The article is extracted from Pain Management Techniques, edited by Hang Yannan Cao Jianguo, Zhengzhou University Press, March 2005 P313-323
Almost everyone has experienced pain, and in fact, pain is the most common complaint among patients in all clinical departments. Pain is divided into 4 main categories: i. Aggressive irritative pain (tissue injury), ii. Neurogenic pain (neuralgia), and iii. Sympathetic-derived pain (blood flow disorders), iv. Psychogenic pain (psychological effects) and other four types of pain. At present, in clinical practice, the first three types of pain are recognized, while pain caused by psychogenic effects is often ignored. Mao Jialiang, Department of Cardiology, Shanghai Renji Hospital
Pain caused by psychological factors we call psychogenic pain. Psychogenic pain syndrome is mostly manifested as chronic pain for more than 3 months to 6 months. According to statistics, about 30% of adults suffer from chronic pain, and there are at least 100 million pain patients in China. In July 2002, a survey of chronic pain in six cities in China found that in just one month, as many as 136,000 chronic pain patients visited hospitals in six cities. Moreover, only some of the patients could find the cause of their chronic pain, and most could not find the cause. Statistics on the causes of chronic pain in Europe and France show that cancer is not a major cause of pain, accounting for only 3% of patients with chronic pain. In comparison, back pain is the most important, accounting for 44%; headaches amount to 7% at the European level and 15% in France. In addition, the proportion of chronic pain caused by job loss was 14% in France, and chronic pain caused by depression amounted to 18%. Researchers at Stanford University found through a multi-year study of 100 people with low back pain that many people who frequently complain of low back pain may be caused by psychological problems alone. At the 11th annual meeting of the German Association of Psychotherapeutic Medicine, it was suggested that about 30-50% of people who experience pain and discomfort in modern society are suffering from excessive mental stress and do not have organic physical lesions. The physical pain caused by mental stress is also diverse, mainly headache, back pain, gastrointestinal pain or vertigo, and in severe cases, even local paralysis. Researchers have performed spinal injections to guide pain in 100 participants and performed MRI examinations. Psychological tests were also performed on all of them, and it was found that those with poorer mental health were nearly three times more likely to report low back pain. Even those who had undergone spinal injections to induce pain showed much less low back pain than those with poor mental health. Perhaps the emergence of this theory explains why many people often complain of low back pain, but always fail to find the cause of their pain.
Section 1: The relationship between pain and psychology
Pain is closely related to psychology because it is a very complex subjective experience, highly individualized by the patient himself, and unlike heart rate and blood pressure, which have a standardized instrument to measure, it cannot be corroborated by others. Pain is both a physical sensation and an emotional response to that sensation, and because of this, current definitions have prioritized the psychological component of the pain experience, which is seen as more of a psychological event than just a somatic one.
Historically, pain has been viewed as a somatic symptom that is proportional to the degree of injury, i.e., the greater the intensity of the stimulus, the more intense the pain. However, clinical evidence shows that this view is a misconception and that pain is much more complex than this simple understanding. Not only do different people experience pain differently for the same injury, but the same person also experiences pain differently at different times. Similarly, it is commonly believed that only tissue injury causes pain, but clinicians often encounter patients with pain as the main complaint who have never suffered any tissue injury, especially after a variety of tests have not found any organic lesions corresponding to the pain site, or the degree of lesion is not consistent with the severity of the patient’s pain complaint, at this time, we should consider that pain may be caused by psychological disorders. The nature and intensity of pain are influenced by many factors, and experiments have shown that even when we are fully awake, the injury does not necessarily cause us to feel pain. Some people have a large injury, but they feel very little pain and do not even complain of pain. Others have very mild injuries but feel severe pain. This evidence suggests that nociception is not just a function of physical injury, but that it is more unstable and changeable than previously believed. The currently accepted concept, developed by the International Association for the Study of Pain (IASP), is that pain is “an unpleasant sensory and emotional experience triggered by actual or potential tissue damage; or a description of that damage.” It is clear that pain always has a subjective element to it, and that pain is a composite description of sensations and reactions to those sensations.
It is a well known fact that emotions can significantly affect the perception of pain. Fear, anxiety, disappointment, and impatience can lower the pain threshold, while happiness, excitement, and confidence can raise it. Experiments have shown that the mere anticipation of “pain” can increase the level of anxiety, thus increasing the intensity of pain perception. The elimination of anxiety can alleviate pain. The intensity of pain caused by trauma is still influenced by emotions. Grief, resentment, and anger can increase pain, while improving such negative emotions can also reduce pain. Fear and suspicion due to pain can in turn aggravate pain, such as abdominal pain suspected of cancer, chest pain suspected of coronary heart disease, thus anxiety, and depression strengthens the feeling of pain, and so a vicious circle. Emotions can not only affect the intensity of pain, but some bad emotions themselves can cause pain, especially anxiety and depression.
Pain as a complex psychophysiological phenomenon, we have not been able to explain many pain phenomena, especially a “phantom limb pain syndrome” is confusing. According to most patients who have undergone amputation, they feel a phantom limb soon after the amputation. A few months later, nearly 30 percent of amputee patients experience phantom limb pain, and nearly 5 percent of patients complain with grief that they feel extreme pain in the amputated limb. A small number of patients with phantom limb pain even cause or greatly enhance this pain when touching other body parts or when emotionally disturbed. To date this phenomenon cannot be explained by current physiological knowledge, and severing the spinal thalamic tract does not permanently eliminate this phantom limb pain.
Section 2: Psychological hazards of pain
Acute pain is mostly a warning effect of tissue injury and is easier to control clinically. Although patients often experience a certain degree of anxiety due to pain, such pain and its accompanying anxiety usually disappear automatically with tissue recovery; chronic pain caused by psychogenic causes is not as “excruciating” as acute pain, but it is Chronic pain of psychogenic origin is less painful than acute pain, but its persistence and persistence often make it more painful for the patient. It causes irritability, depression, anxiety, insomnia, irritability, mental anguish, and personality changes. Mildly, it affects the quality of life, and in severe cases, it makes people unbearable to produce light thoughts and even leads to suicide. In addition, pain has a strong suggestive effect on the human psyche, and repeated pain may leave a serious psychological disorder, which is an endless nightmare for the patient. It can cause psychogenic pain secondary to this pain, and the patient’s main attention is drawn to this pain, and his or her body and psyche are tormented by the pain, which can cause serious tension and functional disability, and inability to work and cause family livelihood problems, and at the same time, the The person becomes a long-term object of care, which can indirectly affect the life of the family and the mood of the family members, making the relationship between family members significantly damaged or destroyed. These patients may exhibit abnormal disease behaviors – reduced activity, social withdrawal, psychological and social adjustment disorders, significant emotional depression, and in severe cases, almost total loss of functional activities (Table 3-1). In many cases, chronic pain due to psychological disorders is often overlooked by patients and physicians as the true cause of the disorder, with limited comprehension. Patients are unable to relieve their pain even after repeated tests, medications (sometimes involving substance abuse and addiction), and other treatment measures, resulting in an extreme waste of medical and social resources, which in turn increases the psychological and economic burden on patients, creating a vicious cycle. Table 3-1 Effects of pain-induced psychological disorders
Item
Result
Psychological aspects
Increased anxiety
Increased depression
Decreased sense of self-worth
Hopelessness
Fear
Anger
Behavioral
Decreased mobility
Sick role
Pain behaviors
Passive coping behaviors
Social aspects
Decreased social activities
Withdrawal
Increased family problems
Rising work stress
Section 3 Psychosocial factors affecting pain
Often, pain is not proportional to the objective degree of impairment because pain, as a subjective experience of the individual, is influenced by a variety of psychosocial factors related to the individual.
(i) Early experiences It is commonly believed that a child’s experience of pain is strongly influenced by parental attitudes. If parents make a fuss about a child’s average cut or bruise, the child will grow up with too many pain warnings from parents and will develop into an easily anxious, pain-sensitive person.
(ii) Significance of context Individuals’ differing cognitive evaluations of pain-producing situations also affect the degree and nature of pain perception. Beecher, a medical scientist, observed severely wounded soldiers during World War II and found that only 1/3 complained of great pain and requested morphine. In contrast, 4/5 of civilians with similar injuries felt severe pain and requested morphine. Beecher believes that this is largely because wounded soldiers react differently to injury than civilians do to major surgery; for soldiers, injuries are commonplace in war, and for civilians, major surgery is a frustrating and unfortunate event.
(iii) Attention and distraction When concentrating on a stressful task or activity (such as a competition of some kind), a cut and bleeding hand or body will not be felt at all, and you will only realize the injury when someone else sees it and tells you about it. Many patients with cancer pain often tell their doctors that the pain is heavier at night than during the day. This is because they will engage in various activities during the day, plus the stimulation of light and sound, which will distract the patient’s attention from the pain, while at night they will stop the activities, without the stimulation of light and sound, and their attention will be focused on the pain area, and the pain will be aggravated.
(iv) Suggestion or hypnosis In the clinic, doctors sometimes use placebo to relieve pain. One study reported that 35% of post-surgical pain can be relieved by placebo. This is using the effect of suggestion on pain. In addition, when a person enters a hypnotic state, attention is highly focused on the practitioner and attention to other stimuli is significantly diminished, thus also affecting the individual’s perception of pain.
(v) Emotional state It is a well known fact that emotions can significantly affect the perception of pain. Fear, anxiety, disappointment, impatience, can increase sensitivity to pain; while cheerfulness, excitement, and confidence can decrease sensitivity to pain.
(vi) Interpersonal factors Interpersonal relationships significantly influence patients’ pain experience and reinforce or inhibit certain behaviors. In particular, repeated reinforcement by people who are important to the patient has a significant effect on the patient’s pain experience. For example, in a patient with somatization disorder, his pain disorder can be transformed into a way of life that changes the behavior of others. Even sometimes changes in family, finances, etc. can have a huge impact on the patient’s pain experience and pain behavior
(vii) Personality People with different personalities, differ in their sensitivity to pain and differ in their expressions or behavioral responses to pain. Those with high self-esteem believe that pain tolerance is a virtue and are reluctant to talk about pain easily. In contrast, some timid, easily stressed patients tend to overstate their pain. And some people with hysterical personality traits are susceptible to suggestion and have a greater variation in pain perception.
(viii) Socio-cultural factors Socio-cultural factors can also influence the degree of pain. For example, religious believers can calmly endure severe pain excitement during the rituals they perform. There are also differences in pain tolerance among different races, such as the tendency of Americans to retreat when the pain is severe, and to cry or moan or sigh if they are alone. Jews, on the other hand, tend to shout, complain, and openly seek help and sympathy.
Section IV Mechanisms of psychogenic pain
Although pain is an unpleasant experience, it is a signal of damage to the body, which tells people that the organism is being harmed and is therefore a helpful warning with a protective and positive meaning. Pain can also be a message for people to interact with. For example, pain can be a message indicating fear and can be a cry for help, prompting the patient to seek help. Pain may also sometimes be a manifestation of anger or an indirect expression of anxiety, depression, and other emotional needs, as in counseling, where some patients with anxiety and depression are accompanied by various pain phenomena.
The personalities of patients with psychogenic pain are often introverted, silent, dependent, depressed, anxious, and have many inner experiences, etc. However, there are also patients with psychogenic pain whose personalities are not introverted or even cheerful, but they are often idealists, pursuing perfection in the world, having high standards of requirements for themselves, often holding but not letting go of things, having high expectations of life and work, often exceeding their In the process of doing things, it is easy to worry, always feel that there will be bad problems and can not rest assured. These two kinds of people are sensitive and suspicious, and they can easily feel all kinds of bad stimuli in the environment and form bad emotions, they have high psychological pressure and strong psychological conflicts, but they do not want to tell others, so they often use the metaphor of “pain” to express the unhappiness or trauma they have suffered, so as to draw others’ attention, sympathy and concern, or use it to This is a way to draw the attention, sympathy and concern of others, or to divert and avoid the problems encountered in life and work.
In psychogenic pain, the area where the pain is felt is often related to some type of psychological problem. For example, back pain is often caused by excessive anxiety and stress at work. Headaches are often associated with anger, guilt, or psychological trauma. Anger-induced pain is also often accompanied by tension in the neck and shoulders. Guilt-induced pain is a form of self-punishment.
In addition, many recurrent pain episodes can produce psychological problems, and these same psychological problems also have an impact on the development of chronic pain. First, through the pain receptors we know the pain and we notice the stimulus. In this regard, the fact that each individual feels the same painful stimulus differently even when it is the same involves the fact that each individual perceives it differently from each other. Next, the individual will make a judgment about the perceived stimulus, and at this point, the difference in individual perceptions still shapes the outcome of the judgment. This judgment process does not need to be logical, but depends on the individual’s experience and information obtained from relatives and friends.
Finally, the pain stimulus is cognitively processed by the individual to form an adjustment strategy, which is a plan for dealing with the pain. This includes cognitive aspects, such as distraction or reassessment, and behavioral aspects, such as taking a walk or taking medication. So far, we can see that theories of pain production have been developed not only for physical stimuli, but also for cognitive and behavioral aspects. These adaptive strategies will then produce behaviors that, once produced, will be shaped by learning to develop further. For example, if the behavior receives a positive feedback (reward), the behavior will occur again, and if the behavior receives a negative feedback (external punishment), the behavior will disappear.
From a psychological point of view, the psychological problems of patients with psychogenic pain are often repressed and do not “emerge” to the conscious level. There are various reasons for this repression: the traumatic experience may be too painful to remember, or there may be a subconscious feeling that psychological problems cannot be understood by others, whereas physical illness and pain are more easily accepted and sympathized with, thus leading to the “somatization” of psychological problems.
The term somatization was coined by Stekel at the beginning of this century to refer to the hypothetical process by which “deep-rooted” neuroses cause somatic disorders. Later, Katon et al. described somatization as a phenomenon in which somatic symptoms are used to express mental discomfort, mainly due to the sociocultural context, i.e., social and interpersonal relationships, as a means of expressing and coping with social and personal troubles. Kleinman sees somatization as a “biological, psychological, and social” evolutionary process through which somatic symptoms are used to express and explain personal and interpersonal problems, and are experienced as somatic symptoms. In other words, somatic symptoms are described, while social and psychological problems are expressed. The manifestation of somatization symptoms is often complex and multi-site, it can involve any organ and function and can mimic any kind of disease manifestation. The most common symptoms are pain, such as headache, chest pain, abdominal pain, and muscle pain; common symptoms include fatigue and weakness, dizziness, shortness of breath, palpitations, and abdominal distention; they can also manifest as indigestion, diarrhea, cough, difficulty walking, difficulty urinating, fainting, or loss of consciousness. In terms of duration, it can be transient or persistent.
From a neuropsychological perspective, psychogenic pain has different mechanisms from physiological pain. In the case of physiological pain, the source of pain is in specific parts of the body that transmit signals of pain to the brain. In the brain, the signals are divided into two paths, one to the “sensory area” of the brain, where the person feels the area of pain (low back, back, head ……) and the mode of pain (dull, sharp, pressure, stabbing…). …). The other way the signal goes to the “limbic lobe”, the part of the brain responsible for the emotional memory, where the person feels the emotional reaction to the pain (“it’s unbearable”, “it’s hopeless “, “I can’t take it anymore” ……). In the case of psychogenic pain, the source of pain is in the “limbic lobe” responsible for emotions. Past traumatic experiences or other causes of emotional problems cause continuous activation in certain parts of the “limbic lobe”, and this activation is transmitted through neural pathways to the “hypothalamus”, where the neural activation is transmitted through different pathways to specific parts of the body to produce pain. Here, the activation of nerves is transmitted through different pathways to specific parts of the body to produce pain.
Section V. Clinical manifestations of psychogenic pain
It should be clearly pointed out that psychogenic pain is not “faked” or imagined by the patient, but the experience of pain is real and not a fraud. If we ignore or misinterpret the patient’s feelings, it will often cause undesirable doctor-patient conflicts and create difficulties for further treatment.
Cardiac pain is not the name of a disease, but rather a group of clinical syndromes that often present as chronic pain for more than 3 to 6 months. Cardiac pain can be clinically manifested in two forms. One is cardiac pain without any other cause of organic tissue injury, caused solely by psychological disorders, and can be called primary cardiac pain, which is characterized by: (1) chronic pain and other somatic symptoms as the main manifestation, with a wide range of diverse and variable symptoms, sometimes resembling the pain caused by organic diseases. ②In parallel with chronic pain, patients often have mild depressive symptoms such as decreased interest, decreased libido, anxiety, and sleep disturbances, which are heavy in the morning and light in the evening. ③Repeated visits to internal, external, neurological and traditional Chinese medicine departments are often treated with “kidney deficiency, plant nerve dysfunction and neurasthenia because no positive signs can be detected, but they are not effective. ④ Psychotropic drugs and psychotherapy can bring about rapid relief of symptoms. The other kind is that although there are various causes of organic tissue injury, the pain is aggravated with the emergence of psychological disorders during the development of its disease, resulting in long-term, complicated and difficult to treat pain, which is called secondary psychogenic pain.
(A) Primary psychogenic pain
1. Tension pain
This type of pain is often caused by psychological conflict. When a person is in a state of psychological conflict or chronic mental stress, if he or she cannot relieve these pressures well, in addition to symptoms such as tension, worry, insomnia, etc., the most common is headache, back pain, toothache or back pain, which is a way to relieve stress and get rid of the dilemma of psychological conversion. The obvious feature of this pain is that it worsens with the increase of mental stress and subsides with the reduction of mental stress. Tension headache is a headache that most people experience from time to time. Eighty percent of the population has had a tension headache in the past year. The incidence is significantly higher than that of migraine. The pain is characterized by recurrent headaches with no specific clinical presentation. The International Headache Society requires 10 typical episodes in the history to diagnose tension headache. However, a patient may not experience that many attacks at any one time in the natural course of the disease. The diagnosis of tension headache requires two of the following four characteristics: (1) bilateral headache; (2) stable or pressure pain; (3) mild or moderate pain; and (4) daily activities that do not exacerbate the headache. Tension headache is often located in the cheeks, occipital area or orbital area, and sometimes accompanied by pressure pain of scalp muscles.
2.Implied pain
Psychological suggestion can lead to the production of pain. For example, a patient felt discomfort in the upper abdomen, and when he went to the hospital for upper gastrointestinal imaging, he heard the technician say, “There is a retrograde peristaltic wave in the duodenum (which is normal).” However, the patient did not ask further questions to understand correctly, but thought he had an incurable disease. Thereafter, the patient experienced persistent dull pain in the epigastrium, accompanied by nausea and vomiting, and recurrent episodes, but multiple tests failed to detect an organic cause, which was finally relieved by psychotherapy. This kind of medical implication is often one of the causes of pain generation in various clinical specialties. 3, depressive pain
According to WHO estimates, the current global incidence of depressive mental disorders is as high as 3% to 5%, depression among adults is increasing at a rate of 11.3% per year, depression is becoming a common and frequent disease in people’s daily lives. One of the common clinical symptoms of depression is various kinds of pain. These patients often go to general hospitals for physical pain and other discomfort because they are unaware that some physical pain may be caused by a depressive psychiatric disorder. Patients often believe that depression is the result of untreated pain rather than the cause. Studies have found that 87% of chronic pain patients who visit pain centers are finally diagnosed with depression, and 83% of these patients have pain relief after treatment with antidepressants.
Headache was the most common of the various pains associated with depression, accounting for 94%, followed by low back pain at 62.5%, extremity or joint pain at 56%, stomach pain at 6.3%, and chest pain at 6.3%. One scholar evaluated 1016 physical examiners with a questionnaire and found that people with two or more unexplained somatic pains had an increased risk of being diagnosed with depression, which shows that pain predicts depression. In addition, somatic pain symptoms are more common in middle-aged women with depression. In addition to pain, depression-induced psychogenic pain is associated with other symptoms of depression, such as poor mood, decreased interest, low confidence, guilt, fatigue, memory and concentration loss, decreased ability to learn and work, nausea, and sleep disturbances.
4.Anxiety pain
Anxiety disorder is also one of the common diseases in general hospitals, but patients themselves are often unaware that their anxiety may cause pain, and the site of pain in anxiety disorder is not as fixed as the site of pain in depression. The reason why anxiety can cause pain is that anxiety can cause muscle tension and contraction in many parts of the body, especially in the head and neck, and is therefore a common cause of myotonic headache. Myotonic headaches usually begin in a state of emotional stress and often last from a few days to a few weeks, presenting as a tightening or heavy pressure, and are often misdiagnosed clinically as cervical spondylosis. Anxiety can also cause precordial pain, abdominal pain, or back pain. People with precordial pain often suspect they have a heart condition. In addition to pain, anxiety-induced cardiac pain must be accompanied by obvious anxiety symptoms, such as easy tension, inability to relax, worry, difficulty breathing, and also panic, sweating, frequent urination, urgent urination, etc. The examination may reveal signs of tension such as tremor of the extremities, tachycardia and enlarged sleep holes. Acute anxiety attacks (panic attacks) can be associated with hyperventilation, which can lead to dizziness, headache, tingling in the hands and feet, and discomfort in the precordial region. Panic attacks are often associated with a sense of suffocation and near death, and each attack lasts from 30 minutes to an hour. However, the patient often avoids similar situations that caused the attack, such as riding in a car, going to a store or restaurant. Since anxious patients are prone to worry, when one of their relatives or friends suffers from a serious illness or dies of a similar symptom, it will cause the patient’s anxiety to increase further, thus increasing the related symptoms and pain at the same time.
5, neurasthenia pain
The pain of neurasthenia is a feeling of tightness and swelling in the head, accompanied by easy excitement, fatigue and fatigue, insomnia, or dreamy and easy to wake up, uncontrollable and disorganized associations and memories, inattention, easy to worry, irritable and other symptoms.
6.Pain in hypochondria
The nature, degree, and location of pain are mostly unstable and lack corresponding physical signs. Patients often have the characteristics of a hypochondriac, such as sensitivity, paranoia, anxiety, etc. Although their somatic discomfort symptoms by various tests show normal, on this basis, even if given adequate explanation and assurance, their worries and doubts still can not be eliminated.
7.Hysterical pain
The pain is characterized by spasmodic and episodic, and can be seen in any part of the body, but more in the head, neck, precordial area and lower back, the nature of which can range from dull pain to sharp pain, vague and variable, and with imitation and exaggerated colors. Pain has a clear relationship with psychological cues and the presence of psychosocial stressors, such as pain that can cause the patient to avoid certain things that are detrimental to him.
8. Pain of menopausal syndrome
This kind of pain often involves multiple organs, multiple parts, or unnamable pain, accompanied by symptoms of plant nerve disorder, emotional irritability and irritability. Pain occurs at the age of menopause and is more common in women.
9.Persistent somatic form of pain disorder
It is the only psychological disorder in which pain is the main manifestation. Its prominent feature is the main complaint of persistent, severe, excruciating pain, which can affect any part of the body, but the back, head, abdomen and chest are the most common. The pain cannot be fully explained by physical processes or somatic disorders. Emotional conflicts or psychosocial problems are associated with the onset of pain. Patients’ social functioning is significantly impaired, and they spend a lot of energy time and money actively seeking help and treatment to get rid of the pain.
10. Hallucinatory delusional pain
People with schizophrenia occasionally complain of pain, which may be related to hallucinations or delusions, and is called hallucinatory delusional pain. For example, a patient may complain of chest pain and then claim that electrical waves from an acquaintance are stimulating his chest, or even that his mind and body are being controlled by the waves. Some patients complaining about the cause of the pain believe that someone else has given him poison and broken his body. Without further questioning, it may also not be known whether these pain complaints are due to organic damage or to delusions.
(ii) Secondary psychogenic pain
The main cause of secondary psychogenic pain is the presence of pain or the exacerbation of the original pain due to fear, disappointment and intolerance of disease and pain. Secondary psychogenic pain can occur in the context of any organic disease or pain onset. It is characterized by the patient’s presentation of a degree of pain that is clearly inconsistent with the degree of tissue damage and causes functional impairment that far exceeds the degree of impairment that can be caused by the organic lesion. At this time, the patient will appear or be accompanied by more obvious emotional problems or psychological disorders, such as thoughtfulness, worry, tension, anxiety, depression, and also accompanied by fatigue, insomnia and other symptoms. It is more difficult to determine in this group of patients whether his pain has psychological involvement because it is a gradual developmental process that is not easily detected clinically, and with the same problem, these patients are more inclined to deny the influence of psychological problems in their pain.
Therefore, secondary psychogenic pain covers a wide range of conditions that cannot be summarized in a single sentence. The following types of chronic pain are more likely to be associated with secondary psychogenic pain.
1. Migraine
Migraine is a kind of headache with periodic attacks, which mostly starts in adolescence and is often closely related to psychological and emotional symptoms. The clinical manifestation is throbbing or swelling pain in the forehead, temporal and orbital areas of one side, and there may be aura symptoms, such as flashing lights and blackness in front of the eyes. Migraine has a high incidence and causes a lot of pain to patients and their families. A typical migraine attack can be divided into four phases. Phase I: prodromal symptoms; Phase II: aura; Phase III: headache phase; and Phase IV: remission phase. Typical pain is mostly unilateral, throbbing, moderate to severe, and aggravated by mood swings and tension, but different patients can show their own characteristics. The accompanying symptoms of migraine are mostly pale, photophobia, phonophobia, nausea, vomiting, sensory allergy, also blurred vision, polyuria and other symptoms.
Myofascial pain syndrome Myofascial pain is a local pain syndrome characterized by multiple trigger points and tension bands, which can occur in many parts of the body, but most commonly in the neck and lumbar region. These syndromes are often caused by minor trauma or degenerative osteoarthritis, but are prone to psychological problems over the course of a long period of time, which can lead to increased pain development.
3.Fibromyalgia
Fibromyalgia is a clinical syndrome characterized by chronic, diffuse pain and multiple pressure points, most often seen in women. Diffuse pain must be distributed above and below the lumbar region, bilaterally, and affect at least 11 of the 18 pressure points. Characteristic manifestations include fatigue, sleep disturbances, stiffness, sensory abnormalities, headache, irritable bowel syndrome, Raynaud’s phenomenon, often accompanied by depression, anxiety, insomnia and chronic fatigue syndrome.
4.Chronic pelvic pain
Recurrent pelvic pain lasting for 6 months or more is called chronic pelvic pain, which can be caused by medical, surgical and obstetrical diseases, mainly due to endometriosis, pelvic adhesions, chronic pelvic inflammation, and also chronic pelvic pain syndrome without organic causes, where the degree of pain or discomfort is often disproportionate to physical abnormalities, which also easily causes psychological problems.
Section 6 Diagnosis and differential diagnosis of psychogenic pain
(I) Diagnosis
The diagnosis of psychogenic pain has always been a difficult problem in clinical practice, and misdiagnosis is common, not only because of its complexity and extensiveness, but also because its diagnostic criteria are mostly subjective and empirical, lacking objective and experimental criteria. Coupled with the fact that pain patients who visit general hospitals usually believe that their pain is always caused by tissue damage, they always adopt avoidance and denial of psychological problems. In turn, physicians of various specialties are accustomed to looking for the cause in organic lesions and are always worried about missing the diagnosis of organic diseases. At the same time, pain of psychogenic origin cannot be clarified by means of relevant biological tests, therefore, whenever specialists encounter such patients, they often feel confused and perplexed.
The diagnosis of psychogenic pain can be helped if the patient with chronic pain has the following characteristics.
1. The patient is convinced that his pain comes from a physical disease and endlessly seeks physical diagnosis and treatment, refusing psychological and sociological explanations and help.
2. The patient has received many medical and surgical treatments with no real effect, but often leads to drug addiction.
3.Dependent on the physician, demanding that the physician take responsibility for curing him, but refusing to make an effort to adapt to the effects of pain on him.
4. Indulging in the role of being sick, which eventually causes others to become bored and reject him, leading to his alienation from everyone else.
5. Lack of social skills, unrealistic expectations of many things or fear of failure, and afraid to assume the role of a healthy person.
According to the American Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), pain is coded as a somatic disorder, also known as “pain disorder associated with psychological factors” (307.80) or “pain disorder associated with psychological factors and somatic conditions” (307.89). “(307.89). The diagnostic criteria are.
1. The main manifestation is pain in one or more anatomical areas, and the pain is severe enough to attract clinical attention.
2, Pain causes significant depression and diminished functioning in social, work, or other important areas.
3.Psychological factors play an important role in the onset, severity, worsening or maintenance of pain.
4. Symptoms of functional deficits are not intentionally made or faked out.
In addition to chronic pain in the diagnosis of other types of psychogenic pain, there should be diagnostic criteria that meet various psychological disorders, such as depression, anxiety, dysthymia, neurosis and hypochondria.
(ii) Differential diagnosis
However, as a clinical specialist in a general hospital, when encountering a patient with chronic pain, he or she should first try to distinguish whether the pain is functional or organic, and also note that even if the patient has a physical disease, he or she should still try to identify how much of the patient’s pain is caused by physical disease and how much is caused by psychological factors, usually through detailed history, physical examination, laboratory tests and psychological assessment scales. It is important to note that some patients who can be treated with orthopedic or neurological treatment may have intractable pain due to strong psychological factors and may be misdiagnosed as having purely psychogenic pain. A report from a multidisciplinary pain center documented that of 120 patients with chronic pain, 40% were diagnosed inaccurately or incompletely. Frequently missed diagnoses included facial muscle disorders, facial disorders, peripheral neuropathy, and herniated discs. After detailed examination, 98% found an organic cause.
Section 7: Treatment of psychogenic pain
The management strategy for pain is to identify the cause of the pain and then take appropriate measures to eliminate it. Pain is often caused by somatic damage or dysfunction, this is called “organic pain”, the treatment focuses on the treatment of somatic lesions, various analgesics can have the effect of relieving pain. These contents are described in detail in the relevant books and will not be repeated here. This section focuses on the treatment and management of psychogenic pain.
The current treatment of psychogenic pain is often difficult and ineffective because most pain patients attending general hospitals are reluctant to recognize the relationship between their problem and psychosocial stress and thus refuse any psychotherapy. They seek a dependent doctor-patient relationship, where the problem persists for a long time and thus always needs the doctor’s help and seeks treatment, where the patient is asking for somatic treatment for his or her non-somatic illness.
The biopsychosocial model of medicine has important implications in the diagnosis and treatment of psychogenic pain. The first step is to accept and understand that the patient does experience pain, express his or her desire to help him or her relieve the illness, and gain the patient’s trust. Then further understanding the psychosocial factors affecting the patient’s pain, caring for his past pain experience, the pain situation at that time, attention to the pain, the presence of suggestion or hypnosis, and emotional factors. A complete and thorough physical examination of the patient during this process is necessary to alert the patient to possible new physical illnesses, to provide sufficient evidence to convince the patient later if negative, and to protect the patient from unnecessary and costly or dangerous tests. Clinically, patients are often pessimistic and fearful because no evidence of organic pathology can be found, but the pain is difficult to heal and they think they have an incurable disease. Therefore, on the basis of a full understanding of the patient’s medical history and examination, the patient should be informed of the results of the physical examination and the psychological causes of the disease, point out the relationship between psychosocial factors and pain, correct their wrong ideas, eliminate their fear and pessimism, reassure them, relax their emotions, and lay a good foundation for the patient’s cooperation and active treatment.
In the treatment of pain, psychotherapy is the main treatment, and if there are serious psychological disorders, such as anxiety, depression and hypochondria, it is necessary to supplement with drug treatment.
(A) Psychological treatment
For chronic pain of psychogenic origin, the treatment guidelines for psychiatrists are.
1. The focus of chronic pain management is not only to reduce pain, but also to improve function.
2. Develop an appropriate treatment plan, and try to identify the role of psychological factors and somatic conditions in the onset and maintenance of pain.
3.Psychological factors often determine the response of chronic pain patients to treatment methods.
4. Realize that pain often occurs in conjunction with other psychiatric disorders and that pain may be a symptom, a cause, or both of these psychiatric disorders.
5. Realize that the efficacy of treating chronic pain often depends on the patient’s ability to cooperate, learn, and actually relieve the pain.
6. Avoid excessive application of benzodiazepines or opioid analgesics that may aggravate the condition.
According to gate control theory, pain relief can be achieved not only by directly altering nociceptive afferents through biochemical methods, but also by altering motivational formation and cognitive processes to achieve pain control. This provides a rational basis for psychiatrists to further help pain patients deal more effectively with pain and other stressors, and to reduce their dependence on medications. Commonly used clinical approaches are: (i) behavioral and cognitive therapies, including operant conditioning, relaxation training, biofeedback, and cognitive therapies such as attention shifting, imagery, and redefinition; and (ii) hypnotherapy and epiphanies.
The theoretical basis of operant conditioning is that any operant and practice behavior is a response to the environment. The goal of treatment is to reduce the patient’s dependence on medication, to reduce the decompensation associated with chronic pain, to reinforce positive or healthy behaviors, and to eliminate destructive behaviors that perpetuate pain, such as complaints of pain and reluctance to engage in rehabilitation. The psychiatrist should then take steps such as ignoring the patient’s pain behaviors and praising and rewarding positive behaviors. Studies have shown that this approach is effective in increasing the patient’s level of functioning and reducing the use of medications.
Many patients experience recurrent episodes of pain due to underlying physiological processes that are often caused by stressors. If these patients are able to control the stressor or physiological process that triggers the pain, the frequency and severity of the pain can be effectively reduced. A good example is headache, where classical theory suggests that cerebral vasodilatation causes migraine, while persistent head, neck, and shoulder muscle contractions cause tension headaches. Stressors can cause these physiological processes through the autonomic nervous system or the musculoskeletal system. Biofeedback therapy is more effective in relieving tension headache, while relaxation training is more effective in migraine. Follow-up studies have shown that the application of relaxation training or a combination of biofeedback can provide pain relief for at least 2 years. Cognitive therapy reduces pain perception by identifying and correcting distorted attitudes, beliefs and expectations. The goal is first to make the patient aware of the factors that aggravate or alleviate pain and second to motivate the patient to adjust behavior accordingly. The specific methods of operation are:
1, attention shifting This technique is to reduce the attention to the discomfort by focusing on painless stimuli in a direct contact environment. This technique works best for mild to moderate acute pain, and moderate persistent pain can be relieved if one can concentrate on an activity such as watching a movie or reading a book.
2. Imagination This technique is used to reduce attention to discomfort by imagining pictures in the mind that are not related to pain. It is similar to the attention diversion technique in many ways, the main difference being that imagination is based on the patient’s imagination rather than on objects or events that exist in the environment, and therefore can be utilized when the patient needs it, without relying on the environment. Imagery is more effective in relieving mild to moderate pain.
Patients apply imagined or actual thoughts about the pain experience to replace thoughts of being threatened or hurt. Therapists can help patients redefine the pain experience through a variety of methods. This can be effective for patients with severe pain. Studies have shown that hypnosis can relieve acute pain, with the most significant pain relief in more suggestible patients and efficacy comparable to cognitive therapy. For chronic pain, hypnosis has similar effects to placebo.
(ii) Stimulation therapy
The following are commonly used clinically: ①TENS (transdermal electrical stimulation): an electrode is placed near the painful area and mild electrical stimulation is given. It is mainly used to relieve acute muscle pain or post-operative pain, and its efficacy is certain. ② Acupuncture: using a milli-needle to pierce the skin in a specific area and gently rotate it to produce stimulation, and its efficacy is certain.
(iii) Pharmacological treatment
The main discussion is on pharmacological treatment for psychological disorders in pain, while the pain relief pharmacological treatment for pain itself is described in the relevant chapters and will not be repeated in this chapter. As a variety of new antidepressant and anxiety drugs with good efficacy and few side effects are now available, when we cannot be sure for a while but highly suspect that the patient’s pain is psychogenic, we can apply antidepressant and anxiety drugs for diagnostic treatment.
1.Anti-anxiety and sedative-hypnotic drugs
Benzodiazepines (BDZ) are the main drugs, with small doses playing an anti-anxiety and tension role, and larger doses playing a sedative-hypnotic role. The mechanism of action of the drug is not completely elucidated, it is generally believed that the anxiolytic effect of BDZ is related to the affinity of the drug with the special receptors of BDZ in the brain, and the high selectivity of the hippocampus, amygdala and other functional parts of the limbic system, and its sedative-hypnotic effect may be related to the inhibition of the reticular upstream activation system.
Anti-anxiety and nervousness commonly used are: eszopiclone (Scholastin), 1~2 mg/dose, 2~3 times a day orally; alprazolam (Glaxoquine), 0.2~0.8 mg/dose, 2~3 times a day orally; diazepam (Valium), 2.5~10 mg/dose, 2~4 times a day orally; non-benzodiazepine anxiolytics, buspirone, 5~10 mg/dose, 3 times a day orally Phenobarbital (luminal), 15~30 mg/dose, 2~3 times a day orally. Commonly used for sedation and hypnosis are: triazolam (Hailsham), 0.25~0.5 mg, eszopiclone, 1~2 mg, orally at bedtime; clonidine (Clonidine), 1~2 mg, orally at bedtime; midazolam (Sulfanil), 7.5~15 mg, orally at bedtime; zopiclone (Yimengzhi), 7.5 mg, orally at bedtime.
However, BDZ has drug resistance and withdrawal reactions, mainly manifested as a decrease in therapeutic effect after several weeks of use, and the dose needs to be adjusted or changed to achieve the original effect. And often have cross-resistance to each other. Therefore, it is not clinically advisable to take the same drug for a long period of time and to reduce, change or intermittently take the drug when necessary. Withdrawal reactions are mainly withdrawal symptoms, mostly seen in long-acting BDZ and long-term heavy users. The symptoms are insomnia, dizziness, headache, tinnitus, tremors, anorexia, etc. The withdrawal symptoms often appear 3 days after stopping the drug. Treatment is to slowly reduce the drug, or short-acting BDZ (eszopiclone, triazolam, alprazolam, midazolam) instead of long-acting BDZ (clonidine, diazepam) method, or give a trial of beta-blocker ponerol. Excessive sedation is another adverse effect of BDZ. Patients mainly show tiredness, fatigue, fine motor effects, reduced alertness, reduced concentration and learning. Another rare adverse effect of BDZ is called disinhibition and pharmacogenic depression, i.e., small doses of BDZ may occasionally cause impulsive excitement or euphoria, or even reduced behavioral control and berserk behavior, but not the disease itself. The symptoms of the disease itself should be carefully observed, and the drug should be stopped or changed in time.
2.Antidepressants
The principles of antidepressant treatment: the diagnosis is clear, the patient’s symptom characteristics are fully considered, and the medication is individualized and rational; the dose is gradually increased, and the smallest effective dose is used to minimize adverse reactions and improve compliance; if the small dose is not effective, the dose is increased to the full dose (the upper limit of effective drugs) and a long enough course of treatment (>4-6 weeks) according to the adverse reactions and tolerance; if it is not effective, a change of medication can be considered (another drug of the same type or another drug with a different mechanism of action). Another drug or another drug with a different mechanism of action). As far as possible, a single drug should be used in sufficient quantity and for a full course of treatment. Combination of two or more antidepressants is generally not recommended.
It must be noted that in the treatment of psychogenic pain, in addition to explaining the patient’s condition before treatment, the nature, effects and possible adverse reactions of the drugs and countermeasures should be clarified to the patient and his family before the administration of the drugs, because it is not the patient’s hope to be given such treatment drugs, so it is necessary to explain to them in order to obtain their understanding, to obtain their active cooperation, to be able to take the drugs on time and in accordance with the instructions, to observe closely during the treatment period During the treatment period, we should closely observe the disease and adverse reactions, and deal with them in time.
Depression is often a chronic, relapsing disease, it has a whole course of treatment concept: can be divided into acute treatment, consolidation treatment and maintenance treatment.
(1) Acute treatment: The goal of acute treatment is to control symptoms and achieve clinical recovery as much as possible. Drug treatment generally starts to take effect in 1~2 weeks, and the efficiency of treatment is linearly related to time. If the patient does not work with drug treatment for 6-8 weeks, it may be effective to switch to other drugs with different mechanisms of action.
(2) Consolidation treatment: After the acute treatment, the patient’s symptoms have been basically relieved, and social function is gradually restored, at this time, the drug should not be immediately reduced, because the maintenance of a larger drug dose, consolidation treatment for a period of time, supplemented by the corresponding psychotherapy. From the complete remission of symptoms, should continue to consolidate treatment for 4-8 months.
(3) Maintenance treatment: The goal of maintenance treatment is to prevent relapse. The patient can start to reduce the dosage of medication after the acute and maintenance treatment, when the symptoms are controlled, the social function is further restored, and the patient is aware of the disease and the need for treatment.
Suggested duration of treatment, first episode:6-8 months; second episode:2-3 years; more than 2 episodes; long-term treatment. After the maintenance treatment period, the disease is stable, the drug can be slowly reduced until the termination of treatment, but should be closely monitored for early signs of relapse: once the early signs of relapse are detected, the original treatment should be quickly resumed.
TCAs also block other receptors such as histamine receptors and toxopamine receptors, and side effects are caused by blocking other receptors (dizziness, weakness, drowsiness, dry mouth, constipation, etc.). (dizziness, fatigue, drowsiness, dry mouth, constipation, etc.). Since high doses of TCAs can have significant arrhythmic side effects on the heart, TCAs need to be used with caution in cardiovascular medicine, but small doses are still safe. Doxepin is commonly used, starting at 12.5 mg/dose twice daily and gradually increasing to 50-75 mg daily. onset of action is 1 to 2 weeks.
5-Hydroxytryptamine reuptake inhibitors (SSRIs) are a new class of antidepressants developed in recent years, with the main pharmacological effect of selectively inhibiting 5-HT reuptake and increasing the synaptic gap 5-HT content for therapeutic purposes. Clinical use characteristics: anticholinergic adverse reactions are small, the impact on cardiovascular and liver and kidney function is small, the sedative effect is light, well tolerated by patients, high compliance, easy to take, and can be used safely in various departments of general hospitals. Because of the small sedative effect, it can be taken mostly during the day, and can be taken at night if there is sleepiness and weakness. Commonly used are fluoxetine, 20 mg/dose, once a day in the morning; paroxetine, 10-20 mg/dose, once a day in the morning; sertraline, 50 mg/dose, once a day in the morning.
The main side effects of 5-hydroxytryptamine reuptake inhibitors are nausea, anorexia, abdominal pain, dry mouth, diarrhea, and dizziness, excessive sweating, nervousness, tremor, anxiety, and sexual dysfunction. 5-hydroxytryptamine reuptake inhibitors have a slow onset of action, usually taking 2-4 weeks to improve the patient’s symptoms. Try to reduce the drug slowly at the end of the course of treatment to avoid withdrawal reactions.
5-Hydroxytryptamine and norepinephrine reuptake inhibitors (S N R I s 〉 venlafaxine (formerly known as venlafaxine) is the only existing SNRI S. The main pharmacological effect is to have NE and norepinephrine reuptake inhibitors. The main pharmacological effect is to have NE and 5-HT dual reuptake inhibition, fast onset of action, in 1 ~ 2 weeks after taking the effect. Dosage: Extended-release capsules of 75 mg or 150 mg once daily.
New antidepressant (NaSSA) with enhanced effects on both NE and 5-HT transmission, Mirtazapine, pharmacological effects: (1) blocking α2-adrenergic receptors, increasing brain NE levels. (2) Blocking 5-HT, enhancing the firing rate, promoting the release of 5-HT, and increasing the level of 5-HT in the brain. (3) Inhibit 5-HT2 and 5-HT3 receptors, thus avoiding the side effects of some antidepressants such as SSRIs.
Mirtazapine has good antidepressant and anxiolytic effects, especially for depression with anxiety and sleep disorders and geriatric depression. Common adverse effects include sedation, drowsiness, dizziness, fatigue, dry mouth, and appetite and weight gain. Dosage: 15-30 mg/dose, taken orally each night at bedtime.
Dextran is a combination of a small dose of the antipsychotic trifloxystrobin and a small dose of the tricyclic antidepressant tetramethyl anthracycline, whose pharmacological effects are the result of the combined action of the two components. The pharmacological effect is the result of the combined action of the two components. The main manifestation is to increase the content of different neurotransmitters such as dopamine, NE and 5-HT in the synaptic gap. The two components have synergistic and side effect antagonistic effects in the therapeutic effect, which can effectively anti-anxiety and antidepressant, and improve somatic symptoms. It has a fast onset of action and few side effects. Dosage: Take 2 tablets daily, one in the morning or one in the morning and one at noon.
Typical cases
Case 1: The treatment experience of a patient with abdominal pain
The patient, a 51-year-old woman, had an attack in June 2004, complaining of paroxysmal abdominal pain, which started at a point in the upper right abdomen, then gradually expanded to the size of the palm of the abdomen, and finally developed to the whole abdomen, the pain was scalding-like or knife-like, and when it was severe, it would roll all over the floor, and there was no fixed time for each attack, and there was no obvious physical examination of the abdomen during the attack, but the blood leukocytes were high, at about 9000-13000, and the neutrophil was 90 -At the same time, because of the high blood leukocytes, each attack was treated with antibiotics and acidophilus intravenous drip, and it took five days of continuous drip to completely control the abdominal pain. However, the same symptoms would recur after about ten days and the same treatment was required. During this period, the patient repeatedly underwent various examinations and had more than a dozen abdominal ultrasounds, gastroscopies, CTs and MIRs, and had long been treated in the gastroenterology department with abdominal pain pending investigation. He had been hospitalized three times in the gastroenterology departments of two tertiary care hospitals. He was suspected of having cholecystitis, hepatitis and gastric ulcer, but they were ruled out. In addition, the patient also visited the obstetrics and gynecology, rheumatology and menopause specialist clinics, and also visited the emergency room more than ten times for acute abdominal pain attacks. She also visited a hepatobiliary medical research center overseas three times during her medical treatment, but the results were poor. During the treatment, liver damage was caused by excessive use of antibiotics, and many antibiotics were used until allergies occurred later, leaving only jessamycin available, and each subsequent attack was treated with a combination of jessamycin, sindfadin and tramadol to have a little effect. He also considered removing the gallbladder, but gave up because he was not sure that the surgical treatment would relieve the abdominal pain.
In one visit, the doctor found that the patient had severe gastrointestinal symptoms as well as depressed mood, fatigue, frequent urination, nightmares, and nervousness and agitation, and scored 35 on the ZUN psychological scale for SAS anxiety and 39 on the SDS depression.
According to the above mentioned patient’s performance, depressive and anxiety state with psychogenic pain was considered. The patient’s abdominal pain did not recur and his anxiety and depression improved significantly during the next three weeks of treatment. The patient’s abdominal pain was occasional but significantly reduced in severity and duration at the six-month follow-up.
DISCUSSION: The diagnosis of pain with a cause of concern has always been a difficult problem in clinical practice, and missed misdiagnosis is common, not only because of its complexity and extensiveness, but also because the judgment of its diagnostic criteria is mostly subjective and empirical, lacking objective experimental judgment criteria. Coupled with the fact that pain patients who visit general hospitals usually believe that their pain is always caused by tissue damage, they always adopt avoidance and denial of psychological problems. In turn, physicians of various specialties are accustomed to looking for the cause in organic lesions and are always worried about missing the diagnosis of organic diseases. At the same time, pain of psychogenic origin cannot be clarified by means of relevant biological tests, therefore, whenever specialists encounter such patients, they often feel confused and perplexed. Psychogenic pain is not the name of a disease, but a group of clinical syndromes, often presenting as chronic pain for more than 3 to 6 months. Cardiac pain can be clinically manifested in two forms. One is the cardiac pain caused by purely psychological disorders without any other cause of organic tissue injury, which can be called primary cardiac pain, and is characterized by: (1) chronic pain and other somatic symptoms as the main manifestation, with a wide variety and variability of symptoms, sometimes resembling pain caused by organic diseases. ②In parallel with chronic pain, patients often have mild depressive symptoms such as decreased interest, decreased libido, anxiety, and sleep disturbances, which are heavy in the morning and light in the evening. ③Repeated visits to internal, external, neurological and traditional Chinese medicine departments are often treated with “kidney deficiency, plant nerve dysfunction and neurasthenia because no positive signs can be detected, but they are not effective. ④ Psychotropic drugs and psychotherapy can bring about rapid relief of symptoms. The other kind is that although there are various causes of organic tissue injury, the pain is aggravated with the emergence of psychological disorders during the development of their diseases, resulting in long-term, complicated and difficult to treat pain, which is called secondary psychogenic pain. If, clinically, no clear etiology can be found for the patient’s pain or the degree of pain is obviously inconsistent with the so-called etiology, coupled with the patient’s accompanying mood disorders such as anxiety, it is important to consider whether the patient has the possibility of psychogenic pain, and if anti-anxiety and depression treatment can be given in time, the patient’s pain can be well relieved.
Case 2: The treatment experience of a patient with low back pain
The patient is a 74-year-old male, because he felt that his physique was poor, he went to the park and followed people to walk in order to exercise, but his body did not walk well, but he got out of back pain. In the past two months, he has been suffering from recurrent back pain and lumbago, and when it is serious, he can’t lie down or sit down or walk, and when he goes to the hospital, he has about 10-20 red blood cells in his urine, and he has a twisted ureter on one side. In addition, the patient had left lung destruction due to left tuberculosis 40 years ago and compensatory emphysema on the right side, other than that no other significant abnormalities were found on examination. During the physical examination, the patient had no buckling pain or pressure pain in the lumbar examination, but felt comfortable when pounding on both sides of the lumbar pain and lumbar soreness.
Since there were some problems with the urinary system examination, the patient thought that his lumbago was related to this, so he repeatedly sought medical treatment at the nephrology and urology departments, but his condition was not well relieved. The doctor in question was also perplexed by the patient’s lumbago symptoms and thought that the patient’s lumbago could not be explained by the patient’s clinical examination results.
The patient’s wife died ten years ago due to diabetic myocardial infarction, his only son died eight years ago in a car accident abroad, and his daughter divorced three years ago, and now he lives with his daughter and granddaughter. However, his daughter and granddaughter are very good and do not have any difficulties financially or in life. But he always has to worry about his daughter and granddaughter’s study and work life, afraid that they have something to lose, although he feels very tired, the illness makes him suffer, as far as he is concerned, he thinks it is better to live than to die, but he thinks that even if he can’t do anything, but he has two eyes to help watch them mother and daughter is better, he really can’t rest assured that they, which also increases the psychological burden of patients. During his illness, he was able to go up and down six flights of stairs six times a day, but now he can barely walk twice and feels tired, and his ability to do housework has decreased, and he can’t even take care of himself. At the same time, the patient also has symptoms such as easy tension, worry, fear and insomnia; he also tends to think and worry a lot. According to the patient’s condition, he was considered to be anxious and depressed, and was given anti-anxiety and depression medication in February 2005.
On April 4, 2005, the patient had been taking the medication for more than one and a half months and her back pain had basically disappeared. Her daughter no longer nagged or looked sad when she came home at night. In particular, his sleep has improved significantly. However, he did not dare to move more, fearing that his back pain would return after more activities. At the same time, he felt that he could stop taking the medicine after the back pain was gone, but after persuasion, he agreed to continue to take it again and insisted on treatment for half a year.
(Mao Jialiang)
References
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