Postgrad Med J: first published as 10.1136/pgmj.68.795.44 on 1 January 1992. Downloaded from *Postgrad Med J (1992) 68, 44 - 46 i) The Fellowship of Postgraduate Medicine, 1992

Erythromelalgia - the role of hypnotherapy K. Chakravarty, P.D.P. Pharoah, D.G.I. Scott and S. Barker' Department ofRheumatology and Rehabilitation, Norfolk andNorwich Hospital, Brunswick Road, Norwich NRI 3SR and 'Department ofPsychiatry, David Rice Hospital, Drayton High Road, Norwich NR8 6BH, UK.

Summary: Erythromelalgia is an unusual condition characterized by attacks of burning pain in the hands and feet with local congestion and increased skin temperature. We report a case oferythromelalgia, with transient hypertension and elevated urinary catecholamines successfully treated by hypnotherapy. Such an association has not to our knowledge been previously reported in English language publications.

Introduction The term erythromelalgia was first used by Mitchell After 2-3 days her hands and feet developed the in 1878 to describe a syndrome of red congestion classical appearance of erythromelalgia and be- and burning pain in the hands and feet. The came hot, red and swollen. There was no evidence burning distress in the extremities with local symp- of any collagen connective tissue disease and there toms of redness, warmth and swelling is character- was no skin rash. Her systemic examinations were istic of this condition. It has been described in otherwise normal. by copyright. association with myeloproliferative disorders such The results ofthe following laboratory investiga- as essential thrombocythaemia. The clinical fea- tions were normal or negative on several occasions: tures are believed to be secondary to a platelet full blood count and differential, erythrocyte sedi- mediated arteriolar inflammation and thrombosis. mentation rate, C-reactive protein, urea and elec- Although various types of erythromelalgia have trolytes, bone and liver biochemistry, plasma been described, its association with transient glucose, anti-nuclear factor, immunoglobulins, hypertension and raised urinary catecholamine is cryoglobulins and immune complexes. Twenty- decidedly rare and has not been previously report- four hour urinary hydroxymethyl mandelic acid ed in the English literature. We describe a patient was elevated on 3 separate occasions at 57, 48 and http://pmj.bmj.com/ with erythromelalgia associated with transient 46 mmol/24 h (normal range = 10-35 mmol/24 h). hypertension and raised urinary catecholamines Electrocardiogram, chest X-ray and abdominal who failed to respond to conventional treatment. ultrasound were normal. Hypnosis however induced a complete remission of Pharmacological therapies attempted to control her symptoms without any recurrence. the somatic pain included aspirin, paracetamol, various non-steroidal anti-inflammatories, vaso- dilators, beta-blockers, pethidine, carbamazine, Case report amitriptyline and chemical sympathectomy. None on September 25, 2021 by guest. Protected of these proved effective. Finally, a psychological A previously fit 18 year old woman was admitted approach to pain control was attempted. Her with a 4 week history of constant, severe, burning blood pressure, however, was controlled with the pain in her hands and feet. The pain did not angiotensin converting enzyme inhibitor, capto- respond to simple analgesics and relief was only pril. obtained by immersion in ice-cold water. She was then seen and assessed by the psychia- Physical examination was unremarkable apart trist. A full history and examination took place, from a persistently elevated blood pressure of which revealed a woman of normal premorbid 165-185/110-125 mmHg. Initially her hands and function, from a stable background. No abnor- feet appeared normal with palpable peripheral mality was detected in the mental state examina- pulses and there was no neurological abnormality. tion. There was no evidence to suggest that this was an hysterical conversion syndrome. Hypnotherapy was chosen on account of her Correspondence: K. Chakravarty, M.R.C.P. psychological stability and because the pain was Accepted: 10 June 1991 believed to be acute and organically based. A Postgrad Med J: first published as 10.1136/pgmj.68.795.44 on 1 January 1992. Downloaded from CLINICAL REPORTS 45

standard induction technique was used which culating catecholamines. This hypothesis does not allowed the achievement of the hypnotic state.' explain the transient nature of the hypertension or Whilst in the hypnotic state the patient was the cause of the raised urinary catecholamine encouraged to 'allow' the pain to flow out of the excretion. affected extremities, leaving a 'normal' sensation The role of hypnosis in the relief of pain due to behind. The patient was also, whilst in the hyp- cancer, obstetric and surgical operation and dentis- notic state, taught to induce the state of self- try has been well documented. It is considered to be hypnosis and hence self-control over the painful one of the best forms of psychological treatments symptoms. for pain. Hypnosis should be considered for acute The initial effects were satisfactory, and the organically based pain in psychologically stable techniques and instructions were repeated on a patients. There are, however, various ingenious further 3 occasions. methods for suggesting the reduction of pain and The patient was seen 2 weeks later and was pain the 3 classes ofprocedures are: the direct suggestion free. At the time of discharge she was totally of pain reduction; altering the experience of pain, asymptomatic although anti-hypertensive therapy even though the pain may persist; and directing was continued. Two weeks after her discharge from attention away from the pain and its source. None hospital she was found to be hypotensive by her of these procedures is, however, mutally exclusive. general practitioner and the anti-hypertensive Our patient was treated by direct suggestion. therapy was discontinued. She has since remained Hypnosis is quick, efficacious and free from side normotensive and her 24 h urinary excretion of effects, ifcarried out under appropriate indication. catecholamines were within the normal range. It has a specific effect which is thought to derive She was reviewed at 6 months when she was from the hypnotisability of the patient and both noted to be asymptomatic and exhibited no psy- sensory and reactive components of the pains are chological abnormality. The family interview this affected. time confirmed the impression of a perfectly nor- The underlying mechanisms are not understood, mal woman who has had the misfortune to develop but would appear to act at a primary central level. a painful physical condition. It is possible for something to occur at an intellec- by copyright. tual level but not be available to the consciousness of the hypnotized person, as highlighted in the Discussion 'hidden observer' theory.6 The 'hidden observer' is a convenient label for the information source Primary erythromelalgia is a rare condition of tapped through experiments with automatic writ- unknown aetiology, characterized by burning pain ing or automatic talking. It is possible that it brings in the hands and feet.2 Secondary erythromelalgia about a split in the consciousness by means of a may, however, be associated with systemic diseases central stimulation which modifies the spinal re-

such as myeloproliferative disorders and connec- sponses due to pain. http://pmj.bmj.com/ tive tissue diseases.3 Our case highlights the rarity ofthe syndrome of In the primary condition, a local disturbance in erythromelalgia and episodic hypertension and the vasomotor regulation has been postulated as a refractory nature of its response to treatment with pathogenic factor, but treatments aimed at altering conventional analgesic. Perhaps a greater aware- vascular tone are not consistently effective. More ness is necessary amongst clinicians so that diag- recently it has been suggested that the condition nosis can be attained early and hypnotherapy tried might be explained by a local reduction in the as a first line of treatment. Fortunately, with a number ofautonomic nerve terminals in the affect- revival of interest in hypnosis in the nineteenth on September 25, 2021 by guest. Protected ed area.4'5 A French report describes one case4 of century, active antagonism to hypnosis is no longer erythromelalgia associated with hypertension and prevalent and its use in pain relief, while not elevated urinary catecholamines. Although the widespread, is increasing. exact mechanism of sensory-autonomic inter- action involving the production of pain is not known, Blanchard et al.4 postulated that both the Acknowledgements pain and the hypertension may be the result of a local reduction in autonomic nerve terminals with We extend our grateful thanks to Mrs Julia Dosser and subsequent denervation hypersensitivity to cir- Mrs S. Turner who have kindly typed the manuscript.

References 1. Orne, M.T. & Dings, F.D. In: Wall, P.D. & Melzak, R. (eds) Textbook ofPain. Churchill Livingstone, Edinburgh, London, 2. Drenth, J.P.H. & Michiels, J.J. Three types oferythromelalgia. 1989, Chapter 77, pp. 1021-1031. Br Med J 1990, 301: 454-455. Postgrad Med J: first published as 10.1136/pgmj.68.795.44 on 1 January 1992. Downloaded from 46 CLINICAL REPORTS

3. Babb, R.R., Alarcon-Segovia, D. & Fairbairn, J.F. Erythro- 5. Uno, H. & Parker, F. Autonomic innervation of the skin in melalgia. Review of 51 cases. Circulation 1964, 29: 136-141. primary erythromelalgia. Arch Dermatol 1983, 119: 65-71. 4. Blanchard, P., Grenier, B., Marchland, S. & Ruchoux, M.M. 6. Hildgard, E.R. & Hildgard, J.R. Hypnosis in the ReliefofPain. Erythromelalgia, hypertension arterielle et excretion accrue de Kaufman, Los Altos, California 1983, pp. 166-188. catcholamine urinarire. Arch Fr Pediatr 1987, 44: 799-802. by copyright. http://pmj.bmj.com/ on September 25, 2021 by guest. Protected