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
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