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 Complex Regional Pain Syndrome, Type 1 May Represent a Dissociative Defense Against
Injury or Trauma

David C. Flemming, MD. Michael J. Gainer, PhD.

American Pain Society Annual Scientific Meeting
New Orleans, 1997

 Introduction

Debate continues as to whether or not behavioral components exist in Complex Regional Pain Syndrome, type 1 (CRPS-1), are primary to the disease or, if treated, can lead to clinical improvement9. We suggest that several features of the disease demonstrate an association with the psyche. For example, in most patients, symptoms vary with stress1; major life stress within eighteen months of onset is common; and the placebo response is high8. Objective consideration of such possibilities may lead to a clearer understanding of the disease resulting in improved outcome.

This report describes response to the introduction of specific psychological modalities as part of an integration of medical, rehabilitative and psychological services. While a thesis that treatable psychological components of CRPS-1 exist is supported by this report, it neither overlooks or negates the disease's obvious physical nature.

Several authors2,3,4 have described treatment of CRPS-1 aided by hypnosis. Gainer and Flemming (1992)5,6 separately described long term remission when hypnosis was included with the treatment plan.. Flemming, Gainer and Low, et al repeated this assertion in 1997 with a larger series7 in which integration of standard medical treatment with specialized forms of hypnotherapy lead to long term remission in 60% of patients who had not been helped by standard medical and rehabilitative modalities alone.

Clinical observation of these patients lead to a new conceptual understanding of CRPS-1. We propose that the emotional and behavioral impact of CRPS-1 can become established as a maintaining factor for the disease. The capacity to behaviorally dissociate may predispose to CRPS-1. If accurate, an integration of treatments including medical, rehabilitative and behavioral/psychological modalities is more likely to lead to long term remission than a medical and rehabilitative approach alone in most patients. 

We suggest that in many cases, physiological patterns associated with CRPS-1 can enmesh with and emerge as the physiological signature of a dissociated ego-state. Patients responding to treatment aimed at re-integration of this ego-state learn to modify labile features of the disease using direct and ultimately conscious control over autonomic function. The resulting remission is long term because voluntary control over autonomic function ultimately becomes habitual. Further, factors that promote dissociation become recognized leading to their abandonment by the patient. This understanding defines a primary role for the psychological component in this integration of services.

The concept provides an understanding of both treatment success and failure in most cases. It addresses some common questions (see Ochoa8) regarding etiology, conflicting response to treatment, issues of gain, placebo response and other features of CRPS-1. Since dissociative defense represents a normal component of behavior in dissociative individuals, we do not directly link psychopathology to CRPS-1's onset or maintenance.

Abstract

Eighty-five percent of 41 patients with credibly diagnosed CRPS-1 selected by failure to respond to medical and rehabilitative management demonstrated a high hypnotic capacity using a standard measure. Fifteen percent demonstrated a low or absent hypnotic capacity. No patients in this group was found to have average hypnotic capacity. All highly hypnotizable subjects could modify both pain perception and labile features of the disease using hypnotic technique. Of the entire sample, sixty percent were able to achieve remission of symptomsóall from the group of highly hypnotizable patients. Remission is defined as: Absent pain, or minimal pain easily managed by the patient unaided; Absent need for analgesics; Restoration of function. These patients were followed for a period of one to five years and all maintained this remission. A brief description of the various hypnotherapeutic approaches used together with details and implications of the results is presented. Integration of services seems material to outcome and the potentiating effect of medical, rehabilitative and psychological modalities on the others is briefly explored. Since in the general population only five to ten percent of individuals possess this degree of ability to use hypnosis, high hypnotizability was over-represented in this patient sample. These patients may be predisposed to contracting this disease The biological foundations of hypnotizability and dissociation, and their implications in understanding pain as a manifestation of autonomic function are briefly discussed.

Treatment AlgorithmOutcome

These clinical observations invite rigorous scientific evaluation of the role of psychological method as a primary treatment modality in CRPS-1. They call for evaluation of psychological and behavioral factors as maintaining factors in CRPS-1 and possibly other chronic pain conditions. If these outcome observations are reproducible, they will impact significantly on the clinical management of CRPS-1. Finally, they invite evaluation of this evaluation and treatment model for effect in other physical illnesses having autonomic roots.

What is Hypnosis?

In this context, hypnosis is the generation of images within the mind that leads to change in autonomic function. For example, an image of lemons can lead to salivation, one of fear to tachycardia and a sexual fantasy can lead to sexual arousal. In general terms, the more powerful the physiologic response to mental imagery, the higher is the personís hypnotizability. Hypnotizability follows a normal distribution, which means the greatest number of people possesses average ability. High and low hypnotic capacities are attributes of about 10%-15% respectively of a normal population. In our sample of 41 patients 15% had low or absent hypnotic capacity while 85% had a very high capacity. No patients had average capacity. An under-representation of average hypnotic capacity may render people invulnerable to CRPS-1.

Three abilities facilitate use of hypnosis:

  1. High dissociative capacity.
  2. Willingness to suspend reality.
  3. Motivation to become involved.

Hypnotherapeutic Approach

A variety of hypnotherapeutic approaches were used depending on the patientís individual capacities, insight and psychological-mindedness. All patients were given an initial standardized test of hypnotizability, modified after the Speigel Hypnotic Induction Profile (HIP)10. During this initial evaluation session, patients were given direct suggestions for pain relief and modification of other labile features of the disease. Based on the response to these suggestions, other techniques were introduced using a hierarchy of complexity. After direct suggestion, they included imaginative variation, symbolic transformation and ego-state therapy. Subjective reporting of pain level using a visual analogue scale, clinical and objective measurement of changes in skin temperature, release of muscle spasm, improved range of movement in affected joints and change in edema measured the effectiveness of the hypnotherapeutic intervention. Cognitive and other specific psychological modalities were also used as indicated. Hypnotherapeutic intervention was sometimes provided during anesthetic block procedures which provided an experiential anchor to be used in later hypnotherapeutic interventions. This provided a pairing phenomenon useful in classical behavioral conditioning of a 'no-pain' behavior.

The following implicate dissociation as a maintaining factor for CRPS-1:

  1. People with average dissociative capacity in whom dissociative defenses are seldom utilized were not represented in this population, whereas 85% of patients were noted to have high dissociative capacity. Dissociation also occurs in people with a low dissociative capacity, but not in an fashion accessible for intervention based on imagery.
  2. There appears to be an association between life stresses potentially causing dissociation in highly dissociative individuals and the onset of disease.
  3. Co-existence is seen between CRPS-1 and symptoms and signs of other dissociative issues.
  4. The disease responds to management that included the psychological modalities used to reintegrate dissociated ego-states.

What is an Ego-State?

Federnís (1952)11 original concept of "ego-states" was refined and described by Watkins and Watkins (1979, 1980)12,13. They consider personality to be built of an organized system of different behaviors termed ego-states, bound together by a common principle. Each ego-stateís boundary is more or less permeable. Ego-states have more or less autonomy in relation to other states and overall personality. Their different characteristics become the dominant feature of overall personality depending on the perceived needs of current circumstance. Ego-states are characterized by verbal style, body language and mood and each carries a reproducible physiological signature, for example, a characteristic heart rate, skin perfusion or variation within any labile physiological parameter. We build ego-states during personal growth and development, by copying from others, from cognitive choice and by our own spontaneous response to new circumstances, all of which can be adopted as patterned behavior. Ego-states can be understood as the characteristic neuro-psycho-physiological state that occur typically in an individualís varying social roles and adaptations to their environment. They are the building blocks of personality.

What is a Dissociated Ego-State?

As a normal response to pain, stress or even boredom, people with a high dissociative capacity may dissociate into a protective ego-state. In this ego-state they become isolated from events and to varying degrees, communication between this and the individual's normal family of ego-states can be lost. As previously noted, high hypnotic capacity is over-represented in the CRPS-1 population. Many CRPS-1 patients dissociate in response to pain or injury. This may prove a maintaining factor for the disease by isolating core and dissociated ego-states  from their spontaneous ability to communicate and self-treat.

Can Autonomically based Illness Enmesh with a Dissociated Ego-State?

We propose that autonomic activity can become patterned within the autonomic nervous system by a process of learning or conditioning. CRPS-1 is rich in autonomic activity and when this activity repeatedly occurs in association with a particular ego-state, it can become enmeshed with that ego-state. Highly hypnotizable or dissociative individuals may isolate themselves from adversity as much as possible using dissociative mechanisms and by doing so, paradoxically dissociate themselves from psychological resources needed to encourage those patterns to fade. If high hypnotizability is a risk factor for CRPS-1, this particular dynamic may emerge as responsible.

Eighty five percent of our sample was highly hypnotizable, so by definition, had a high dissociative capacity. Hypnotherapy, including forms of ego-state therapy, was effective in treating this particular psychological dynamic in the majority of patients.

What is Ego-State Therapy?

Ego-state therapy is a process by which a dissociated ego-state is invited to reveal itself in a way that encourages therapeutic dialogue between this and other ego-states that comprise the patient's overall personality, similar to the goals of family therapy. The intention is to determine the ego-stateís purpose with the goal of discovering ways to achieve its function, in ways that do not harm the individual as a whole. Hypnosis is able to provide an emotional environment providing the safety needed to dissolve barriers between dissociated ego-states.

Integration of Therapeutic Modalities

Since CRPS-1 has medical and psychological components, and because medical, myofascial, physical and rehabilitative therapy each has specific indication during treatment, all these modalities were represented in the clinic .Used alone, these modalities seldom lead to remission. We suggest that outcome is improved when clinical services are offered in a seamlessly integrated fashion.

For example, provision of pain relief using drugs or procedures can provide an experiential anchor during future hypnosis sessions and can encourage patterning of autonomic response. This seemed easier to achieve if the anesthesiologist and psychologist worked in a shared environment. Myofascial therapists were trained in simple forms of therapeutic imagery. In addition to release of muscle spasm associated with CRPS-1, myofascial therapy allowed time to process psychological intervention and served to reinforce reduction of pain using behavioral technique. Because patients could benefit conveniently from several different modalities based in the same location, we assume close geographical and temporal locations for treatment may contribute to improved outcome.

Significance

  1. We do not assume that our sample of patients necessarily represents all individuals with CRPS-1.  
  2. While clinical end-points seemed unambiguous they were not confirmed by impartial observers.
  3. For these reasons, objective confirmation of concepts and outcome in a large sample of patients is necessary

Summary

After CRPS-1 had failed to respond to management including medical and rehabilitative therapy, 41 unselected patients were offered specific psychological modalities as part of an integration of medical services. Many of these interventions were conducted under hypnosis and treatment modalities were similar to those used to treat dissociative disorders. Long term remission occurred in 60% of these patients. A treatment algorithm based on these patients suggests reasons for response or lack of response to this integrated medical service.

  • A working paradigm for complex regional pain syndrome, type 1 (CRPS-1) is presented suggesting that the disease may have treatable behavioral components.
  • We suggest that clinical features of CRPS-1 are maintained after healing of the triggering injury by dissociative mechanisms.
  • Cost of therapy is greatly reduced using these concepts because treatment is more effective, comparatively brief and relatively non-invasive.
  • Long term remission from CRPS-1 may be available for a majority of patients if medical and rehabilitative therapy is integrated with specialized and specific psychological services.
  • Clinic architecture, equipment, staffing and even authority structure will require redesign should these concepts prove accurate.
  • If applicable to the whole population of sufferers, long term remission is available to a majority of patients.
  • Corroborative study is required.

Bibliography

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