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Psychological factors: Chronic stress , anxiety , depression , and post-traumatic stress disorder (PTSD) all significantly perpetuate myofascial pain through multiple pathways: Sustained sympathetic nervous system activation elevates ACh levels at the NMJ, promoting trigger point formation HPA axis dysregulation alters cortisol and inflammatory mediator balance Altered descending pain modulation from stress-induced changes in the periaqueductal gray (PAG) and rostral ventromedial medulla (RVM) reduces endogenous pain inhibition
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