Borderline Personality Disorder and Chronic Pain: A Practical Approach to Evaluation and Treatment

  • Vicki Kalira
  • Glenn J. Treisman
  • Michael R. Clark
Psychiatric Management of Pain (M Clark, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Psychiatric Management of Pain

Abstract

Patients with chronic pain present a spectrum of complexity that can be overwhelming for the individual practitioner. These patients require thoughtful care and a comprehensive treatment plan. This complexity should be acknowledged, not avoided, and the patient should be engaged, not shunned. A practical approach will assist in developing expertise and proceeding empathically. The presence of a superimposed personality disorder significantly increases the difficulty of caring for these patients. Studies investigating the prevalence of borderline personality disorder in patients with chronic pain averaged 30 %, highlighting the importance of being able to effectively treat this patient population. Appropriate management of these patients should focus on a collaboration to practice productive behaviors despite intense emotional distress. Longitudinal research provides a foundation for an optimistic prognosis that can be enhanced with this rehabilitative approach.

Keywords

Chronic pain Borderline personality Personality disorders Difficult patient Pain Personality Psychotherapy Cluster B 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Dr. Vicki Kalira reported no potential conflicts of interest relevant to this article.

Dr. Glenn J. Treisman reported no potential conflicts of interest relevant to this article.

Dr. Michael R. Clark is a Section Editor for Current Pain and Headache Reports.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Press Inc.; 1994.Google Scholar
  2. 2.
    Wasan AD, Wootton J, Jamison RN. Dealing with difficult patients in your pain practice. Reg Anesth Pain Med. 2005;30:184–92.PubMedGoogle Scholar
  3. 3.
    Stern A. Psychoanalytic investigation of and therapy in the borderline group of neuroses. Psychoanal Q. 1938;7:467–89.Google Scholar
  4. 4.
    Norman WT. Toward an adequate taxonomy of personality attributes: replicated factors structure in peer nomination personality settings. J Abnorm Soc Psychol. 1963;66:574–83.PubMedCrossRefGoogle Scholar
  5. 5.
    Costa PT, McCrae RR. The NEO personality inventory manual. Orlando: Psychological Assessment Resources; 1985.Google Scholar
  6. 6.
    Widiger TA, Lowe JR. Five-factor model assessment of personality disorder. J Pers Assess. 2007;89:16–29.PubMedCrossRefGoogle Scholar
  7. 7.
    Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry. 1993;50:975–90.PubMedCrossRefGoogle Scholar
  8. 8.
    Svrakic DM, Whitehead C, Przybeck TR, et al. Differential diagnosis of personality disorders by the seven-factor model of temperament and character. Arch Gen Psychiatry. 1993;50:991–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Hirano S, Sato T, Narita T, et al. Evaluating the state dependency of the temperament and character inventory dimensions in patients with a major depression: a methodological contribution. J Affect Disord. 2002;69:31–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Grucza RA, Przybeck TR, Spitznagel EL, et al. Personality and depressive symptoms: a multi-dimensional analysis. J Affect Disord. 2003;74:123–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Nestadt G, Costa Jr PT, Hsu FC, et al. The relationship between the five-factor model and latent Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorder dimensions. Compr Psychiatry. 2008;49:98–105.PubMedCrossRefGoogle Scholar
  12. 12.
    Terracciano A, Costa Jr PT, McCrae RR. Personality plasticity after age 30. Pers Soc Psychol Bull. 2006;32:999–1009.PubMedCrossRefGoogle Scholar
  13. 13.
    Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. Prediction of the 10-year course of borderline personality disorder. Am J Psychiatry. 2006;163:827–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Skodol AE, Gunderson JG, Shea MT, et al. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. J Personal Disord. 2005;19:487–504.CrossRefGoogle Scholar
  15. 15.
    Costa Jr PT, Patriciu NS, McCrae RR. Lessons from longitudinal studies for new approaches to the DSM-V: the FFM and FFT. J Personal Disord. 2005;19:533–9.CrossRefGoogle Scholar
  16. 16.
    Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med. 2002;64:773–86.PubMedCrossRefGoogle Scholar
  17. 17.
    Vendrig AA, Derksen JJ, de Mey HR. MMPI-2 Personality Psychopathology Five (PSY-5) and prediction of treatment outcome for patients with chronic back pain. J Pers Assess. 2000;74:423–38.PubMedCrossRefGoogle Scholar
  18. 18.
    Weisberg JN. Personality and personality disorders in chronic pain. Curr Rev Pain. 2000;4:60–70.PubMedCrossRefGoogle Scholar
  19. 19.
    Weisberg JN, Vaillancourt PD. Personality factors and disorders in chronic pain. Semin Clin Neuropsychiatry. 1999;4:155–66.PubMedGoogle Scholar
  20. 20.
    Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates and disability of personality disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2008;69(4):533–45.PubMedCrossRefGoogle Scholar
  21. 21.
    Hathaway SR, McKinley JC. Minnesota multiphasic personality inventory manual (rev ed). New York: Psychological Corporation; 1967.Google Scholar
  22. 22.
    Turk DC, Fernandez E. Personality assessment and the Minnesota Multiphasic Personality Inventory in chronic pain: underdeveloped and overexposed. Pain Forum. 1995;4:104–7.CrossRefGoogle Scholar
  23. 23.
    Vendrig AA. The Minnesota Multiphasic Personality Inventory and chronic pain: a conceptual analysis of a long-standing but complicated relationship. Clin Psychol Rev. 2000;20:533–59.PubMedCrossRefGoogle Scholar
  24. 24.
    Sternbach RA. Psychological aspects of pain and the selection of patients. Clin Neurosurg. 1974;21:323–33.PubMedGoogle Scholar
  25. 25.
    Riley 3rd JL, Robinson ME. Validity of MMPI-2 profiles in chronic back pain patients: differences in path models of coping and somatization. Clin J Pain. 1998;14:324–35.PubMedCrossRefGoogle Scholar
  26. 26.
    Fishbain DA, Cole B, Cutler RB, et al. Chronic pain and the measurement of personality: do states influence traits? Pain Med. 2006;7:509–29.PubMedCrossRefGoogle Scholar
  27. 27.
    Loranger AW, Lenzenweger MF, Gartner AF, et al. Trait-State artifacts and the diagnosis of personality disorders. Arch Gen Psychiatry. 1991;48:720–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Bronisch T, Klerman G. Personality functioning: change and stability in relationship to symptoms and psychopathology. J Personal Disord. 1991;5:307–17.CrossRefGoogle Scholar
  29. 29.
    Stuart S. Are personality assessments valid in acute major depression? J Affect Disord. 1992;24:281–90.PubMedCrossRefGoogle Scholar
  30. 30.
    Hellerstein DJ, Kocsis JH, Chapman D, et al. Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: effects on personality. Am J Psychiatry. 2000;157:1436–44.PubMedCrossRefGoogle Scholar
  31. 31.
    Gatchel RJ, Mayer TG, Eddington A. MMPI disability profile: the least known, most useful screen for psychopathology in chronic occupational spinal disorders. Spine. 2006;31:2973–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Applegate KL, Keefe FJ, Siegler IC, et al. Does personality at college entry predict number of reported pain conditions at mid-life? A longitudinal study. J Pain. 2005;6:92–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Malmgren-Olsson EB, Bergdahl J. Temperament and character personality dimensions in patients with nonspecific musculoskeletal disorders. Clin J Pain. 2006;22:625–31.PubMedCrossRefGoogle Scholar
  34. 34.
    Conrad R, Schilling G, Bausch C, et al. Temperament and character personality profiles and personality disorders in chronic pain patients. Pain. 2007;133:197–209.PubMedCrossRefGoogle Scholar
  35. 35.
    Greenberg J, Burns JW. Pain anxiety among chronic pain patients: specific phobia or manifestation of anxiety sensitivity? Behav Res Ther. 2003;41:223–40.PubMedCrossRefGoogle Scholar
  36. 36.
    Lethem J, Slade PD, Troup JDG, et al. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther. 1983;21:401–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Reis S. Expectancy theory of fear, anxiety, and panic. Clin Psychol Rev. 1991;11:141–53.CrossRefGoogle Scholar
  38. 38.
    Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317–32.PubMedCrossRefGoogle Scholar
  39. 39.
    Zvolensky MJ, Goodie JL, McNeil DW, et al. Anxiety sensitivity in the prediction of pain-related fear and anxiety in a heterogeneous chronic pain population. Behav Res Ther. 2001;39:683–96.PubMedCrossRefGoogle Scholar
  40. 40.
    Asmundson GJG, Norton PJ, Norton GR. Beyond pain: the role of fear and avoidance in chronicity. Clin Psychol Rev. 1999;19:97–119.PubMedCrossRefGoogle Scholar
  41. 41.
    McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain. 2003;106:127–33.PubMedCrossRefGoogle Scholar
  42. 42.
    Sansone RA, Sinclair JD, Wiederman MW. Borderline personality among outpatients seen by a pain management specialist. Int J Psychiatry Med. 2009;39:341–4.PubMedCrossRefGoogle Scholar
  43. 43.
    •• Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality. Innov Clin Neurosci. 2012;9(1):10–4. Comprehensively demonstrates the impact of borderline personality disorder on chronic pain.PubMedGoogle Scholar
  44. 44.
    Tragesser SL, Bruns D, Disorbio JM. Borderline personality disorder features and pain: the mediating role of a negative affect in a pain patient sample. Clin J Pain. 2010;26:348–53.PubMedCrossRefGoogle Scholar
  45. 45.
    Hasenbring M, Hallner D, Klasen B. Psychological mechanisms in the transition from acute to chronic pain: over- or underrated? Schmerz. 2001;15:442–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Severeijns R, Vlaeyen JW, van den Hout MA, et al. Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clin J Pain. 2001;17:165–72.PubMedCrossRefGoogle Scholar
  47. 47.
    Sullivan MJ, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17:52–64.PubMedCrossRefGoogle Scholar
  48. 48.
    Folkman S, Lazarus RS, Gruen RJ, et al. Appraisal, coping, health status, and psychological symptoms. J Pers Soc Psychol. 1986;50:571–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Jensen MP, Turner JA, Romano JM, et al. Coping with chronic pain: a critical review of the literature. Pain. 1991;47:249–83.PubMedCrossRefGoogle Scholar
  50. 50.
    Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality. Innov Clin Neurosci. 2012;9(1):10–4.PubMedGoogle Scholar
  51. 51.
    Waddell G, Newton M, Henderson I, et al. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157–68.PubMedCrossRefGoogle Scholar
  52. 52.
    Mannion AF, Muntener M, Taimela S, et al. A randomized clinical trial of three active therapies for chronic low back pain. Spine. 1999;24:2435–48.PubMedCrossRefGoogle Scholar
  53. 53.
    Mannion AF, Junge A, Taimela S, et al. Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy. Spine. 2001;26:920–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Vowles KE, Gross RT. Work-related beliefs about injury and physical capability for work in individuals with chronic pain. Pain. 2003;101:291–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Fordyce W, Fowler R, Lehmann J, et al. Operant conditioning in the treatment of chronic pain. Arch Phys Med Rehabil. 1973;54:399–408.PubMedGoogle Scholar
  56. 56.
    Prevedini AB, Presti G, Rabitti E, et al. Acceptance and commitment therapy (ACT): the foundation of the therapeutic model and an overview of its contribution to the treatment of patients with chronic physical diseases. G Ital Med Lav Ergon. 2011;33(1 Suppl A):A53–63.PubMedGoogle Scholar
  57. 57.
    Buchi S, Buddeberg C, Klaghofer R, et al. Preliminary validation of PRISM (Pictorial Representation of Illness and Self Measure) – A brief method to assess suffering. Psychother Psychosom. 2002;71:333–41.PubMedCrossRefGoogle Scholar
  58. 58.
    McCracken LM. Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain. 1998;74:21–7.PubMedCrossRefGoogle Scholar
  59. 59.
    Hayes SC, Strosahl K, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavior change. New York: Guilford; 1999.Google Scholar
  60. 60.
    Karaklic D, Bungener C. Course of borderline personality disorder: literature review. Encephale. 2010;36(5):373–9.PubMedCrossRefGoogle Scholar
  61. 61.
    Sansone RA, Sinclair JD, Wiederman MW. Disability and borderline personality in chronic pain patients. Pain Res Manag. 2010;15:369–70.PubMedGoogle Scholar
  62. 62.
    • Bellino S, Rinaldi C, Bozzatello P, Bogetto F. Pharmacotherapy of borderline personality disorder: a systematic review for publication purpose. Curr Med Chem. 2011;18(22):3322–9. One of the first articles to provide an overview of medication options in treating borderline personality disorder.PubMedCrossRefGoogle Scholar
  63. 63.
    Stoffers JM, Völlm BA, Rücker G, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012;15(8):CD005652.Google Scholar
  64. 64.
    Moen R, Freitag M, Miller M, et al. Efficacy of extended-release divalproex combined with “condensed” dialectical behavior therapy for individuals with borderline personality disorder. Ann Clin Psychiatry. 2012;24(4):255–60.PubMedGoogle Scholar
  65. 65.
    Rifkin A, Quitkin F, Carrillo C, et al. Lithium carbonate in emotionally unstable character disorders. Arch Gen Psychiatry. 1972;27:519–23.PubMedCrossRefGoogle Scholar
  66. 66.
    Stein DJ, Hollander E, Liebowitz MR. Neurobiology of impulsivity and the impulse control disorders. J Neuropsychiatry Clin Neurosci. 1993;5:9–17.PubMedGoogle Scholar
  67. 67.
    American Psychiatric Association, Practice guidelines for the treatment of patients with borderline personality disorder. Arlington, Virginia, 2001.Google Scholar
  68. 68.
    NICE. Borderline personality disorder: treatment and management. London: National Institute for Health and Clinical Excellence; 2009.Google Scholar
  69. 69.
    Rizvi SL. Treatment failure in Dialectical Behavior Therapy. Cogn Behav Pract. 2011;18:403–12.CrossRefGoogle Scholar
  70. 70.
    Bedics JD, Atkins DC, Comtois KA, et al. Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of dialectical behavior therapy versus nonbehavioral psychotherapy experts for borderline personality disorder. J Consult Clin Psychol. 2012;80(1):66–77.PubMedCrossRefGoogle Scholar
  71. 71.
    Gutteling BM, Montagne B, Nijs M, et al. Dialectical behavior therapy: is outpatient psychotherapy an effective alternative to individual psychotherapy? Compr Psychiatry. 2012;53:1161–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Vicki Kalira
    • 1
  • Glenn J. Treisman
    • 1
  • Michael R. Clark
    • 1
  1. 1.Department of Psychiatry & Behavioral SciencesJohns Hopkins MedicineBaltimoreUSA

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