printer-friendly version (PDF) - Reflex Sympathetic Dystrophy ...

INTERVIEW | COVINGTON
Q. Have any studies demonstrated the relationship
between CRPS and personality abnormalities?
DR. COVINGTON Cross-sectional, correlational studies demonstrate
that there is an association between personality abnormalities
and chronic pain. If you go to any chronic pain unit, you
will see considerable evidence of personality disorder. By the
same token, an association can also be shown between obesity
and diet cola. That does not mean that diet cola causes obesity.
A common error in medical discussions is to assume that when
two things are associated, one must cause the other. Obviously,
this is not the case.
In a 1993 study of tertiary pain patients, researchers compared
CRPS patients with patients who had back pain or neuropathic
pain (1). Findings showed that the CRPS patients were
just like the neuropathy patients, which is not surprising, since
CRPS is a neuropathic pain syndrome. Their similarities
included their symptom reporting, illness behavior, and psychological
distress. The incidence of disability was a little higher in
CRPS. When CRPS patients were compared to back pain
patients, actually the back pain patients tended to have more
diffuse, ill-explained complaining, and more non-specific symptoms
than the CRPS patients. Sexual abuse, physical abuse,
emotional abuse—traumas that we think contribute to the formation
of physical symptoms in the absence of physical disease,
were no more prevalent in people with CRPS than in those
with back ache or neuropathic pain. This is pretty strong evidence
that old ideas about special sorts of psychiatric profiles of
CRPS patients were specious.
Q. How does personality affect the way an individual
copes with CRPS, or any other disease?
DR. COVINGTON There’s an old story about a little boy who was
whistling when he had to shovel manure on Christmas morning.
When his companion asked how he could be so happy, the
boy replied, ‘With all this manure, I figure there has to be a
pony someplace.’ So with all the manure that people have written
about CRPS, we must wonder, ‘Is there a pony someplace?’
That is, is there a kernel of truth here? I think the truth lies in
the fact that the mind plays a role in all suffering and in all
function. It’s the mind that copes or fails to do so, whether the
stress is a stock market crash, the death of a spouse, or a painful
disease. Among intractable cases, failures of coping and adaptation
will be disproportionately represented. There are people
with CRPS who have managed to transcend it and have a life.
For others, it’s less the case that they have CRPS than that
‘CRPS has them.’ CRPS has taken over their lives. People who
have problems with coping and those who have personality
disorders are the ones most likely to have difficulty dealing
with a disaster or catastrophe of any kind, including CRPS.
The problem, of course, is to know whether the person failed
to cope because of poor coping skills, or whether it was
because of an unusually severe case of CRPS.
If we define personality as a bias towards certain ways of
thinking, behaving, and feeling, then it would stand to reason
that personality has to affect coping strategies, stress tolerance,
and even what sorts of things a person finds stressful. Perso -
nality affects autonomic responses, which contribute to
sympathetically-maintained pain, and influences a person’s
needs to escape demands, stress, and responsibility. It determines
whether a person has healthier ways of dealing with
stress as well as perseverance in recovery efforts. Thus,
personality will affect how a person deals with disease,
and perhaps, his motivation for wellness.
Q. Does CRPS cause emotional problems?
DR. COVINGTON There are studies of CRPS in which most
CRPS patients were contemplating suicide and there are
contrasting studies in which researchers were surprised to find
that most CRPS patients were indifferent and happy. Such
extreme differences in reports are hard to interpret. We do
know that some people with CRPS are depressed, irritable,
tense, and anxious, some will abuse substances, some will get in
trouble with analgesics, some will feel suicidal, some will
become withdrawn—and some won’t.
Q. Is there an association between CRPS and
depression?
DR. COVINGTON Yes. In a 1988 study, Rudy, Kerns, and Turk
confirmed that chronic pain is associated with depression (2). It
was also associated with interference with life; i.e., many people
with chronic pain had ceased such activities as socializing, going
to films, having sex, playing with their kids—the things in life
that gave them joy. These losses were associated with depression.
Also it was common for people with chronic pain to come
to see themselves as helpless and trapped and to feel unable to
do anything about their lives. Those feelings are all associated
(Continued on page 47)
We do know that some people with CRPS are depressed,
irritable, tense, and anxious, some will abuse substances,
some will get in trouble with analgesics, some will feel
suicidal, some will become withdrawn—and some won’t.
42 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6