Complex regional pain syndrome, alexithymia, and psychological distress
Introduction
Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by a continuing (spontaneous and/or evoked) regional pain that is seemingly disproportionate in length of time or degree of pain after trauma or other lesions. The pain usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor edema, and/or trophic findings [1]. The evolution of CRPS varies, but it typically results in functional impairment in the affected limb, which adversely affects one's quality of life [2], [3]. While the etiology of CRPS is still unclear, several underlying patho-physiological mechanisms have been identified. These include aberrant changes in vasomotor function, abnormalities in regulating inflammatory responses on a local, regional and/or central level, and problems with regulation of neuroplasticity [4], [5].
Psychological factors such as stressful life events and psychological states such as anxiety, depression, and anger may alter catecholamine activity. Thus, they may directly affect pain intensity and in this way impact patho-physiological mechanisms of CRPS and contribute to its perpetuation [6], [7]. Therefore, pain in persons with CRPS may be affected by factors relating to emotional regulation. The findings on the relationships between psychological distress, emotional regulation, and pain in persons with CRPS are inconclusive. Understanding these relationships may elucidate effective coping styles and beneficial rehabilitation efforts for persons with CRPS [8].
One indicator of emotional regulation is alexithymia, a multidimensional psychological structure that includes difficulty identifying, verbalizing, or describing feelings and an externally-oriented thinking style [9]. High levels of alexithymia have been reported among persons with various types of pain, including lower back pain (LBP) [10], fibromyalgia [11], and myofascial pain [12], [13]. Conversely, others have found no association between alexithymia and pain among chronic pain patients [e.g., [14]]. The relationship between alexithymia and CRPS has been scantly examined. In a psychiatric evaluation of 34 persons with CRPS it was found that 88% met the clinical criteria of alexithymia [15]. On the other hand, in a prospective study of patients with a fracture in the distal radius, no differences in alexithymia scores were found among patients who subsequently developed CRPS when compared to patients who did not develop CRPS [16].
The relationship between CRPS, anxiety, and depression is inconclusive [see review by 6]. With regards to depression, higher [17], [18], comparable [19], [20], and lower [21], [22] levels of depression have been found in persons with CRPS when compared to other groups. In a similar manner, findings on anxiety and CRPS diverge, with reports of higher [18], comparable [19], and lower [23] anxiety levels in persons with CRPS in comparison to other groups.
Psychological distress may confound the association between pain and alexithymia in persons with CRPS. It has been suggested that alexithymia hinders a successful regulation of negative feelings, which in turn leads to increased negative affect or distress, chronic over-activation of the sympathetic system, and decreased capacity of the immune system. These psychological and physical outcomes may contribute to CRPS exacerbation and increased pain [24], [25]. Accordingly, distress has been associated with pain, demonstrating a more potent association among persons with CRPS in comparison to persons with other chronic pain [17]. In addition, alexithymia has been associated with psychological distress [26], depression [27], anxiety, and higher internalized anger expression [13]. Studies of persons with non-CRPS chronic pain have shown that when controlling for distress factors, the association found between alexithymia and pain did not reach significance [28] or was significant for affective pain but not sensory pain [12].
The objective of the current study is to elucidate the relationships between alexithymia, psychological distress, and pain in persons with CRPS in order to promote accurate assessment of pain and effective rehabilitation initiatives for this population. Accordingly, we examined levels of alexithymia, psychological distress, and pain in persons with CRPS in comparison to gender- and age-matched persons with chronic LBP. A measurement of psychological distress, a multidimensional assessment of pain, and an empirical assessment of alexithymia were utilized.
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Participants
Ninety-three Israeli adults aged 19–65 were approached, of whom 46.2% had a diagnosis of CRPS, and 53.7% reported chronic LBP. Inclusion criteria were: 1. aged 18 or older; 2. experiencing pain for duration of at least 3 months; and 3. Hebrew proficiency. Exclusion criteria were: 1. pain intensity lower than 3/10 on the Visual Analogue Scale; 2. suffering simultaneously from CRPS and LBP; 3. history of CRPS in persons with LBP; and 4. history of mental illness or brain injury. CRPS was diagnosed
A comparison of pain, psychological distress and alexithymia
Alexithymia total scores as well as sub-scale scores (identifying feelings, describing feelings, externally-oriented thinking) were significantly higher in persons with CRPS when compared to controls, t (58) = 5.23, 4.85, 4.93, 3.62, p = 0.01, respectively. Persons with CRPS had significantly higher ratings of psychological distress when compared to those with chronic LBP, t (58) = 4.35, p = 0.01. No statistically significant differences in pain indicators (PRIS, VAS) were found between persons with
Discussion
This study examined the relationships between alexithymia, psychological distress, and pain in 30 persons with CRPS in comparison to 30 gender- and age-matched persons with chronic LBP. Persons with CRPS showed higher levels of alexithymia when compared to persons with chronic LBP. To our knowledge, this is the first cross sectional study with a comparison group providing empirical evidence on the relationship between alexithymia and CRPS. In addition, persons with CRPS had higher levels of
Conflict of interests
The authors have no competing interests to report.
Acknowledgments
There are no funding sources.
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