Psychological Aspects of Reflex Sympathetic Dystrophy (rsd) Complex Regional Pain Syndrome (crps)

Reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS) is a complex form of neuropathic pain associated with hyperpathia; neurovascular instability; neuroinflammation; and limbic system dysfunction. As the condition becomes chronic, the other aspects of this syndrome complete the clinical picture. Inflammation develops, insomnia, agitation and depression affect the patient's diurnal cycle, deprive the patient of resting well and sleeping normally at night and the end result is the full-blown picture of RSD (CRPS). Careful history taking, neurological evaluation, and understanding the nature of emotional components of RSD (CRPS) spares the patient from misdiagnosis and improper treatment. Descriptors. complex regional pain syndrome (CRPS), limbic system, psychological aspects, reflex sympathetic dystrophy (RSD). INTRODUCTION The distressful, complex, chronic, regional pain syndrome of reflex sympathetic dystrophy (RSD) also known as complex regional pain syndrome (CRPS) is felt from the periphery all the way to the spinal cord, the 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 (1). The limbic system has the main function of emotional control, and the 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 (2). EMOTIONAL ASPECTS OF RSD (CRPS) In our review of 824 RSD (CRPS) patients, one or more of the limbic system dysfunctions were present in every case except three. These consisted of insomnia (92%), irritability, agitation, anxiety (78%), (depression (73%), poor memory and concentration (48%), poor judgment (36%), and panic attacks (32%). Understanding 2 the nature of emotional components of RSD (CRPS) spares the patient from misdiagnosis and improper treatment (2). Doctor Mary Lynch reviewed the subject of psychological aspects of RSD (CRPS) (3). 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 psychological etiology. It has often been suggested that certain personality traits predispose one to develop sympathetically related pain syndromes. A review of the literature reveals no valid evidence to substantiate this claim.” On the other hand, De Good et al found patients suffering from RSD (CRPS), when compared to patients suffering from back pain and headaches, had the highest level of pain intensity, but demonstrated relatively less emotional distress(4). Early in the twentieth century the Freudian School of Neuropsychiatry even claimed that there was a personality trait for patients developing Multiple Sclerosis (MS). Obviously there is no personality trait for either RSD (CRPS) or MS. However, because of the nihilistic approach of the neurologists in regard to any form of a chronic disease causing neuropsychological dysfunction, the RSD (CRPS) patients are frequently called neurotic, and histrionic. There is no doubt that the RSD (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 (CRPS) patient is expected to be stoic, and to be able to sleep through the constant protopathic and allodynic pain. Otherwise, the patient 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 1988, three prominent researchers, Schwartzman, Yokota, and Jankovic have demonstrated that all the above-mentioned types of movement disorder may be secondary to RSD (CRPS) (57). If the patient has a thermatomal sensory loss in the distribution of the branches of brachial or a femoral artery rather than in a dermatomal radicular distribution, the patient is called a malingerer.