RENEW OR SUBSCRIBE TO PPM
Subscription is FREE for qualified healthcare professionals in the US.
5 Articles in Volume 4, Issue #2
Adhesive Arachnoiditis:A Continuing Challenge
Cardiovascular Consequences of Severe Acute Pain
Dramatically Disturbed Patients in Interdisciplinary Pain Programs
Persistent Spine-centered Chronic Pain Scenarios and Treatment Options
Provider-patient Interactions

Dramatically Disturbed Patients in Interdisciplinary Pain Programs

The dramatic personality disorders of the ‘Cluster B’ type — which can wreak havoc in an interdisciplinary pain treatment program — present clinics with a dilemma in handling these troublesome patients.

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

Population Statistics

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.

Table 1. Prevalence of Cluster B personality disorders in chronic pain samples.

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.

Treatment Challenges

There exist numerous problems associated with treating Cluster B personality disorders in interdisciplinary chronic pain management programs. First and foremost is compliance. The antisocial personality has problems with authority, and authority tends to be strong in well-run programs. The borderline personality tends to be manipulative, and may triangulate or split the program staff, playing one professional off against another. Histrionics and Narcissists need to remain sick or disabled in order to generate the attention which they crave. Histrionic patients are also likely to easily feel bored, and may accordingly stir things up in the clinic in order to bring them a sense of excitement. Narcissistic patients will often engage in a narcissistic rage when they are expected to comply with the rules; since they need to be seen as special, the rules do not apply to them. Of considerable concern is medication compliance among these patients since a strong relationship between Cluster B personality disorders and substance abuse has been identified.21,22

In addition to issues of compliance, patients with Cluster B personality disorders tend to have a profound impact on the therapeutic milieu, the integrity of which is critical if patients are to benefit from interdisciplinary chronic pain management. As the antisocial personality’s behavior is characterized by a pervasive disregard for the rights of others, the potential for violence among frustrated chronic pain patients increases when this type of personality is added to the mix. Theft of medications, particularly narcotic analgesics, often becomes a problem. The borderline personality’s problems with impulsivity and anger often results in an unstable environment, which is certainly not ideal. Histrionic patients tend to present a problem for the therapeutic milieu, as they are so aggressive regarding their demands for attention. Problems increase exponentially when the patient population includes multiple histrionic personalities. Their sexual seductiveness may also result in destabilization of the clinic. Narcissistic patients tend to be extremely damaging to the therapeutic milieu, as they present with the inflated need for attention of the histrionic along with the tendency to be interpersonally exploitive of the antisocial personality. It is not uncommon for resentment to build as the Narcissist begins to believe that he or she is actually a staff member, and begins to cross crucial boundaries.

In addition to adversely impacting the therapeutic milieu, Cluster B personalities can have a devastating impact on the emotional well-being of the professional staff. While chronic pain clinicians are generally comfortable in dealing with the day-to-day frustrations of their patients, tolerating narcissistic rage, borderline splitting, antisocial behavior, and constant histrionic attention-seeking can be outside of the scope of expectations for many clinicians. While the psychologists in an interdisciplinary pain management clinic may not be particularly enamored by Cluster B patients, they are likely to have been trained in dealing with them. This may not be the case for physicians, nurses, physical and occupational therapists, vocational counselors, biofeedback therapists and support staff. As difficult as it is to assemble a cohesive pain treatment team, allowing Cluster B personalities to contribute to premature burn-out is probably ill-advised.

Questionable Outcomes

The final problem associated with the treatment of Cluster B personalities in interdisciplinary pain clinics pertains to outcomes, which should be of primary concern. Not surprisingly, little outcome research pertaining to the treatment of Cluster B personalities suffering from chronic pain exists.

Elliot and colleagues23 found that Cluster B personality-disordered patients reported a significantly smaller decrease in pain levels in an outpatient chronic pain management program than did other patients in their sample. Narcissistic personalities were found to be the group reporting the smallest change in pain levels, and the authors suggested that their subjective pain complaints served to preserve their sense of uniqueness. Borderline personality was predictive of not returning to work following the completion of a functional restoration program.17 High anger expressers improved less on lifting capacity following a multidisciplinary pain program than did low anger expressers.24 While the authors did not look at personality disorders per se, their findings suggest that the manner in which patients manage their anger, which is characteristically problematic for Cluster B personalities, exerted a significant influence on outcome apart from the effects of mere anger proneness. The authors suggested that therapists may be less willing to encourage or even approach patients who lash out in anger verbally or behaviorally. What the limited body of research suggests is that whether outcomes are determined by reductions in pain, increases in functional capacity or return-to-work status, Cluster B patients do not fare as well in interdisciplinary pain management programs as do patients without dramatic personality disorders.

Identification of Cluster B Personalities

Accurately identifying Cluster B personalities among the chronic pain population is of the utmost importance. In the research on personality disorders and chronic pain, personality disorders are generally assessed in one of two ways. A number of investigators have utilized the Millon Clinical Multiaxial Inventory (MCMI).25 Now on its third edition, the MCMI is a 175-item instrument, which, among other characteristics, can identify Cluster B personalities. Unfortunately, studies have identified considerable problems with the validity and reliability of the MCMI, particularly in regard to overestimating psychopathology.19,26,27,28 Of greater reliability and validity are structured and semi-structured interviews, which tend to be the assessment tools of choice for researchers. These include the Structured Clinical Interview for the DSM-IV (SCID)29 and the Structured Interview for DSM-IV personality disorders (SIDP-IV).30 In conducting research in academic settings, time is generally on the clinician’s side. This is typically not true, however, in the real world of non-academically-based pain management programs. As structured and semi-structured interviews can require 3 to 5 hours to administer, score and interpret, they have not been widely used with chronic pain patients.31

As the commonly utilized research tools have their shortcomings in the clinical setting, pain clinicians must rely upon history, to a great extent, as well as behavioral observations during the clinical interview, in order to identify Cluster B pathology. Obtaining an accurate psychosocial history, particularly in regard to relationships, vocational history, conduct/legal problems and previous psychiatric or psychological treatment, is critical in the assessment of Cluster B personality disorders. Rage toward family members, employers, insurance adjustors and every physician by whom a chronic pain patient has been evaluated and/or treated can also serve as a red flag.

Conclusion

The treatment of Cluster B personalities, even without chronic pain, is very difficult and requires inordinate amounts of time, particularly given the time-limited nature of most interdisciplinary chronic pain management programs. In addition, likely problems with noncompliance, destruction of the therapeutic milieu, incredible wear and tear on the staff, and the aforementioned limited — yet discouraging — outcome research, a strong argument can be made against admitting these patients to such programs. While Weisberg31 has suggested that “in cases in which a severe personality disturbance is evident, such as a borderline patient, clinicians can modify their reactions accordingly,” it is not realistic to expect non-psychologist treatment team members and other patients to adjust to the chaos which Cluster B personalities can cause in even the most stable of clinic environments. Individual personality differences should certainly be taken into account when designing patients’ treatment plans, but dramatic characterological disturbance can justifiably be utilized as a reason to reject a patient for treatment. While chronic pain is thought to be treated most effectively, in many instances, by a group of clinicians in close communication with each other, these disturbed patients tend to be masters at throwing groups into states of chaos. Since even the most cohesive chronic pain management treatment teams are not immune to the impact of dramatically characterologically-disturbed patients, an argument can be made for leaving their treatment in the hands of a single clinician.

Most communities large enough to support a pain clinic will also include physicians specializing in the long-term management of chronic pain patients through pharmacologic approaches alone. Interdisciplinary chronic pain management clinics should consider these physicians as a treatment option of last resort, and refer Cluster B personality patients to them. Such dedicated pain medication specialists may be better able to manage or avoid potential office disruption and provide more scrutiny of potential narcotic-contract violations which tend to appear with higher frequency in this population.

Rather than risk destroying the interdisciplinary treatment venue for the many other dysfunctional chronic pain patients (i.e. those who are not suffering from a dramatic personality disorder), it seems to this author that steering such patients to a more individualized and isolated environment (i.e. a single-doctor practice) may be in the best interests of all involved.

Last updated on: January 28, 2012
close X
SHOW MAIN MENU
SHOW SUB MENU