Patients living with intractable pain may present with a particular personality profile that requires a unique assessment and treatment approach under the DSM-5.

Personality traits may be described as enduring patterns of perceiving, relating to, and thinking about the environment and oneself that may be exhibited in a wide range of social and personal contexts. When these traits are inflexible, maladaptive, and lead to significant functional impairment or subjective distress, they constitute personality disorders.1 Personality disorders are defined as qualitatively distinct clinical syndromes, and previous diagnostic manuals of the American Psychiatric Association (APA), such as the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), only used a categorical perspective in diagnosis. For example, the DSM-IV categorized personality disorders as paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, or obsessive-compulsive. In the APA’s new DSM-5,2 personality disorders represent maladaptive variants of personality traits that merge subtly into normality and into one another and are approved as an alternative, trait-specific, dimensional model. Thus, personality disorders are included in Section II, which features the same criteria found in DSM-IV, and Section III, which offers a research model.2

The essential feature of a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control.2 This article provides an update to assessing and diagnosing these disorders, including an overview of such personality types among the chronic pain population.

Personality Disorder Prevalence

Research suggests that between 9.1% and 15% of adults in the United States have at least one personality disorder,3,4 and individuals frequently present with co-occurring personality disorders from different clusters. The three personality disorder clusters, all based on descriptive similarities, include:

Cluster A: Odd-eccentric (5.7% prevalence), which includes paranoid, schizoid, and schizotypal personality disorders

Cluster B: Dramatic-emotional (1.5% prevalence), which includes antisocial, borderline, histrionic, and narcissistic personality disorders

Cluster C: Anxious-fearful (6.0% prevalence), which includes avoidant, dependent, and obsessive-compulsive personality disorders.4

See Table I for further detail. It should be noted that this old clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated.2

The Pain Subpopulation

In the chronic pain population, the rate of personality disorders ranges between 30% and 60%.5-9 One study reported that 51% of patients with chronic pain met criteria for one personality disorder, and 30% met criteria for more than one.7 Another study found that 60% of persons with chronic pain met diagnostic criteria for a personality disorder, in contrast to research findings that 21% of patients with acute low back pain met diagnostic criteria.10

Typically, personality disorders are considered to predate the onset of injury and may complicate the course of a pain syndrome.11 Researchers have further noted that a significant number of persons with chronic pain syndromes specifically meet criteria for the Cluster C (anxious-fearful) personality disorders (eg, dependent with 10.6% prevalence and obsessive-

compulsive with 24.5% prevalence).6,11,12 There is also evidence to suggest there are high levels of prevalence of Cluster B (dramatic-emotional) personality disorders in the chronic pain population.9 The range of borderline personality disorder specifically in the chronic pain population ranges between 9.4% to 58%, with an average of about 30%.1,8 See Table I for detailed rates.6

A History of the Pain Personality

Since the time of Aristotle, philosophers have noted the interaction between sensation and emotion.9 Patients with personality disorders have a tendency to overreact to stress, including disease, in the characteristic pattern of their personality disorder.6 Personality type characteristics are accentuated by the medical condition, in this case, chronic pain. Therefore, these characteristics present predictable behavioral management problems.6 Over the past few decades, several theories have been proposed about personality in the chronic pain population.13

The first theory, by Engel in 1959,13 took a psychodynamic perspective. He postulated that underlying emotional conflicts shape personality features that inhibit the expression of emotional pain in an appropriate way. The next theory grew out of a trait approach, which focused on the objective and scientifically sound measurement of stable personality traits.13 Researchers found that a large subgroup of pain patients with chronic pain typically scored the “conversion-v” pattern, that is, elevation of the first three scales (Scale 1: Hypochondriasis, Scale 2: Depression, and Scale 3: Hysteria), of the Minnesota Multiphasic Personality Inventory (MMPI-2).13

With the advent of the biopsychosocial approach in the 1980s, the diathesis-stress model dominated the field. The model accentuates the interplay between an individual’s biological predisposition and the impact of the environment, such as stressors as a result of physical damage, to explain different responses to chronic pain. 13 Cloninger’s temperament and character model is the latest theory to be proposed. 13

Cloninger’s model builds off of the diathesis-stress approach and further differentiates between temperament and character. Temperament is defined as the emotional core of personality and presumed to be moderately inherited, while character describes the cognitive core of personality and is presumed to be influenced by the environment. The Cloninger model views personality along a continuum rather than applying a categorical approach. This take reflects the proposed research model for personality disorder diagnosis and conceptualization presented in the DSM-5.2

In fact, research using Cloninger’s proposal has portrayed a common personality profile of chronic pain. Personality symptoms of Cluster A have been found to be related to low reward dependence; Cluster B to high novelty seeking; and Cluster C to high harm avoidance.5 For example, pain symptoms may function as an interpersonal means of eliciting caring responses from others in patients with borderline personality disorder.8 Overall, patients with chronic pain are characterized by prevailing harm avoidance and lower self-directedness.13,14

Assessing for Personality Disorders in Today’s Pain Population

Personality disorders have traditionally been diagnosed by a mental health clinician after a single or series of patient interviews.15 Semi-structured interviews, which consist of questions asked in a specific order, may also be used.15 Assessment may be complicated by the fact that the characteristics that define a personality disorder may not be considered problematic by the individual. To help overcome this difficulty, supplementary details from other informants may be helpful.15

Some of the more widely used personality self-report measures are the Myers-Briggs Type Indicator, Neo Personality Inventory-Revised, 16-Personality Factor, Million Clinical Multiaxial Inventory, the Schedule for Nonadoptive and Adaptive Personality, the Temperament and Character Inventory, and the Eysenck Personality Questionnaire. In addition to self-report inventories, there are many other methods for assessing personality, including observational measures, peer-report studies, and projective tests, such as the Thematic Apperception Test or ink blots (Rorschach).

The most widely used objective test of personality is the MMPI-2, originally designed to distinguish individuals with different psychological problems. A strength of the MMPI-2 is that it offers an additional psychometric property: validity (ie, correction scales that adjust for a person’s tendency to lie, deny, or exaggerate test responses). The MMPI-2 is also well normed, extensively researched, and provides data about the patient’s test-taking approach. However, since the MMPI-2 is not normed on pain patients and Scales 1 through 3 are often elevated in this subpopulation, proper assessment requires a highly skilled evaluator to interpret the test results.13 The best practice for a frontline practitioner would be to screen those patients who might meet criteria for a personality disorder.

The DSM-5 includes a self-rated, level 1 cross-cutting symptom measure that involves screening questions for personality disorders.2 The two questions are: “Do you not know who you really are or what you want out of life?” and “Do you not feel close to other people or enjoy your relationships with them?” An affirmative answer to both questions may indicate that the patient has a personality disorder and might benefit from further assessment by a psychologist or psychiatrist.

Standard Treatments

Personality disorders are deeply ingrained in both genetics and childhood, and have long been believed to be difficult to treat, especially among the Cluster B personality types.16 Standard treatment typically includes combined psychotherapy and pharmacotherapy.17 Medication management is somewhat controversial in the treatment of personality disorders as there are no medications specifically approved by the FDA to treat these conditions.18 Prescribers therefore use medication to reduce other comorbid symptoms, such as anxiety, depression, or psychosis, and not to manage the personality disorders. Despite the lack of endorsement, serotonergic antidepressants, such as selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, and tricyclic antidepressants may be used.19

Social Skills

Cluster A and Cluster C personality disorders have been shown to respond most positively to social skills training and medication management. Some disorders, especially those that involve psychosis, may interfere with the sufferer’s ability to understand and read other people’s behaviors and feelings, and respond appropriately. Social skills training is often conducted in groups, but can be facilitated individually as a brief, targeted, educational treatment.

Dialectical & Cognitive Behavior Therapies

Borderline type is perhaps the most researched personality disorder within Cluster B. A recent study indicated that 75% of borderline personality disordered patients showed great improvements in their symptoms 18 months after treatment ended.20 The treatment with the strongest research support is dialectical behavior therapy (DBT).21 This therapy takes a cognitive-behavioral approach that increases the patient’s ability to moderate between his/her intense emotions and actions. Its focus includes a combination of mindfulness, interpersonal skills, distress tolerance, and emotion regulation.21

More specifically, cognitive-behavioral therapy (CBT) for chronic pain aims to diminish misinterpretation of nociception, enhance self-efficacy, and lesson avoidance.13 Past research has shown CBT to be highly efficacious in the treatment of chronic pain.22-27 The model is grounded on the notion that pain is a complex experience influenced by its underlying pathophysiology and the individual’s cognitions, affect, and behavior.28 CBT for pain has three components: a treatment rationale, coping skills training, and the application and maintenance of learned coping skills.29 The goals of CBT are to reduce the impact pain has on the patient’s daily life; learn skills for coping better with pain; improve physical and emotional functioning; and reduce pain without reliance on pain medication.

Mentalization and Schema Approaches

Mentalization-based treatment (MBT) and schema-focused therapy (SFT) also have modest research support for the treatment of borderline personality disorder.21 MBT is a form of psychodynamic treatment that aims is to teach the patient how to “mentalize,” or picture/imagine what others are feeling in response to his/her behavior.21 SFT challenges the maladaptive “schemas,” or beliefs/feelings, that the patient may have learned in childhood. SFT also has been shown to be effective for other Cluster B disorders, such as antisocial and narcissistic personalities.21

Summary

Overall, research findings demonstrate that chronic pain is more associated with a particular personality profile then originally expected. Different types of pain are associated with very similar psychosocial states as discussed in this PPM Mental Health series. If the proposition that the nature of the sensory pain experience is not relevant in the psychological experience of pain, then perhaps there may be a mutual personality pain profile as introduced by Cloninger’s temperament and character model.14

Physicians and specialists treating patients with chronic pain may therefore consider shifting from targeting the sensory and psychological state to focusing on the psychological trait, which is a discussion that goes beyond the current scope of this article.

The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs or any other governmental agency.

Read a followup Letter to the Editor regarding this column.

Last updated on: March 4, 2018

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