Psychogenic pain Introduction The cause of pain can be either organic or purely psychogenic or psychological, the latter being referred to as psychogenic pain. Nowadays, both from the clinician’s point of view and from the patient’s point of view, special attention is paid to somatic diseases and organic foci such as from external injuries, and from this point of view, pain becomes one of the most intense stressors encountered. However, pain can also be the “fruit” of purely psychological factors, i.e., psychiatric disorders. This type of pain is not clinically identifiable as an organic lesion or as a site of injurious stimulation. In order to treat pain, patients go around, but it is often not easy to accept the concept and treatment that pain is caused by mental factors. The pain department of Shandong Provincial Hospital, Zhao Xuejun Common psychiatric disorders that can manifest as pain 2.1 Hysteria The unpleasant mood of people with a hysterical personality base can be transformed into somatic symptoms when they encounter unresolved problems and conflicts, many of which are manifested as “pain”. The pain state is a common symptom of the conversion reaction and can occur in any part of the body, especially in the head and abdomen.1 It is not explained by general laboratory and imaging findings. The patient’s expression is distinctive and symbolic, with appealing features like many conversion syndromes, and the patient’s expression has a distinct tendency: “Now that I’m in pain, people can’t ask anything of me anymore, I’ve reached this point …… Now that people should finally care about taking care of I am now ……”. The patient is actually trying to relieve himself of an external or internal obligation or responsibility, warning the outside world and forcing others to help him. The patient gains the benefit of the “illness”, and the repressed instinctive will is somewhat satisfied, causing more sympathy from the outside world. Diagnosis of hysterical pain is based on the following criteria: (1) psychosocial factors as a cause and hysterical multiple personalities; (2) inability to explain the patient’s pain by physical illness and general laboratory and imaging findings. Also social functioning is impaired, there is a clear link between the onset and stressful events, and the course of the disease is mostly recurrent and prolonged, 2. 2.2 Anxiety disorders Anxiety itself is a prevalent and normal phenomenon. The biological function of anxiety and fear is adaptive; it allows the organism to become alert to existential threats and to act appropriately as a result. However, anxiety is only now considered abnormal, 3, when it is too intense and disproportionate to the stimulus, continues after the danger has passed, or has no cause at all. Thus mild anxiety improves the individual’s level of functioning, whereas severe anxiety produces inhibitory effects. Anxiety symptoms can be secondary to somatic disorders such as hypertension, coronary artery disease, hyperthyroidism (anxiety syndromes), or can be accompanied by other psychopathological states such as hallucinations, delusions, obsessive-compulsive disorder, hypochondria, depression, and phobias, but none of them are diagnosed as anxiety disorders. Anxiety disorder is a neurological disorder in which anxiety symptoms are primary. Excessive worry is at the core of anxiety symptoms and is a distressing, unpleasant, and uncomfortable thought that neither terminates spontaneously nor is it proportional to the objective event being feared. Muscle tension in patients with anxiety occurs in conjunction with worry, a subjective feeling of unpleasant tension in one or more groups of muscles, with muscle aches and pains in severe cases, mostly located in the chest, neck, shoulders, and back. Tension headache should be distinguished from headaches due to other causes, such as migraine. This type of pain may be in the form of somatic expression of one’s anxiety. 2.3 Somatoform disorders Somatoform disorders are classified in the third edition of the Chinese Classification and Diagnostic Criteria for Mental Disorders (CCMD-3), 4, as one of the neurological disorders, which include: somatization disorder (Briguets syndrome), undifferentiated somatoform disorder, hypochondriasis, somatoform autonomic disorder, persistent somatoform pain disorder, etc. In clinical practice, these disorders are extremely difficult to be clearly delineated They often intersect or coexist with each other. Somatoform disorder is a neurological disorder characterized by a persistent fear or belief in the predominance of various somatic symptoms. Patients repeatedly seek medical attention for these symptoms, and various negative medical tests and physician explanations fail to dispel their doubts. Even if some kind of somatic disorder is sometimes present, it does not explain the nature or extent of the symptoms complained of by the patient or his or her distress and predominant perceptions. It is often accompanied by anxiety or depression. The disorder manifests itself as attitudes towards multiple forms of abnormal health characteristics and can involve all systems and regions of the somatic body. Among them, symptoms related to the chest, abdomen, head, and neck are particularly common,5 and pain symptoms are present in more than half of the patients, with headache, chest pain, abdominal pain, and low back pain being more common. Fuzzy muscle pain is very common and is sometimes diagnosed as “fibrous histitis,” “muscle fiber pain,” “rheumatism,” and so on. 2.4 Schizophrenia The main types of schizophrenic pain are hallucinatory pain, perceptual syndrome pain, and delusional pain. Hallucinatory pain is more commonly known as phantom touch and hallucinatory abnormal body sensations, which can take various forms, including burning, stabbing, stabbing, hitting, and internal pulling, burning, cutting, or erosion, etc. Patients can describe these physical hallucinations in a very absurd manner and cannot be corrected. Patients may feel that they are being affected by electrical, magnetic, radiological, or other physical processes under the beliefs of relational delusions, delusions of victimization, and delusions of physical influence, which also produce the various forms of pain and discomfort described above. In addition, schizophrenic pain can also be a somatic complaint, which is one of the nonspecific psychopathological manifestations. 2.5 Depression The prevalence of depressive disorders with pain symptoms ranges from 15% to 100% (mean 65%),6,. Lisa et al. reviewed the relevant literature showing that the prevalence of depression is about 30% to 54% in patients with chronic pain, which is significantly higher than in the general population. Although it is recognized that there is an association between depression and pain, it is inconclusive as to whether depression causes pain or pain causes depression. However, depression and pain do increase the risk of mutual morbidity, i.e., depression increases the risk of pain, and pain predicts the risk of depression. Clinical studies have shown that the severity of depression correlates with the severity of pain. bair et al,7, reported that patients with major depressive episodes who had pain symptoms had more severe depression than those without pain symptoms. The duration of depression was longer in those with chronic pain than in those without (19 months:13 months),8,. The more severe the pain, the more frequent the episodes, and the longer the duration, the more severe the accompanying depression, 9. Some people have considered pain symptoms as part of depression and classified major depression as a disorder with three main features: psychological features, somatic symptom features and pain symptom features, 10,. However, the description of depression does not include pain symptoms in either the International Classification and Diagnostic Disorders (ICD), the American Diagnostic and Statistical Manual of Mental Disorders (DSM) or the Chinese Classification and Diagnostic criteria of Mental Disorders (CCMD). In conclusion, there is an association between depression and pain, and the presence of depression and pain seriously affects the social function of patients. Care should be taken to identify certain pain in clinical work to avoid underdiagnosis of depression that may affect treatment. In patients with both depression and pain, more effective treatment methods should be chosen to effectively relieve both pain and depressive symptoms. Diagnosis of psychogenic pain Pain is the fifth major vital sign, pain can occur in a variety of diseases, and pain is seen in all clinical departments. Therefore, when the pain of some patients cannot be explained by organic lesions, and conventional treatment is ineffective or has little effect, the physician should further distinguish whether the pain is caused by organic lesions or purely psychogenic pain. The method is to completely exclude organic pain before considering psychogenic pain, and to consult a psychiatrist or psychologist to further clarify the diagnosis. Treatment of psychogenic pain 4.1 Psychotherapy: Psychotherapy is necessary for psychogenic pain regardless of the cause. Different psychotherapeutic methods can be used according to different psychiatric disorders, commonly used are: 4.1.1 Suggestion techniques: such as the use of placebo, self-referral methods, etc. 4.1.2 Transference method: distract the patient’s attention from the pain, such as arranging the patient to do appropriate activities, entertainment, conversation, etc. 4.1.3 Persuasion and diversion method: explain the condition, believe in the diagnosis and treatment level of the hospital and physicians, and stabilize the patient’s emotion. 4.1.4 Encouragement method: strengthen the patient’s will and self-confidence to overcome the disease. 4.1.5 Relaxation therapy: train patients to relieve pain caused by muscle tension through operant conditioning, such as abdominal breathing and muscle relaxation training for patients. 4.1.6 Biofeedback method: elevate hand temperature with the help of dermal temperature feedback to reduce pain, etc. 4.2 Psychotropic medication 4.2.1 Antipsychotic drugs: mainly used for the treatment of schizophrenia, and often used for patients with dysthymia. At present, atypical antipsychotic drugs are used as first-line medications because of their good efficacy and few and mild adverse effects. The main drugs are: risperidone, ziprasidone, quetiapine, olanzapine, aripiprazole, etc. 4.2.2 Antidepressants and anxiolytics: anxiety and depressive symptoms often occur together, which is called co-morbidity; depression and pain sufferers both have abnormal 5-HT and/or NE function; antidepressants can regulate the emotional state and pain perception through the concentration of 5-HT and NE. Therefore, antidepressants are mostly used to treat depression and pain, and they can be used for all psychogenic pain except schizophrenic pain. Previous relevant clinical studies mostly used tricyclic antidepressants, but due to the high number of adverse effects, the relevant literature reports have gradually increased since the 1990s with the application of selective 5-hydroxytryptamine reuptake inhibitors. Currently, studies have confirmed the efficacy of selective 5-hydroxytryptamine and norepinephrine reuptake inhibitors in the treatment of depression and pain co-morbidity. These antidepressants acting through dual channels can also modulate changes in neurogenic processes and thus treat depression-related somatic symptoms (e.g., pain) more effectively than antidepressants that act only on 5-HT or NE. In conclusion, it is not uncommon for patients to visit the pain department for psychogenic pain, and pain physicians can only improve their practice and avoid misdiagnosis and mistreatment by recognizing this problem and requesting consultations with relevant departments to further clarify the diagnosis when necessary.