Dramatically Disturbed Patients in Interdisciplinary Pain Programs
The efficacy and cost-efficiency of interdisciplinary pain management programs have been well-established.1,2 Nevertheless, the effort expended in helping to restore dysfunctional chronic pain patients to functional lifestyles is extremely difficult, in part because such clinics tend to attract patients with higher levels of psychopathology than is characteristic of chronic pain patients in general.3 While pronounced depression and anxiety are considered typical features with which chronic pain patients present and can be treated effectively through the psychological component of a pain management program, treating the severely characterologically-disturbed is another matter altogether.
Perhaps the most troublesome pain population to treat within an interdisciplinary setting is the dramatic personality disorder, which the DSM-IV4 refers to as the ‘Cluster Bs,’ i.e. the antisocial, borderline, histrionic and narcissistic personalities. Personality-disordered individuals do not change easily, as their symptoms are generally ego-syntonic. While outside observers are likely to recognize severe disturbance among ‘Cluster Bs,’ personality disordered individuals are generally oblivious to their problems themselves. The DSM-IV4 describes their deviant enduring pattern of inner experience and behavior as inflexible and pervasive.
Typical ‘Cluster B’ Personality Traits
In order to understand the problems associated with the treatment of Cluster B personalities within interdisciplinary pain management settings, the individual personality disorders and problems associated with their treatment in patients without chronic pain should first be briefly discussed.
- Antisocial Personality Disorder. The antisocial personality disorder is characterized by a pervasive pattern of disregard for, and violation of, the rights of others.4 Deceitfulness has been reported to have the highest predictive value for this personality disorder.5 Associated behaviors among antisocial personalities have been found to include job troubles, violence, four or more traffic offenses, severe marital problems, vagrancy and multiple arrests.6 Treatment of the antisocial personality is essentially impossible, with no form of psychotherapy or psychopharmacological intervention found to improve the antisocial syndrome.7 Treatment of these patients is considered by some to be dangerous, and concern has been expressed regarding blending treatment efforts with those of other patients due to safety issues.8
- Borderline Personality Disorder. While generally less dangerous than the antisocial patient, the borderline personality disorder is dreaded by most mental health practitioners. The character and behavior of the borderline are typified by instability of interpersonal relationships, self-image and affects, and marked impulsivity.4 While some clinicians believe that this disturbance is amenable to psychotherapeutic treatment, significant gains have been identified only through psychoanalysis and dialectical behavior therapy, both of which involve a year or more of intensive treatment before substantial improvement is generally evidenced.9
- Histrionic Personality Disorder. Displaying some psychopathology similar to that of borderlines, the histrionic personality disorder is characterized by pervasive and excessive emotionality and attention-seeking behavior.4 One of the characteristics of these individuals which often results in their appearance at pain management clinics is that they tend to complain of and exaggerate their health problems as a means of attention-seeking. A 1989 study10 concluded that there were no empirical studies to support the efficacy of any treatment approach for histrionic personality disorder. Since this study, there is still a lack of empirical support for any type of treatment. Again, the two treatment types which have shown any promise whatsoever, psychoanalytic therapy and dialectical behavior therapy, tend to require one or more years to yield results.
- Narcissistic Personality Disorder. Finally, the narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration and lack of empathy.4 These individuals believe themselves to be special, and accordingly present with a strong sense of entitlement. The trait of interpersonal exploitation has been found to carry the highest predictive value for this disorder.5 There exists little literature on the psychotherapeutic treatment of the narcissistic personality disorder, and efforts to treat people with this diagnosis are generally thought to be futile. Even Freud noted that narcissists are not amenable to psychotherapy due to their inability to form the requisite therapeutic alliance with the therapist.11 In group therapy, narcissists are thought to be a problem as their lack of empathy, sense of entitlement and intense need for admiration result in their alienation from the rest of the group.12
In the general population, the prevalence of antisocial personality disorder is thought to be about 2%, borderline personality disorder 2%, histrionic personality disorder 2-3% and narcissistic personality disorder less than 1%.4 Table 1 summarizes some of the results of studies on the prevalence of Cluster B personality disorder in the chronic pain population.
Very striking are the results of a study in which chronic pain patients were significantly more likely to present with Cluster B personality disorders than were criminal defendants referred for evaluation of their competency to stand trial.18
While the disproportionate number of chronic pain patients who suffer from a Cluster B personality disorder has been well-established, the cause of this relationship is still unclear. The lack of social and intrapsychic resources of individuals with personality disorders resulting in enhanced vulnerability to the sequelae of a chronic pain condition has been suggested as the cause of their tendency to populate pain treatment facilities with surprising frequency.19 Weisberg and Keefe’s20 stress-diathesis theory suggests that there is likely to exist a predisposition toward a personality disorder prior to the onset of pain. Psychological coping mechanisms which were adaptive or marginally adaptive prior to the onset of pain and disability become maladaptive under the stress of the pain, resulting in the expression of the personality disorder.