NeuroTalk Support Groups - PSYCHOLOGICAL ASPECTS OF RSD.. article

Interesting artical posted in full.. a friend sent it to me.
Sandra

PSYCHOLOGICAL ASPECTS OF RSD

The distressful, complex, chronic, regional pain syndrome of RSD, is felt from periphery all the way to the spinal cord, brain stem, thalamus up to the limbic system where the sensory input ends in the cerebral hemispheres. This sensory input is completely different from the somatic sensory input which ends up in the parietal lobe in post central gyrus of the opposite hemisphere.

The sympathetic sensory input in the cerebral hemispheres is exclusively in the mesial-frontal and temporal regions (limbic system) of the brain (Benarrock, Mayo Clinic Proceedings, October 1993). The limbic system has the main function of emotional control, influence on memory, judgment, and mood.
The input of the sympathetic impulses into the limbic system on long term basis results in irritability, agitation, depression, insomnia, and poor judgment.
Mary Lynch (Pain:49:337-347, 1992) reviewed the subject of psychological aspects of RSD. Her conclusion was "There is general agreement that profound emotional and behavioral changes can follow these types of pain. Opinions have varied widely on the issue of a psychological etiology. It has often been suggested that certain personality traits pre-dispose one to develop sympathetically related pain syndromes. A review of the literature reveals no valid evidence to substantiate this claim".

Early in the twentieth century the Freudian School of Neuropsychiatry even claimed that there was a personality trait for patients developing multiple sclerosis. Obviously there is no personality trait for either RSD or MS.
However, because of the nihilistic approach of the neurologists in regard to any from of chronic disease causing neuropsychological dysfunction, the RSD patients are frequently called neurotic, and histrionic. There is no doubt that the CRPS affecting limbic system invariably causes psychological disturbances including tendencies for being neurotic, histrionic, exaggeration, poor judgment, poor memory, poor concentration and depression. Yet the RSD patient is expected to be stoic, and to be able to sleep through the constant protopathic and allodynic pain. Otherwise, she is considered to have a "psychiatric disturbance".

If the patient develops movement disorder practically identical to Parkinsonian tremor, dystonia, spasticity and spastic gait in absence of abnormal reflexes, then it is easy to claim that the patient suffers from malingering. However, since 1987, three prominent researchers (Schwartzman, Yokoto, and Jankovic) have demonstrated that all the above mentioned types of movement disorder may be secondary to RSD.
If the patient has a thermatomal sensory loss in the distribution of the branches of brachial or femoral artery rather than in a dermatomal radicular distribution, the patient is called malingerer.

If the patient is being tired in infusion pump and gets excellent relief from infusion of Morphine in the spinal fluid, the patient undergoes a placebo test by draining the Morphine out of the pump, and replacing it with normal saline. By the next day the patient still has pain relief due to the presence of residual of Morphine in the spinal fluid. As the patient continues to have pain relief in the face of normal saline infusion, then the patient is called malingerer and all the treatment are discontinued. The patient is told that "It is all in her head".

If the patient at the beginning of the course of treatment responds satisfactorily to sympathetic nerve blocks with complete relief of pain (sympathetically maintained pain-SMP), and after several months develops enough ischemia and injury to the somatic nerves for the pain to become sympathetically independent pain (SIP), the repeated nerve block does not control with the pain and the patient is told that she never had RSD to begin with because the nerve blocks are not helping her any more.

After years of denial of diagnosis and treatment, eventually the patient is told that she is being sent to a doctor in a large medical center who is supposed to be the ultimate expert in RSD. With plenty of hype and build up of expectation, the patient is sent to a doctor who agrees that the patient has RSD. By now the doctor is a God in the eyes of the patient who for the first time has found someone who believes her. Obviously any treatment that this doctor applies is accomplished by a lot of hope and feeling of relief.

On the background of such a hype and high expectation the doctor gives the patient a placebo. There is enough power of suggestion and positive psychotherapy that the patient is going to express improvement of pain. This is not an exact neutral type of "placebo test". This especially is the case when realizing that the patient already has disturbance of judgment due to the pathologic state of the limbic system function in RSD.

Sunderland & Kelly as early as 1948 (Aust. New Zealand J. Surg. 18:1948:75-118), reporting on the subject of causalgia, state. "Harassed by continuous pain and lack of sleep, the patient after a time may become a nervous wreck. If seen at this stage by enthusiastic clinician with a psychosomatic bias, he may have his mind probed in search of psychic trauma, and the practitioner who suspects a psychogenic cause does not often fail to uncover a confirmatory history". In the year 1995, the neurologists are routinely practicing what Sunderland & Kelly warned against.

Unfortunately, IF THE CAT SCAN OR MRI IS NEGATIVE AND IF THE PATIENT BELONGS TO THE 35% TO 45% OF CASES THAT SHOW NO ABNORMALITIES ON BONE SCAN, THEN THE PATIENT IS DOOMED TO BE DIAGNOSED AS NEUROTIC, PSYCHOTIC, OR MALINGERER. CAT SCAN AND MRI ARE ROUTINELY NORMAL IN RSD, AND A SIMPLE X-RAY OF BONES IS MORE LIKELY TO SHOW OSTEOPOROTIC CHANGE. THE OSTEOPOROTIC CHANGES OBVIOUSLY ARE NOT NECESSARY FOR THE DIAGNOSIS OF RSD. NEITHER ARE ATROPHY, LOSS OF FINGERNAILS, LOSS OF HAIR, OR OTHER GROSS MONSTRUOUS DEFORMITIES OF THE TOTALLY UNTREATED RSD PATIENTS.

Even one simple nerve block may be enough to prevent the development of the gross, advanced, late stage abnormalities. Yet, the old literature makes us believe that such advances changes are supposed to be present in all RSD patients.

Of the four pillars of the RSD diagnosis (allodynic pain, muscle spasm or tremor, inflammation, and limbic system disturbance), the history of inflammation is over two times as common as the presence of inflammation at the time of the examination. This is because RSD is in a constant state of flux, so it does not show edema or other aspects of inflammation invariably at the time of physical examination.

A more glaring example of the limbic dysfunction being mistaken for "psychological disturbance" or post-traumatic stress disorder, is the case of electrical injuries. In our experience (Hooshmand et al: the neurophysiological aspect of electrical injuries. Clin.EEG. 1989, 20:111-120) and the experience of Nelson & Novy (Pain Digest:1994:4:206-211), such patients are mistaken for being malingerer or suffering from conversion reaction when in fact they suffer from bifrontal cerebral dysfunction secondary to the electrical injury.

Even when the patient is given the credit of being evaluated by a psychologist, it is rare for the psychologist to utilize objective detailed neuropsychometric tests such as Halstead-Reitan or Luria-Nebraska tests. Instead they check the patient's IQ and do the standard superficial neuropsychometric tests or MMPI tests. The MMPI tests quite frequently shows evidence of anxiety which is very common in RSD patients. Such evidence similar to the evidence of normal CAT scan and normal bone scan are utilized to rule out RSD.

RSD PATIENTS ARE EXPECTED TO BE DEPRESSED IN MORE THAN 3/4 OF THE CASES, ANXIOUS IN PRACTICALLY EVERY ONE OF THE CASES, AND TO SUFFER FROM INSOMNIA, AGITATION, IRRITABILITY AND POOR JUDGMENT IN PRACTICALLY EVERY ONE OF THE CASES. THESE MANIFESTATIONS ARE ONE OF THE FOUR CRITERIA FOR DIAGNOSIS OF RSD. THERE IS NO WAY THE LIMBIC SYSTEM CAN BE LEFT INTACT IN THE FACE OF RSD.

THE FACT REMAINS THAT REGARDLESS OF WHATEVER THE NIHILISTS WANT TO CALL IT, BE IT RSD, CRPS, MIMOCAUSALGIA OR ANY OTHER NAME, THE RSD BASED ON THE ABOVE MENTIONED FOUR PRINCIPLES HAS A STEREOTYPED CLINICAL PICTURE THAT CANNOT BE MISTAKEN FOR ANY OTHER DISEASE. THIS IS A DIAGNOSIS MADE ON THE SO-CALLED "DUCK PRINCIPAL". THE WELL KNOWN DUCK PRINCIPAL DESCRIBES "IF IT WADDLED LIKE A DUCK, QUACKS LIKE A DUCK, LOOK LIKE A DUCK IS CALLED A DUCK, THEN IT MUST BE A DUCK."