Beyond diagnosis in general practice: Predictive processing, a novel framework for persistent physical symptoms 2026 van Boven et al

Background​

Persistent physical symptoms are among the most common and challenging presentations in general practice, whether investigations are normal or reveal pathology insufficient to explain their severity. Patients and clinicians alike often experience these presentations as a dead end. Traditional biomedical models assume that symptoms passively reflect structural pathology, and that normal test results imply the absence of illness.

Objectives​

To introduce predictive processing as a theoretical framework for understanding persistent physical symptoms in general practice, and to outline its implications for clinical explanation and management.

Methods​

This opinion paper draws on the predictive processing and active inference literature to develop a clinically applicable account of symptom perception, illustrated with clinical scenarios from general practice.

Results​

Predictive processing proposes that symptoms are active perceptual constructions, generated by the brain as it infers the state of the body from incoming signals and prior beliefs. When prior beliefs of danger or irreversibility are strong, and peripheral signals are weak or ambiguous, these prior beliefs can dominate perception, producing substantial suffering in the absence of clear pathology. This framework explains symptom–test discordance and reframes normal results: they do not end clinical responsibility, but shift it towards modifying symptom-sustaining priors towards expectations of safety and recovery.

Conclusion​

For the general practitioner, this framework provides a coherent scientific rationale for explanation, continuity of care, expectation management, cognitive approaches and graded activity. These interventions emerge as core clinical tools, not consolation, when “nothing is found”.

KEY MESSAGES​

• Predictive processing explains why symptoms may persist despite normal or inconclusive clinical investigations.
• It accounts for discordance between reported symptoms and test results, and for variation between patients and over time.
• General practice interventions—expectation management, continuity of care, and graded activity—offer meaningful care beyond establishing a diagnosis.

Open access

Patients and clinicians alike often experience these presentations as a dead end

The idea that our experiences are in any way similar is ridiculously offensive. It's not a dead-end to clinicians, they just move on to the next and forget all about it while our lives fall further into despair and misery. It's precisely because the stakes imbalance is so wide that nothing has improved in decades. We are not in this together at all, there is literally no common we, it's cruel, indifferent systems vs people with zero influence who have been cast out of society, rejected as worthless by systems that clearly see us as being beneath their concern.

Predictive processing proposes that symptoms are active perceptual constructions, generated by the brain as it infers the state of the body from incoming signals and prior beliefs. When prior beliefs of danger or irreversibility are strong, and peripheral signals are weak or ambiguous, these prior beliefs can dominate perception, producing substantial suffering in the absence of clear pathology. This framework explains symptom–test discordance and reframes normal results: they do not end clinical responsibility, but shift it towards modifying symptom-sustaining priors towards expectations of safety and recovery.

Would you look at that, exact same junk as before, presented as "novel", which is the exact same junk as before. And of course ending clinical responsibility, hell voiding it entirely, is and has always been the explicit goal.

This would be considered plagiarism if it wasn't for the fact that no one in the industry seems to care that it's always the same recycled nonsense. For some reason they use "processing" instead of coding, so pretty much did a simple search-and-replace with predictive coding and clearly journals don't care about perpetuating nonsense.

We can already apply a simple LLM test: would an LLM do better than this? If easily so, and this is the case here, it's clearly not worth publishing. But of course the only goal here is to void clinical responsibility entirely, they simply have goals that are antagonistic to our welfare.

What I still don’t understand after reading this paper is how the language of metaphor differs from the language of ‘brain process’, except in style? What exactly is this brain process? Wouldn’t a theory like this be easy to prove experimentally? Something that the authors don’t address is that the vast majority of people expect to recover completely after an infection, as do their doctors, families, and employers. Yet some of them don’t.

The standard of evidence in psychosomatic ideology has always been: if it can be imagined and it conforms with the traditional conversion disorder model, then it must be correct. It simply has to be imagined as being possible to be considered certain. They can simply imagine that some people might behave this way, and make life-and-death decisions about tens of millions without ever caring about the outcomes.

This is why it never matters when evidence contradicts the model. The model is entirely made out of hallucinations, and only perpetuates because of failed systems that rely on those hallucinations as excuses for their failures.

The narratives are entirely for them, to make them feel not only good about failing, but to feel better the worse they fail because they inverted reality to make it all work.

Yet another «imagine a world» paper that presents opinions as facts. Pretty much all of their references are other opinion pieces.

It’s even made by AI:

The authors used AI-assisted tools during the preparation of this manuscript, specifically for iterative drafting, structural editing and consistency checking of the text. All scientific content, clinical judgements and conclusions are the sole responsibility of the authors, who reviewed and edited all AI-assisted output and take full responsibility for the final manuscript.

Explanation as core intervention.
Explanation becomes a therapeutic act, not merely a way of delivering results.

But it isn't just the explanation, it's the changing of someone's mind, influencing someone's belief, that is the intervention.
It's so arrogant to think that if you just “explain” something the patient will think differently.

Crucially, clinicians should then check whether this has actually updated the patient’s beliefs. Asking ‘Does this make sense to you?’ or ‘are there other worries that remain?’ ensure that the reassurance is not merely delivered but received.

No, it doesn't make sense to me. No, the reassurance is not received.

For some patients the language of ‘brain process’ is acceptable; others may respond better to metaphors such as ‘sensitised alarm system’ or ‘symptom sensitivity’

I respond poorly to doctors and psychologists. I respond poorly to manipulation tactics, stupid rhetoric, and the patronising tone they always use. Also to someone trying to change my belief from being based on my own experience, what I think is convincing evidence and what makes sense to me, to just whatever the doctor said because “trust me”.
I respond poorly to placing too much emphasis on belief in general. I don't really care about what I believe about this, and I don't think what I believe or not is within my or others control.

Clinicians should anticipate that such explanations may initially be met with skepticism

Yes. Why would the patients be skeptical? Maybe look into that before you attempt to change someone's mind? The arrogance of thinking you can change someone's mind before even understanding their story and why they believe what they believe.
How are you planning on being seen as convincing (which is the important part of the intervention!!) if you can't even understand the basics of what's on the patient’s mind or what it is like to be them.
When people assume I'm scared of exercise, they have immediately lost me, and they don't even understand how ridiculous and annoying they sound. I immediately see them as incompetent, uncurious, and untrustworthy. Why would I ever even want to believe a person like that above my entire life story, instincts, common sense and understanding of reality?

Graded activity and exposure provide lived experiences that disconfirm catastrophic priors: when feared activities are tolerated safely, prediction errors update expectations towards safety.

Well obviously!!!! Obviously, for most people, their experience would shape their beliefs. When activity stops causing deterioration for me, my belief will update. You are instead asking me to change my belief before my experience changes, so that my experience might change due to my belief. How many decades of my actual experience must I live before you will permit me to believe in it?

If my beliefs wasn’t based on what I felt was convincing evidence and not based on my experience, then I don’t know what my beliefs would be grounded in or how you’d go about trying to change them.

Asking someone to believe something both against their own experience and against evidence is really predatory. It would make someone very vulnerable in life.

careful explanation and thoughtful non-investigation

Important to have some nice adjectives.

The standard of evidence in psychosomatic ideology has always been: if it can be imagined and it conforms with the traditional conversion disorder model, then it must be correct. It simply has to be imagined as being possible to be considered certain. They can simply imagine that some people might behave this way, and make life-and-death decisions about tens of millions without ever caring about the outcomes.

Yet another «imagine a world» paper that presents opinions as facts. Pretty much all of their references are other opinion pieces.

Two of the reliable tells about this garbage are:

1. The constant repackaging of old failed ideas and claims as new breakthroughs, stuffed with arse covering conditionals like may, could, can, possible, promising, etc.

2. The endless bootstrapping of unsubstantiated 'expert' opinion into widely accepted fact that no reasonable person could possibly object to.

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The crucial message is that this process is real, bodily and potentially reversible,...​

To state that as an indisputable established fact is straight fraud.

Part of the sales pitch is to disown their previous untenable position of anything resembling the shameful hysterical/fabulist/malingering/lying patient framing by adding this bit:

...not a sign that symptoms are imagined or fabricated.​

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These guys seem to think that the simple act of 'explaining' is all that is required, that an 'explanation' is sufficient in and of itself, independent of the veracity of the explanation.

It is deeply shockingly insane, and very cruel.

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They are not getting better, they are getting worse.