Psychogenic pain should not be ignored Psychogenic pain is defined as chronic pain without an organic etiology or without a sufficient organic reason to explain it. Typical symptoms include chronic headache, persistent low back pain, atypical facial pain, and abdominal or pelvic pain of unknown etiology. The majority of these cases suffer from organic pathologic changes, but evidence from clinical evaluation suggests that in many of these cases it is primarily a psychological disorder that affects the intensity of pain and the degree of dysfunction. Diagnosis The diagnosis may be aided if the chronic pain patient has the following characteristics. 1. A strong belief that the pain comes from a physical illness, an endless search for physical diagnosis and treatment, and a refusal to accept psychological or sociologic explanations or help. 2. The patient has received many medical and surgical treatments that have had no real effect, but have often led to drug addiction. 3. Dependent on the physician, demanding that the physician take responsibility for curing him, but refusing to make any effort to adapt to the effects of pain on him. 4. Indulgence in the role of the sick, which eventually causes boredom and rejection of others, leading to alienation from the crowd. 5. Lack of social skills, unrealistic expectations of many things or fear of failure to take on the role of a healthy person. Diagnostic Criteria: The main manifestation is pain in one or more anatomical areas, and the pain is severe enough to warrant clinical attention. 1, Pain causes significant depression and reduced functioning in social, work, or other important areas. 2, Psychological factors play an important role in the onset, severity, worsening, or maintenance of pain. 3, Symptoms of functional deficits are not intentionally feigned. Treatment The treatment of psychogenic pain should be based on psychotherapy, which should be supplemented with medication in cases of severe psychological disorders, such as anxiety, depression, and hypochondriacs. I. Psychotherapy The commonly used clinical methods are: 1. Behavioral and cognitive therapy, behavioral therapy, including operational conditioning, relaxation training, biofeedback, cognitive therapy, such as attention diversion, imagination, redefinition; 2. Hypnotherapy and epiphany and so on. Behavioral therapy. 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 medications, reduce the functional decline that accompanies chronic pain, reinforce positive or healthy behaviors, and eliminate destructive behaviors that perpetuate pain (e.g., complaints about pain and unwillingness to undergo rehabilitation). The physician should take steps at this time (e.g., ignoring the patient’s painful behaviors and praising and rewarding positive behaviors). 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 physiologic processes that are often caused by stressors. If these patients are able to control the stress or physiologic process that triggers the pain, the frequency and severity of the pain can be effectively reduced. A good example of this is headaches, where the classical theory suggests that cerebral vasodilation causes migraines, while sustained muscular contractions of the head, neck, and shoulders lead to tension headaches. Stressors, on the other hand, can cause the above physiological processes through the autonomic nervous system or the musculo-marrow system. Biofeedback therapy is more effective in relieving tension headaches, while relaxation training is more effective in migraine. Cognitive Therapy. Cognitive therapy works by identifying and correcting the patient’s distorted attitudes, beliefs, and expectations so that the patient feels less pain. Its therapeutic goal is first to make the patient aware of the factors that exacerbate or alleviate the pain, and second to motivate the patient to adjust his or her behavior accordingly. Attention Diversion: This technique is used to reduce attention to discomfort by focusing on the non-painful stimulus in a direct-contact environment. This technique works best for mild to moderate acute pain, and moderate persistent pain can be relieved by focusing on an activity, such as watching a movie or reading a book. Imagery: This technique is used to reduce attention to uncomfortable sensations by visualizing pictures in the mind that are not related to the pain. It is similar to the distraction technique in many ways, with the main difference being that imagery is based on the patient’s imagination rather than objects or events present in the environment, and is therefore available when the patient needs it, without having to rely on the environment. Imagery is more effective in relieving mild to moderate pain. Redefining Pain: The patient applies imagined or actual thoughts about the pain experience to replace thoughts of being threatened or hurt. Therapists can help patients redefine the pain experience in a variety of ways, which can be effective for patients with severe pain. Hypnosis. Studies have shown that hypnosis relieves acute pain, with pain relief most pronounced in more suggestible patients, and with efficacy comparable to cognitive therapy. For chronic pain, hypnosis has a similar effect to placebo. Second, stimulation therapy Clinically used as follows. 1, transdermal electrical stimulation therapy (TENS): an electrode is placed near the site of pain, giving mild electrical stimulation. Mainly used to relieve acute muscle pain or postoperative pain, the efficacy of the treatment is certain; 2, acupuncture: using millipercentrifuge needles in a specific part of the skin, gently rotating to produce stimulation, the efficacy of the treatment is certain. Third, drug therapy Due to the emergence of a variety of new therapeutic efficacy and small side effects of antidepressant anxiety drugs, when we are not sure but highly suspicious of the patient’s pain for the cardiac cause, you can apply antidepressant anxiety drugs for diagnostic treatment. Anxiolytic tension and sedative-hypnotic drugs. Benzodiazepines (BDZ) are the mainstay of the treatment, providing anxiolytic effects in small doses and sedative-hypnotic effects in larger doses.BDZ have drug resistance and withdrawal reactions. Drug resistance is mainly manifested as a decrease in the therapeutic effect after a few weeks of use, the need to adjust the dose or change the species to achieve the original effect, and there is often cross-resistance between drugs. Therefore, clinically, it is not advisable to take the same drug for a long time, if necessary, should be reduced, changed or intermittent medication. Withdrawal reaction treatment method for the slow reduction of drugs, or the choice of short-acting BDZ (eszopiclone, triazolam, alprazolam, midazolam) to replace the long-acting BDZ (clonazepam, diazepam) method, or give a trial of beta-blocker propranolol. Antidepressants. The principles of antidepressant treatment are basically clear diagnosis, comprehensive consideration of the patient’s symptomatic characteristics, individualized and rational use of medication; gradually increasing the dose, using the smallest effective dose, to minimize adverse effects and improve drug compliance; when the efficacy of a small dose is not good, according to the adverse effects and tolerance, to increase to the full amount (the upper limit of effective drugs) and with a sufficiently long course of treatment (> 4-6 weeks); if ineffective, can consider switching (another of the same type or another type with a different mechanism of action), and then use the same type of drugs for a longer period. If ineffective, consider switching drugs (to another drug of the same class or another class with a different mechanism of action). As far as possible, a single drug should be used, with sufficient quantity and duration of treatment. Combining two or more antidepressants is generally not recommended.