Dear Vicc and Betsy -

I certainly didn't mean to overwhelm Betsy, and my most sincere apologies if I did. One of the things that writing as a lawyer taught me to do was to string quotations together, where the reader would then rely on the quotation itself in order to understand what was being communicated. If I failed in that regard, my apologies again. But I don't believe - and take some umbrage with the suggestion - that the entire thread is unfair to her. I will attemp to explain why.

In simple terms, let's start with the article on "Hostile Marital Interactions, Proinflammatory Cytokine Production, and Wound Healing," stressful events in peoples lives can interfere with immunological responses, to the point of effecting the closure of wounds. And as a side-note, let me also add the following study:

"Marital conflict in older adults: endocrinological and immunological correlates," Kiecolt-Glaser JK, Glaser R, Cacioppo JT, MacCallum RC, Snydersmith M, Kim C, Malarkey WB, Psychosom Med., 1997 Jul-Aug; 59(4): 339-49:

OBJECTIVE: To assess endocrinological and immunological correlates of marital conflict and marital satisfaction, 31 older couples (mean age 67 years) who had been married an average of 42 years were studied. METHOD: Couples were admitted to the Clinical Research Center and a catheter was placed in each subject's arm. Blood was drawn on entry for immunological assays; for hormone analyses, five blood samples were drawn during a 30-minute conflict discussion and a 15-minute recovery session. The conflict session was recorded on videotapes that were later coded for problem-solving behaviors using the Marital Interaction Coding System (MICS). RESULTS: Among wives, escalation of negative behavior during conflict and marital satisfaction showed strong relationships to endocrine changes, accounting for 16% to 21% of the variance in the rates of change of cortisol, adrenocorticotropic hormone (ACTH), and norepinephrine (but not epinephrine). In contrast, husbands' endocrine data did not show significant relationships with negative behavior or marital quality. Both men and women who showed relatively poorer immunological responses across three functional assays (the blastogenic response to two T-cell mitogens and antibody titers to latent Epstein-Barr virus) displayed more negative behavior during conflict; they also characterized their usual marital disagreements as more negative than individuals who showed better immune responses across assays.

CONCLUSION: Abrasive marital interactions may have physiological consequences even among older adults in long-term marriages.

(I will be happy to email the full text of this one to anyone who wants it, just send me a PM with your email address.)

Now consider my insertion of the full text of "A 2 1/2-year-old girl with reflex sympathetic dystrophy syndrome (CRPS type I): case report," an anecdotal report of RSD following extreme stress, and a "plain language" discussion of the literature tying stress to RSD. Perfectly appropriate? I think so.

Then we get to the thrust of my argument, and here's where the science cuts in. I'll try to be as clear as possible. In "Chronic stress and age-related increases in the proinflammatory cytokine IL-6," Janice K. Kiecolt-Glaser, et al, PNAS, etc., the authors established that depression/stress by themselves could increase the levels of C-reactive proteins and IL6 (remember the article about wound healing and marital stress). And then we have the Schwartzman piece showing high levels of IL6 in the spinal fluids of CRPS patients. Which is if course a direct tie-in to not only the Turkish study on the 2 and 1/2 year old girl, but also the abstract of the one small study that's looked at the issue directly "Stressful life events and psychological dysfunction in Complex Regional Pain Syndrome type I.," Geertzen JH, de Bruijn-Kofman AT, de Bruijn HP, van de Wiel HB, Dijkstra PU, Clin J. Pain, 1998 Jun;14(2):143-7:

OBJECTIVE: To determine to what extent stressful life events and psychological dysfunction play a role in the pathogenesis of Complex Regional Pain Syndrome type I (CRPS). DESIGN: A comparative study between a CRPS group and a control group. Stressful life events and psychological dysfunction evaluation was performed with a life event rating list and the Symptom Checklist-90 (SCL-90). SETTING: A university hospital. SUBJECTS: The CRPS group consisted of 24 patients with a history of upper extremity CRPS of less than 3 months. The control group consisted of 42 hand pathology patients waiting for elective hand surgery within the next 24 hours. MAIN OUTCOME MEASURES: Stressful life event rating was measured using the Social Readjustment Rating Scale. Psychological dysfunction was measured using the SCL-90. RESULTS: Stressful life events were experienced by 19 patients (79.2%) in the CRPS group and by 9 patients (21.4%) in the control group. This difference was significant. Testing of psychological dysfunction (SCL-90) in CRPS patients and the control group demonstrated some significant differences: male patients were more anxious than male controls; female patients were statistically more depressed, had feelings of inadequacy, and were emotionally less stable than female controls. In multivariate analysis, no significant differences were found across gender, age, or gender x group interactions. Of the SCL-90 dimensions, only insomnia correlated with the experienced stressful life events. CONCLUSION: Stressful life events are more common in the CRPS group, which indicates that there may be a multiconditional model of CRPS. The experience of stressful life events besides trauma or surgery are risk factors, not causes, in such a model.

The evidence shows that (1) stress and depression can, without any other intervening variable, trigger the development of pro-inflamatory cytokines, (2) the same stress/depression significantly interferes with the normal functioning of the immune system, (3) pro-inflammatory cytokines are "associated" with CRPS and (4) there are at least two reports - the Turkish study and the Geertzen article - that begin to go to the direction of the causal link between "stress" and RDS/CRPS. But all that said, if anyone won't even read the materials I've included because they don't agree with the conclusions, then there's not much I can say.

Finally, I will grant that there may be a piece of the chain that could be filled in here or there, but overall, I see the evidence as powerful. And that and that alone was the point I was trying to make.

Mike

A somewhat "off-topic" post-script: This is one reason why I am a booster of utilizing "Mindfulness Based Stress Reduction", e.g. meditation and body awareness, for people with RSD: on the theory that if stress plays a role in the onset of the disease, perhaps reducing the stress will keep the disease in check. Of course, even if it doesn't work directly on the disease - and I won't warrant that it does - there are always the mindfulness and equinimity components, which do in fact "work" from my personal experience.