annals of Internal Medicine. 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC6913029/
- 988 Suicide & Crisis Lifeline. “988 Suicide & Crisis Lifeline.” Accessed 2026. https://988lifeline.org/
- Institute for Advanced Psychiatry. “Chronic Pain.” Accessed 2026. https://www.psychiatryfortworth.com/services/chronic-pain/
Medical disclaimer
This article is for general education and is not medical advice, a diagnosis, or a treatment recommendation for any individual. Reading it does not create a physician-patient relationship. Treatment decisions, including whether any medication or procedure is appropriate for you, should be made with a qualified clinician who knows your history. Do not start, stop, or change a psychiatric medication without talking to your prescriber. If you are experiencing a medical or mental health emergency, call 911 or 988.