Anorexia nervosa and reflex sympathetic dystrophy syndrome

Complex Regional Pain Type 1

Complex regional pain syndrome is increasingly recognized in the pediatric population. Owing to the nature of presentation with pain, many of these children present to the emergency setting at different stages of the syndrome with or without numerous prior interactions with health professionals. Complex regional pain syndrome type 1 (CRPS1) is a clinical syndrome characterized by amplified musculoskeletal limb pain that is out of proportion to the history and physical findings, or pain due to non-noxious stimuli (allodynia/hyperalgesia), and accompanied by one or more signs of autonomic dysfunction. Differential diagnosis may include significant trauma (eg, fractures), inflammatory conditions, malignancies, and systemic illness. The diagnosis is clinical. The treatment goals for CRPS1 are restoration of function and relief of pain. Education, physical, and occupational therapy with psychotherapy and defined goals of achievement with reward are the mainstay of treatment for this population. Most children with CRPS1 will have a favorable outcome.

Chicken or the egg: anorexia nervosa and systemic lupus erythematosus in children and adolescents

Systemic lupus erythematosus (SLE) frequently has neuropsychiatric involvement including affective disorders, psychosis, and cognitive dysfunction. Evidence suggests that anorexia nervosa (AN) in adolescents with SLE may be triggered by steroid-induced changes in weight and body shape. We propose that AN may be another manifestation of neuropsychiatric SLE and should be considered in this patient population. A retrospective chart review identified 7 children/adolescents diagnosed with SLE and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for AN, restrictive subtype, at the Hospital for Sick Children in Toronto between January 1989 and January 2011. One patient developed AN 15 months after being diagnosed with SLE that was attributed to prednisone-induced weight gain and cushingoid appearance. Of the remaining 6 patients, the median age at onset of AN symptoms was 12.2 years and diagnosis of AN was 13.6 years. The median age at SLE diagnosis was 14.2 years with median time after onset of AN symptoms of 20 months (7.5-32 months). All patients had evidence of joint symptoms and a positive antinuclear antibody, and 50% had lymphopenia at the time of SLE diagnosis. Treatment of SLE resulted in improvement of AN in all patients. The timing of the clinical presentation of AN in relation to the diagnosis of SLE and response to SLE treatment suggests that AN may be a novel presentation of neuropsychiatric SLE. Patients with AN who present with or develop joint symptoms, a positive antinuclear antibody, or lymphopenia should be investigated and followed for possible SLE.

Children and adolescents with complex regional pain syndrome: more psychologically distressed than other children in pain?

BACKGROUND

Historically, in both adult and pediatric populations, a lack of knowledge regarding complex regional pain syndrome (CRPS) and absence of clear diagnostic criteria have contributed to the view that this is a primarily psychiatric condition.

OBJECTIVE

To test the hypothesis that children with CRPS are more functionally disabled, have more pain and are more psychologically distressed than children with other pain conditions.

METHODS

A total of 101 children evaluated in a tertiary care pediatric pain clinic who met the International Association for the Study of Pain consensus diagnostic criteria for CRPS participated in the present retrospective study. Comparison groups included 103 children with abdominal pain, 291 with headache and 119 with back pain. Children and parents completed self-report questionnaires assessing disability, somatization, pain coping, depression, anxiety and school attendance.

RESULTS

Children with CRPS reported higher pain intensity and more recent onset of pain at the initial tertiary pain clinic evaluation compared with children with other chronic pain conditions. They reported greater functional disability and more somatic symptoms than children with headaches or back pain. Scores on measures of depression and anxiety were within normal limits and similar to those of children in other pain diagnostic groups.

CONCLUSIONS

As a group, clinic-referred children with CRPS may be more functionally impaired and experience more somatic symptoms compared with children with other pain conditions. However, overall psychological functioning as assessed by self-report appears to be similar to that of children with other chronic pain diagnoses. Comprehensive assessment using a biopsychosocial framework is essential to understanding and appropriately treating children with symptoms of CRPS.

Eating disorders in adolescents and young women with spina bifida

This is the first report of the association of spina bifida and eating disorders. Five patients were diagnosed rather late in the course of their illness. They all had been overweight premorbidly and had been urged to lose weight for years in order to improve their mobility. As they dieted, they experienced their weight loss as a source of power that could somehow compensate for their losses and neurologic limitations. They responded to a multidisciplinary intervention. Clinicians taking care of patients with spina bifida need to be cognizant that they may be at risk of developing an eating disorder. Such awareness should influence the quality of nutritional counseling (prevention aspect) and the clinical assessment of sudden weight loss (early intervention).

Eating disorders and reflex sympathetic dystrophy syndrome: is there a common pathway?

The comorbidity of eating disorders and reflex sympathetic dystrophy syndrome in the same patients raises the possibility of a common pathway for both conditions. Reflex sympathetic dystrophy syndrome may be manifesting itself in those individuals who have sympathetic overdrive. Microtrauma, often induced by compulsive exercise, and depression may be contributory factors. It is recommended that: patients with eating disorders who develop pain in an extremity should be investigated for possible reflex sympathetic dystrophy syndrome; patients with reflex sympathetic dystrophy syndrome should be discouraged from dieting, and eating disorders should be suspected if they begin to lose weight or are already malnourished.

A review of the autonomic nervous system and exploration of diagnoses associated with reflex sympathetic dystrophy

The hand therapy literature about reflex sympathetic dystrophy (RSD) tends to discuss this phenomenon in terms of traumatic hand or upper-extremity injury etiology. Hand therapists' bibliographies run the risk of being inbred and delimited to orthopedic and neurologic sources. Nonetheless, this well-developed body of knowledge identifies cardinal signs and symptoms, stages, and clinical types of RSD. Therapy guidelines have been well detailed in accordance with pathophysiologic explanations. The purpose of this article is to provide an overview of the autonomic nervous system (ANS), to briefly consider the history of the term "sympathetic," and to explore familiar and less well-known predisposing events and associated diagnoses. Appreciating the gamut of diagnoses associated with RSD may promote additional opportunities for hand therapist collaboration in the care for this complicated and challenging diagnostic group.

Hypnotherapy for reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) is an unusual, debilitating, chronic pain syndrome thought to be the result of a continuous excessive discharge of regional sympathetic nerves. Supportive and stress-reduction psychotherapies are commonly recommended as adjunctive treatments. Biofeedback is a more direct symptomatic treatment. Although hypnotherapy is effective in altering sympathetic reflex and pain responses, there are no reports of its use for the treatment of RSD. This article reviews some promising results of hypnotherapy with three RSD sufferers. I discuss the role of hypnotherapy as a supportive adjunct to medical treatment. I also explore the possible role of hypnotherapy as a complementary treatment.