Underlying Personality Disorders Can Complicate Chronic Pain Management

Understanding and addressing these disorders can improve the patient's mental health as well as their chronic pain and other comorbid conditions. Incorporating cognitive behavioral therapy and mindfulness-based cognitive therapy into the management of chronic pain has been shown to improve pain outcomes.

Pain syndromes are commonly associated with other comorbid conditions, including personality disorders. Understanding and effectively treating a patient’s underlying personality disorder can greatly improve pain control and outcomes.

During a morning session on the final day of the 2013 American Academy of Pain Medicine annual meeting, held April 12-14 in Fort Lauderdale, FL, Ravi Prasad, PhD, Stanford University Medical Center in Redwood, CA, provided an overview of personality disorders and explained how they can impact and complicate efforts to provide effective pain management. He said personality disorders typically begin in adolescence or young adulthood, and are associated with inflexibility and pervasiveness. Theses conditions are typically stable over time and lead to disturbances and impairment. Patients typically present with an evolving pattern of behavior, which differs from cultural norms.

Prasad discussed the different clusters of personality disorders, as outlined by the DSM IV. He said there are three clusters of personality disorders: cluster A, cluster B, and cluster C. Cluster A patients are typically “odd and have an eccentric presentation,” he said. Cluster A disorders include paranoid personality disorder, schizoid, and schizotypal. Individuals with paranoid personality disorder are typically distrusting, suspicious of others, and reluctant to confide but do not present with psychotic features. Individuals with schizoid presentation are detached from social situations and relationships and are commonly isolated and solitary. Individuals with schizotypal disorder do not like close relationships and have social anxiety. They typically question the loyalty of others but have magical thinking and can present with odd speech.

Prasad said cluster B patients are typically dramatic, emotional, and erratic. Disorders characterized as cluster B include antisocial, borderline, histrionic and narcissistic personalities. Individuals with an antisocial personality have a disregard for the law and safety. They can be deceitful, show a lack of remorse, and present with aggressive behavior. Individuals with borderline personality disorder have a fear of abandonment, commonly have instability in relationships, and are reckless, impulsive, and often engage in self mutilation. Individuals with histrionic personality types need to be the center of attention and commonly are very dramatic. They overvalue relationships and engage in seductive and provocative behavior. Individuals with a narcissistic personality are grandiose, arrogant, jealous, and aggressive. They commonly lack empathy and are excessive fanatics about power.

Cluster C patients are anxious and fearful upon presentation. Disorders characterized as cluster C include avoidant, dependent, and obsessive/compulsive. Individuals with an avoidant personality are fearful of rejection and engage in low-risk behaviors. They commonly feel inadequate and engage in avoidance behavior. An individual with a dependent personality has low self-confidence, constantly needs advice, and goes to extreme lengths for support. Individuals with obsessive/compulsive disorder are preoccupied with order and details. They are obsessed with perfectionism and inflexible and commonly rigid and miserly upon presentation.

Prasad said that many individuals exhibit some of these personality traits but do not meet enough criteria to be clinically classified as having a personality disorder. While drug therapy is an option for treatment of some of these personality disorders, Prasad said cognitive behavior therapy (CBT) is an effective option for patients. The foundation of CBT lies in being aware of thoughts and understanding how thoughts can influence behaviors. By encouraging patients to understand this, CBT aims to shift dysfunctional thoughts into more positive behaviors that provide for better outcomes in thinking and other comorbid conditions such as pain.

Beth Darnall, PhD, of Stanford University in Redwood, CA, further expanded on CBT and discussed how patients can self-manage pain by being aware of their thoughts, feelings, and behaviors. Darnall discussed recent studies that demonstrated the efficacy of CBT in improving pain, disability, mood, and catastrophizing.

Another option for treating pain and personality disorders is mindfulness mediation, which involves “paying attention on purpose,” in the present moment, without judgment. It is an acquired skill that focuses on everyday activities. There are different approaches to mindfulness mediation, including Zen meditation, mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT).

MBSR is typically done as a part of program that involves several weeks of treatment and includes a body scan, mindful yoga, sitting mediation, guided mindfulness recordings, and homework for mindfulness in daily activities. While this approach can be expensive, it has demonstrated improvements in attention, rumination, emotional activity, and self-compassion. It has also been associated with decreased blood pressure, improved immune function, reduced cortisol levels, and increased cognition. Darnall said MBSR is an excellent monotherapy for stress management but more effective as an adjunct to treatment for patients with anxiety, depression, and chronic pain.