With continued medical advances, we are living longer healthier lives. Survival rates in cases of physical trauma continue to rise. Rapid, effective emergency services increase the numbers of survivors of once fatal accidents. As a result, with the miracle of physical survival comes the reality of chronic pain and emotional trauma, the sequelae of personal injury. Physicians are pressured to develop more effective medical pain treatments and psychologists are asked to address the impact of psychological factors on the management of chronic pain and residual post-traumatic stress. Every psychologist who has practiced for a number of years has encountered the enigma of chronic pain.

When chronic pain results from a physical trauma, it is a continuing reminder of that trauma and is thus retraumatizing, serving as a reminder of the original event (Moser, In press). It is estimated that 10% of chronic pain patients suffer from post traumatic stress disorder (Lebovitz, Yarmush, & Lefkowitz, 1990). We do not have to be rehabilitation psychologists, disability specialists, or forensic consultants in order to evaluate or treat chronic pain. However, we do have an ethical and moral obligation to become knowledgeable about this phenomenon, to understand the role of psychological factors, and to competently evaluate and treat afflicted individuals. The purpose of the present article is to educate the psychologist about a specific type of chronic pain disorder, Reflex Sympathetic Dystrophy (RSD), which is particularly problematic, rarely remits and is often mistakenly attributed to psychogenic causes.

RSD has been known as causalgia, sympathetically maintained pain, or complex regional pain syndrome (Backonja, 1994). It is a neuropathic pain disorder that usually develops after a physical trauma or disease. It was first reported in the research literature in the mid to late 1800's through observations of war-time injuries involving the peripheral nervous system (Lynch, 1992). Today, it is frequently seen in personal injury or workmen's compensation cases in which the individual sustains an injury to an extremity resulting in severe pain, muscle spasms, hypersensitivity, and vasomotor and skin changes (Backonja, 1994). What is striking is that 1) the injury may seem relatively mild in contrast to the intensity of pain experienced; 2) the pain may not manifest itself until sometime after the injury; and 3) the pain travels or spreads beyond the injured area of the affected limb. These three factors may mislead the naive, uninformed therapist or evaluator to suspect that the individual's chronic pain is factitious in nature or that the individual is a malingerer. A complete review of the literature on RSD, from the late 1800's to present, has not supported the notion that psychological factors or particular personality characteristics have been predisposing factors for the development of RSD (Lynch, 1992).

An interesting biopsychosocial model of RSD has been proposed (Van Houdenhove & Vasquez, 1993). It is suggested that RSD sufferers experience significant losses, such as the loss of independence, financial security, an active lifestyle, or of a career. Helplessness is a response to the loss and can result in 1) lack of motivation, passive coping, and less use of the limb, or 2) stress-related sympathetic overreactivity and higher norepinephrine levels. Both of these pathways contribute to increased, localized neuronal dysfunction and a worsening of the RSD.

RSD is an especially painful and debilitating disorder. Three stages of RSD have been outlined by Bruehl & Carlson (1992). In the Acute Stage 1, the individual complains of unremitting aching or burning pain. The affected area vacillates from a warm to a cyanotic, cool, and clammy presentation and is particularly sensitive to touch. The Dystrophic Stage 11 is characterized by generally cool, cyanotic skin, with hair loss in the affected area and cracking of the fingernails if the hands are involved. In the Atrophic Stage III osteoporosis may set in and the skin appears shiny and thin. Throughout these stages, there is continuous burning pain which is associated with sympathetic hyperactivity (Ochoa & Verduga, 1995).

Individuals are often evaluated and created by pain specialists, most frequently neurologists or anesthesiologists, whose first line of treatment is sympathetic nerve blocks. If applied early in the disorder and combined with physical therapy, nerve blocks can be a most effective intervention. However, complete eradication of the pain is not often observed. Rather, goals which focus on pain reduction are the most reasonable. Thus, individuals tend to continue to experience some level of chronic pain and for many of those who go undiagnosed and untreated for months, the disorder progresses as does the pain. Individuals begin to feel demoralized and apathetic, they lack motivation to improve, and they lose confidence in health care providers. They become models of learned helplessness. Their physicians and families also feel helpless. They are now referred for psychological intervention.

The medical profession is beginning to appreciate the necessity of early psychological intervention in RSD before the individual loses hope and develops a fatalistic attitude. An early, concurrent, multidisciplinary approach from the outset of treatment which includes nerve-block therapy, pharmacotherapy, physical rehabilitation, acupuncture, behavioral/cognitive psychotherapy, biofeedback, and relaxation training has been proposed (Lebovitz, et. al., 1990; Van Houdenhove, et al., .1 992). Other modalities such as hypnosis and meditation are gaining increasing support, in the management of chronic pain (Dale & DeGood, 1997-8; Gainer, 1993).

Psychologists should recognize two critical roadblocks to recovery: 1) physical pain often increases when the individual begins treatment such as physical therapy, and 2) the misdiagnosed individual who has been accused of malingering or of exaggerating symptoms may feel reviolated, angry, and resistant. It Is the psychologist's role to provide support, encouragement, and stress management training while the individual is undergoing physical therapy or other medical treatments. Otherwise, lack of motivation can result in poor compliance with treatment and a reduction in use of the limb with accompanying atrophy. Furthermore, directly processing feelings of retraumatization and anger can reduce the likelihood of guilt, low self esteem, and resistance in the psychotherapeutic process. Involvement in chronic pain groups and family therapy can provide the individual with opportunities to gain environmental support and reassurance and to help break the myths and misconceptions surrounding this disorder.

Treating and managing the chronic pain patient can be especially disconcerting for the psychologist. Often few gains are achieved and the best that can be hoped for is preventing a downhill spiral. Psychologists who choose to treat the RSD sufferer must be able to accept the likelihood of limited or no significant improvement in pain. Developing realistic treatment plans with reasonable goals, working with a team of health care professionals, and including family members as support systems can help prevent professional burnout.

References:

Backonja, M. (1994). Reflex sympathetic dystrophy/sympathetically maintained pain/causalgia: the syndrome of neuropathic pain with dysautonomia. Seminars in Neurology, 14 (3), 263-271.

Bruehl, S., & Carlson, C. (1992). Predisposing psychological factors in the development of reflex sympathetic dystrophy. The Clinical Journal of Pain, 8, 287-299.

Dale, J. A., & DeGood, D. E. (1997-1998). The emerging role of the psychologist in pain management. Advances in Medical Psychotherapy, 9, 1-20.

Gainer, M. (1993). Somatization of dissociated traumatic memories in a case of reflex sympathetic dystrophy. American Journal of Clinical Hypnosis, 36 (2), 124-131.

Lebovits, A., Yarmush, J., & Lefkowitz, M. (1990). Reflex sympathetic dystrophy and posttraumatic stress disorder. The Clinical Journal of Pain, 6, 153-157.

Lynch, M. (1992). Psychological aspects of reflex sympathetic dystrophy: a review of the adult and paediatric literature. Pain. 49, 337-347.

Moser, R. S. (In press). Psychological factors and treatment issues in reflex sympathetic dystrophy. Advances in Medical Psychotherapy.

Ochoa, J., & Verduga, R. (1995). Reflex sympathetic dystrophy: a common clinical avenue for somatoform expression. Neurologica Clinics, 93 (2), 351-363.

Van Houdenhove, B., & Vasquez, G. (1993). Is there a relationship between reflex sympathetic dystrophy and helplessness? General Hospital Psychiatry, 15, 325-329.

Van Houdenhove, B., Vasquez, G., Onghena, P., Stans, L., Vandeput, C., Vermaui, G., Vervacke, G., Igodt, P., & Vertommen, H. (1992). Etiopathogenesis of reflex sympathetic dystrophy: a review and biopsychosocial hypothesis. The Clinical Journal of Pain, 8. 300-306.