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EXPLORING
PSYCHOSOCIAL
ISSUES IN CRPS
An Interview with Edward C. Covington, MD, Director of the
Chronic Pain Rehabilitation Program at the Cleveland Clinic Foundation
Q. What is the current thinking about the relationship
between the psyche and the soma in CRPS?
DR. COVINGTON A recent search for articles on CRPS, which
are being published at the rate of about 100 per year, showed
that there is still tremendous controversy about the nature
of this disease, and whether it is a psychiatric rather than a
medical condition.
Authors have proposed several theories about how the
psyche might be related to the soma in this syndrome, and
each has varying support. Some believe that CRPS is a psychiatric
illness—a conversion disorder—that there is something
‘in the head’ that makes it come about. Others see CRPS as a
result of a psychiatric illness or personality disorder that makes
some more likely to get it than others. Some contend that CRPS
causes psychological symptoms or psychiatric illness, while others
think that psychological factors modify the course of CRPS—
making it better or worse. Others think that adjustment and
function in CRPS are determined by psychological factors.
CRPS AND PERSONALITY
Q. Are people with particular personalities
prone to certain diseases?
DR. COVINGTON There was a very old theory that held that different
personality types were vulnerable to different illnesses.
For example, that particular personality types had Crohn’s disease,
others had migraine headaches, and that other types had
CRPS. These ideas were widely taught, but never substantiated,
and had been essentially discredited by the time I was in training
25 years ago. Few people now believe this theory, although
occasionally you’ll hear someone refer, for example, to
migraineurs as compulsive, but this is essentially just folklore.
Q. What about the relationship between personality
and CRPS?
DR. COVINGTON People often mistakenly equate correlation
with causation. Personalities change when people are miserable
and unable to function. So CRPS patients may be irritable,
complaining, or demanding, leading others to conclude that
these traits led to the disease. Another reason people have
thought that personality disorders predisposed to CRPS is
because there are often extreme behavioral changes following a
trivial injury. Thus the inclination is to think, ‘Oh, c’mon, that
couldn’t hurt that bad.’ Psychogenic theories also flourished
because, despite the last twenty years of research, the condition
remains ill-defined. Its pathophysiology is obscure. We don’t
have a good understanding of exactly what CRPS is and why
some people get it and others don’t.
It is common to assume that when no explanation for a
condition can be found, then it must be psychogenic. If doctors
can’t figure it out, perhaps ‘it’s all in the head.’ People with
fibromyalgia and irritable bowel syndrome have been subjected
to the same sort of ideas, and I’m convinced that both are
absolutely organic diseases, as is CRPS.
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