The National Council of Psychotherapists
PSYCHOTHERAPY WITH REFLEX SYMPATHETIC DYSTROPHY PATIENTS
Reflex Sympathetic Dystrophy (RSD) is a painful physical condition in a limb or other area of the body that develops as the result of overuse, surgery to correct a problem, or accidental injury. These traumas to the body, some very minor in nature, cause abnormal sympathetic nerve activity and abnormal regulation of blood flow which starts a vicious cycle of pain in the affected limb or area that continues long after the trauma has passed. "In effect, the damaged nerve becomes 'epileptic' and the spontaneous discharges from the sensory nerve may give rise to the episodic pain. This could be due to lowered threshold or heightened mechanical sensitivity." (Hendler, 1989).
In other words, the body reacts with pain as if it is being repeatedly assaulted, though the pain experienced in RSD is usually different from the original pain sensation and may be in a different location. The pain is variously described as burning, throbbing, aching, shooting, stabbing, tingling. The abnormal sympathetic activity and associated abnormal blood flow in the affected limb also produce a variety of changes in the muscles, skin, nails, and hair. This syndrome has been given various names, such as causalgia and Sudeck's Atrophy because it results from various causes and has various manifestation. Hendler (1989) slates: "Physicians should recognize that RSD is a symptom complex that is a cluster of symptoms and signs, and that patients do NOT present with all the signs and symptoms during the course of their disease. In fact, very often, they may have only one or two of the signs and symptoms of the disorder."
Janig (1990) states: "An important reason to use the generic term reflex sympathetic dystrophy is the experience that temporary or permanent blockade of sympathetic activity to the affected extremity or area by whatever means, commonly, (but not always) relieves the pain. When sustained, this is followed by a restitution of trophic changes and of the disturbed autonomic regulation, provided this procedure has been performed early enough." In the first stage of RSD which lasts approximately from one to three months, the main symptoms are severe, burning pain which increases with movement, hypersensitivity to touch, localized swelling, muscle spasm, stiffness, limited mobility, changes in skin from warm, red, and dry to cold, blue, and sweaty, and spotty osteoporosis.
In the second stage, which lasts about three to six months, pain becomes more severe and more diffuse, swelling spreads and changes from a soft to a brawny type. There is increased thickness and stiffness of the joint, the beginning of muscle wasting, the skin is cold, pale to canonic and moist. There are also changes in the hair and nails, either a thickening and coarseness, or a scantness of hair and cracked, brittle nails.
In the third stage there is marked, irreversible trophic changes in the skin, nails, hair, muscles, marked and diffuse bone deossification, intractable pain (regional aching or throbbing in addition to the burning discomfort) involving the entire limb. There is .also limited motion of the limb caused by atrophy of the muscles, extreme weakness in joints, and contraction of flexor tendons. Complete recovery is likely for those whose treatment begins in the first stage and possible for those whose treatment begins in the second stage, By the third stage treatment provides symptomatic relief, but no full recovery. The aim of medical treatment is to break the vicious cycle of pain in the affected limb. Sympathetic nerve blocks in various locations, using various chemical substances, administered by physicians temporarily suppresses the sympathetic nerve activity and the symptoms associated with vasoconstriction. Repeated nerve blocks have a cumulative effect. If treatment is started early, there may be an excellent chance for full recovery. Various medications are also prescribed to increase the substances in the body that reduce the flow of noradrenaline, which mediates the sympathetic nerve activity and to also reduce vasoconstriction. Stages of RSD may progress differently in each individual case.
Blumberg explains the effects of vasoconstriction as follows: "When the VVT (vasoconstrictor neurons supplying veins) is higher than the AVT (vasoconstrictor neurons supplying arteries), venous return is impaired in the affected regions, capillary infiltration pressure increases, and oedema (swelling) results. This leads to higher interstitial pressure, which may excite peripheral nociceptors. Alternatively or additionally, increased filtration from blood vessels may induce disturbances of the micromilieu which 'chemically' excite nociceptors. Independent of the actual mechanism causing nociceptor activation, this activation supports oedema formation, since a neurogenic inflammation' is induced.
Excitation of nociceptors then reflexly maintains the disturbance of vasoconstrictor outflow. A vicious cycle has begun. Ficat and Arlet found in 29 RSD patients that there was increased bone pressure with diminished venous return from bone circulation.
They interpreted their finds to be the result of disturbed sympathetic control of blood vessels. We regard this increase in bone pressure as the most likely mechanism for spontaneous deep pain in early stages of RSD. Indirect evidence supports this idea, since hyperaemia and oedema in bones is a common finding in RSD. Roberts (1990) has proposed the following theory to explain why RSD develops after an injury -
1. A precipitating trauma leads to sensitisation of spinal wide dynamic range (WDR or convergent) neurons.
2. Subsequent sympathetic activation of the low-threshold mechanoreceptors results in excessive firing or hyper-excitable WDR neurons and therefore 'spontaneous' pain. 3. Mechanical activation of low-threshold mechanoreceptors results in excessive firing of hyper-excitable WDR neurons and therefore pain (allodynia).
Blumberg (1990) explains Roberts' theory as follows:
"Based upon experimental findings in animals, he considered sensitised spinal cord wide dynamic range neurons (WDR neurons) to be the source of spontaneous pain and allodynia. Mechanoreceptive and nociceptive inputs converge onto these neurons. The spinal neurons may become sensitised following a noxious event. This sensitisation is maintained by a mechanoreceptive input, which in turn is produced by the spontaneous activity of sympathetic fibres, which excite mechano afferent structures in the skin. This finally leads to spontaneous pain and allodynia, initially located at the site of the original noxious event. Pain and allodynia may spread, as neighbouring neurons at the spinal cord level also become sensitised. Sympathetic therapy can interrupt sympathetic excitation of mechanoreceptors, which reduces afferent input and reverses the sensitisation of the WDR neurons."
Although there is considerable scientific support for this theory, both Roberts and Blumberg indicate that other factors may also be operating to produce the wide range of symptomatology in RSD. Blumberg (1990) expands upon Roberts' theory to explain why a particular injury may lead to RSD: "The cause for increased neural activity of the sympathetic vasoconstrictor system appears to be a central spinal vulnerability' at the time of the noxious event. This sheds some light on the question as to why the same type of lesion initiates RSD in some but not most individuals. Thus psychological, medical, constitutional, or other factors, do not seem to be primarily involved, but their influence on spinal sensitisation processes cannot be ruled out."
While RSD is caused by physical trauma and has precise physical stages, there is a widespread opinion in the literature and among doctors treating RSD that psychological factors and even a personality predisposition are causal factors in the development of RSD. The main arguments are: a)the initial injury is often so slight it cannot be the sole cause of the subsequent severe symptoms, b)even when an injury to a limb is severe, it rarely leads to the development of RSD, c)patients with RSD are emotionally unstable, dependent, angry people, Haddox (1990) makes the interesting comment: "In reviewing the studies in which emotional aspects of RSD have been noted, one is impressed by the number of reports from non-psychiatrists that comment on psychologic issues." In an earlier (1984) article entitled, ‘Depression Caused by Chronic Pain’, Hendler made a similar observation: "Indeed, it is my belief that the psychogenic pain diagnosis is made far too freely, often without reference to the patient's actual psychiatric status and history. Frequently this label is applied by professionals other than psychiatrists or psychologists, such as by nurses, neurosurgeons, orthopaedic surgeons, etc. either because the patient fails to respond to medical or surgical treatment or because the patient is extremely difficult to manage.......It is also my experience when orthopaedic surgery, especially disc surgery, fails to clear pain symptoms, the psychogenic label is often applied. The patient is told, 'The pain is in your head,' rather than, 'The surgery didn't give the good result we hoped for.' The patient, of course, knows the pain is real, and he or she is infuriated to have someone suggests that there is a mental problem...The clinician needs to be ever vigilant to the possibility that the patient's pain and other physical complaints may have a psychological origin. Psychiatric problems, especially depression, can arise from physical disease......Chronic pain almost always leads to depression." Hendler also makes the point that chronic pain is rarely fabricated. It is almost always real to a patient, though it may be unconsciously exaggerated.
When one considers that most RSD patients have had numerous prior injuries to their affected limb that did not lead to RSD, the supposition that their personality traits predisposed them to develop RSD makes little sense. Besides, reviews of the research literature indicates there is no proof for this supposition. Abram (1990) reports: "Although discussions of predisposition to RSD often mention such terms as 'the typical RSD personality’, or ‘Underlying psychopathology’, there is little evidence to support such notions." Lynch (1992) reports: "Most authors have concluded that the behavioural and emotional changes are a result rather than a cause of pain. Despite this the possibility of a psychological aetiology continues to receive some support both in clinical practice and in the medical literature. This, in addition to the fact that patients are sometimes accused of malingering and mismanagement and increased suffering.
In summary, there is general agreement that the behavioural and emotional issues in patients suffering from RSD are important and can be profound. However, a complete review of the literature from the late 1800's to the present reveals no worthwhile evidence to substantiate the claim that psychological factors or certain personality traits predispose one to develop RSD." Despite the lack of evidence of any specific psychological causal factors, the idea that psychological factors are responsible for the initiation of RSD is still being promoted. Weiss (1994) reports: "Bernstein found that children who showed Reflex Sympathetic Dystrophy were accepting of responsibility beyond their years. Psychological testing suggested that they had difficulty expressing anger.
A high frequency of family conflict was noted, and the reflex sympathetic dystrophy enabled them to avoid conflict. McNerney described the personality profile of RSD patients as people with 'inadequate personalities' and in so doing, implied underlying passive aggressidity. He described them as extremely dependent, insecure, and unstable. They tend to blame others for their problem. Lankford and Thompson were the first to recognize that certain personality types had a predisposition for developing RSD. According to these authors, RSD patients have been described variously as sympathetic hyper-reactors, inadequate personalities, and persons trying to avoid responsibility. They can escape into chronic pain and appear 'to like' being disabled. Weiss concludes: "These studies are suggestive of psychological problems, but the problem description is too vague to be useful for diagnostic purposes." He then quotes some studies that he feels are more precise because they use the Minnesota Multi-Phasic Personality Inventory. Generally when the MMPI is given, hypochondriasis and hysteria tend to be elevated along with the depression scales." Weiss accepts the conclusions of researchers who used the MMPI as if they were proven fact: "Grunert said that patients who experience RSD are often repressors. They tend to deny the existence of stress, anxiety and depression and tend to emphasize physical dysfunction and minimize psychological factors."
However, Weiss failed to note that the MMPI was designed to detect psychiatric illness in the general population, not in pain patients. Therefore, it is not known the degree to which the MMPI scale elevations in RSD patients is a response to their painful physical condition. In other words, without a comparison between patients' pre-RSD and post-RSD MMPIs, there is no proof that these scale elevations are casually related rather than a reaction to RSD. Weiss also quotes several researchers as finding "that the initial traumatic lesion, even when minor, plays a great emotional role and the patient relates it to a 'bad and unlucky period in his life.'" However, the clinical literature indicates that many RSD patients do not even recall the initial injury. Besides, in my clinical experience RSD patients have had previous injuries that were much worse, but did not lead to RSD. Their intense emotional reaction was due to their intense pain from their RSD, not from the injury itself. The idea that the injury that led to RSD occurred during a "bad luck period" in the RSD patient's life is one I have not come across in my clinical practice or anywhere else in the literature. However, even if many RSD patients agree with this, it does not necessarily mean that it is a causal factor because the patient may adopt this notion as a way of explaining their "bad luck" in developing RSD. Furthermore, even if this observation is actually accurate, it still can't be automatically trusted as a causal factor. It may very well be pure coincidence. It is not at all uncommon for people to have ups and downs in their life and to have minor injuries that do not lead to RSD. Prior to their RSD diagnosis, many patients are severely stressed by the reactions of other people to their painful condition because their reported pain is so much greater than expected for the extent of their injury. Often doctors, employers, work supervisors, co-workers, Worker's Comp claims' representative, friends, and family believe they are exaggerating or faking their pain for sympathy or financial gain. Haddox (1990) reports: "Due to the disparity between patient complaints and the expected clinical course of the inciting event, (fracture, sprain, carpal tunnel release, etc.) the patient often receives messages that the pain is psychogenic. Occasionally, the implication is that the patient with RSD is even a malingerer." Hannington-Riff (1990) reports: "Patients often recognize early on that a minor injury has become complicated by inappropriate pain and disability. These patients are frequently dismissed as neurotic until the signs of RSD are well advanced."
Early detection of RSD is essential to its successful treatment. Thermography involving quantitative symmetrical thermal emission, including clear thermal demarcation and abnormal distal longitudinal gradient power is an excellent diagnostic tool to document the reduced skin temperature. ( comments from Robert Ilko, M.D, San Diego, California, RSD Association of CA Medical Advisor.) "Very often patients with RSD are diagnosed as having psychosomatic disorders and thermography can be a most convincing diagnostic tool to confirm the otherwise subjective complaint." (Hendler, 1989) Other important diagnostic tests are bone scans and the patient's response to a sympathetic block. Hendler states: "All patients suspected of having RSD should have at least three sympathetic blocks."
Once they are diagnosed with RSD, some patients feel they are being blamed for their condition. This "blaming the victim" adds "insult to injury." It is hard enough for RSD patients to have lost much of their independence and freedom to engage in basic physical activities involving every aspect of their life, including hygiene, domestic chores, work, and recreation. Now they have to also deal with a supposition that something is wrong with them emotionally and/or mentally. The notion that RSD patients are somehow responsible for their RSD is a source of great stress to them and not at all beneficial to their treatment, as will become evident further in this article. What many medical doctors who treat RSD don't realize is that the marked emotional disturbance they observe in many RSD patients is the result, not the cause of their physical condition. "If one studies chronic pain patients in a longitudinal fashion and follows them during the course of their odyssey through chronic pain, it is quite apparent that in previously well adjusted individuals personality changes occur as a result of chronic pain." (Hendler, 1982).
"Continued incapacity despite apparent medical recovery after an injury may be due to several factors other than malingering. Physical injury and pain often produce a regression, characterized by a breakdown of the more mature coping mechanisms. Injured patients may become totally dependent on their families, physicians, and attorneys, even though they were formerly quite autonomous. Injury that causes incapacity is a stress upon one's psychological integrity, a challenge to one’s self concept as a mature person, and a fundamental threat to one's sense of personal worth. One reaction to such strength is to abandon ambition in favour of more infantile, dependent activities." (Rogers, 1988, pg. 93).
RSD patients are very distressed not only by their severe, debilitating pain, but also by the loss of activities that were a source of both pleasure and self esteem. Of course, the more physically active and the more achievement oriented the RSD patient, the more upsetting is the loss of their ability to engage in these activities. It is not surprising that these patients often become very depressed. Because of uncertainty about their prognosis, it is also not surprising that they begin to appear hypochondriacal because of their intense anxiety, worry and fear about their physical condition. RSD patients who are referred for Psychotherapy need help to deal with all of these issues are causing them so much emotional distress.
At the same time, they need to be made aware that it is a widespread observation that emotional stress affects healing and the experience of pain in physical conditions of all kinds. In addition, RSD patients need specific information to give them a better understanding of their condition, their medical treatment, and why emotional stress plays such an important role in RSD. Most patients already know that adrenalin increases in situations of emotional arousal and stress.
The medical treatment of RSD is aimed at suppressing the flow of noradrenaline and reducing vasoconstriction in the affected limb in order to break the cycle of pain. Every time they relax, RSD patients are enhancing their medical treatment. Any emotional upset works against their medical treatment and increases their RSD symptoms. Unfortunately, these basic physiological facts about RSD can be mistakenly interpreted as a symptom of an hysterical or histrionic personality disorder whose main features are defensive repression and increased physical symptoms in times of emotional stress.
Teaching RSD patients how to reduce their level of stress through a relaxation exercise or biofeedback is an essential part of their psychological treatment. Another important element of their psychological treatment is helping them become aware that they can control their perception, and therefore, their experience of pain. Following is a relaxation positive suggestion exercise that I devised to conduct in session with my patients:
Focus all your attention on a spot, any spot...The longer you focus your attention on the spot the more relaxed you are going to feel...while your attention is focused on the spot all the outside disturbances, like a sudden loud noise, and all the disturbing thoughts in your mind are going to be pushed aside for the time being. Things that have upset you in the past. Things that are bothering you in the present. And things that are worrying you about the future. All of these are going to fade into the background while your attention is focused on the spot. It is these outside disturbances and upsetting thoughts that make your body tense. When they are pushed aside, your body will automatically relax. Except for your eyes. It is very hard to keep staring at the same spot without blinking. Your eyes might have a stinging sensation and your eyelids are going to get heavier and heavier. Close your eyes whenever you want and concentrate on the sound of my voice.
There is an age-old question. If a tree falls in the forest and there is no one around, does it make a sound? What exactly is sound? Is it the movement of the air when the tree hits the ground? Is it the movement of the airwaves against an ear drum? Is it the message along the nerve from the eardrum to the brain? Is it the information processed by the brain? The falling of a tree is a real physical event, but you need a receptor to hear the sound. It is the same with pain. Your pain comes from a real physical event, but you need to pay attention to it to experience it.
Similarly, a radio broadcasting station can broadcast 24 hours a day, but you need to turn on the radio and tune in to that station to get the message. If you want, you can gradually tune it out by turning to another station. For awhile you might hear both stations. Then you can switch completely to the other station.
The same is true with pain. If you want to focus all your attention on it, you can experience it fully.
If you want, you can divert your attention from it by focusing on an enjoyable activity. You have probably already noticed that when you are having a good time, you don't notice your pain as much. When you are alone and have time to think about your condition, you experience much more pain. The choice is yours. If you want to fully experience your pain, you can focus on it. If you want to divert yourself from your pain, you can either find something to entertain you or you can do this relaxation exercise. "When a little boy went into the Monkey House in the Bronx Zoo, he gagged because of the awful smell. His mother told him the smell would go away after a few moments. And it did. After awhile the little boy noticed some people gagging as they entered the Monkey House and he asked his mother about it. She told him he would start smelling it in a few moments. And he did. This story demonstrates selective attention. Every minute of the day we are bombarded with stimulation from many sources. We can't possibly attend to everything at once. We become so used to some stimulation, we hardly notice it. A country person visiting in the city has a hard time falling a sleep because of traffic sounds, but a city person visiting in the country has a hard time falling asleep because of the sound of the crickets. Similarly, a person who lives by train tracks will not pay any attention to a train going by unless a visitor comments on it. These are all examples of selective attention. They demonstrate how we get so used to a certain stimulation, we can block it out of our awareness.
If you choose, you can focus on things other than your pain and thereby reduce, and at times even completely block out, your awareness of your pain. Now picture a peaceful scene. Any peaceful scene will do. You could imagine yourself lying on a float in a pool on a warm summer day. The water temperature is so close to the temperature of the air, you can hardly tell the difference between the two. Or you can imagine sinking yourself into a hammock under a tree. As you sink your body into the hammock and completely supported by the hammock, all the strain you have felt holding your body together and all the pain you have been carrying around is lifted from your body and you can totally relax. Or you can imagine lying in a canoe attached to a dock feeling perfectly safe and comfortable. The water against the side of the canoe is gently rocking you. The shining sun is keeping you from getting too cold and the breeze is keeping you from getting too hot. You can imagine any beautiful, peaceful scene you want. It really doesn't matter. The longer you picture any beautiful, peaceful scene, the more you are going to feel like you are there.
Now I am going to count from 10 to 1. While I am counting, the words that I have said are going to sink deeper and deeper into your mind. Even though you won't remember them exactly, they will guide your behaviour in the days to come. You should practice this relaxation exercise in order to keep your general stress level down and to remind you how to block out your pain. Then if something happens to upset you, you will know how to quickly relax yourself.......l0...9...8…7.... When I reach number 1, you are going to open your eyes. After a few moments of being groggy, you are going to feel very refreshed and in a very good mood because you have learned something today that is going to help you feel better......5.....4....3....2....1.... How do you feel?
Patients vary in their response to this exercise. It seems to depend upon their level of trust in me, based on how trusting they are in general and the length of time they have known me. The great majority immediately report feeling more relaxed at the end of the exercise. Many report a reduction in pain either immediately after the exercise or within a few minutes. But all are willing to use the tape at home and report positive results. Another aspect of psychological treatment is encouraging patients to use their affected limb in gentle activity. They need to make full use of pain free periods to undertake physical exercise. Exercises should be active, regular and gentle until such time as strength and mobility return. Activity should be pursued to the point of obsession, several minutes on the hour every hour. Reliance on sympathetic block alone may be insufficient to achieve a lasting cure, especially in the cases with secondary joint, ligaments, muscle and trophic changes causing addition pain on exercise. (Boas, 1990) In most cases, immobilization of the affected limb has led to worsening of symptoms rather than improvement. (Raja and Hendler, 1990)
Although my reading of the literature convinced me that RSD is a physical condition which is affected by psychological factors and not one caused by psychological factors, in the process of treating several patients diagnosed with RSD or a similar condition, I have made some interesting discoveries. First of all, the majority of these patients are very work oriented individuals.
Regardless of their occupation, they all have received a great deal of recognition for their outstanding work
For example, if they are word processors, they are the fastest most hardworking word processors in their office and they are the ones most willing to work overtime to complete a job. If they have a position of great responsibility within a large organization or system, they receive national recognition for their efforts. They also put a lot of energy into their family, social, and recreational activities. Prior to developing RSD these individuals were very high functioning, strong, and self-sufficient. They displayed none of the emotionally unstable, inadequate, dependent personality characteristics attributed to them. After they developed RSD, they were intensely frustrated and angered by all the limitations their condition placed on their lives, including their need to depend upon others to help them with simple tasks and the uncertainty about their future employment and financial security. Their dealings with Workers' Comp is often an additional source of intense frustration. If there is any predisposing personality factor in RSD patients, it is their strong work orientation. If they had not been devoted to their work, they would not have pushed themselves as hard as they did.
Those who developed RSD because of overuse or surgery to correct overuse might have never developed RSD if they had been less work oriented. Those who developed RSD after accidental injuries on the job might not have had their accidents if they had not been working as hard as they were. However, being a workaholic cannot be considered an actual causal factor in RSD because the large majority of workaholic never develop RSD. Therefore, the main usefulness of this observation in my therapy with RSD patients is my understanding and appreciation of how important their work is to them and how upsetting it is for them to be forced to cut down in their work or to stop their work altogether.
© Written by Amy Lamson, Ph D, for the 1994 'RSDSA NEWS'
RSDSA-CA * PO Box 771 * San Marcos, CA 92079 * http://www.rsdsa-ca.org/
Amy Lamson, Ph D
Dr Lamson received her Ph.D in Clinical Psychology in 1970 from Boston University. She served as Clinical Psychology Advisor for the RSDSA-CA. from 1992-1998. Dr Lamson also served the RSD organization as facilitator for the "Empower Yourself" workshops developed by the Association that focused on behaviour modification & coping skills for RSD patients. Dr Lamson published two articles on RSD for the RSDSA News in 1994 and 1996. She was a Clinical Psychologist in private practice San Diego, CA. until retirement in 1999 due to an illness. Amy Lamson passed away December 13, 2000.
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