by Larry Robins, MD
Patients with moderate-to-severe personality disorders (PD) Are frequently seen in medical practices. It is increasingly important to recognize, limit and manage those with aggressive types of PD. Likewise, it is crucial to recognize those who fit the bipolar spectrum. In particular, the mild end of the spectrum is often missed. The clinical stakes for missing bipolar are enormous, as these patients tend to bounce from antidepressant to antidepressant, with predictably poor results. This article delves into recognition and management of patients whose pain treatment is complicated by psychological concerns.
Personality Disorders at a Clinic
Consider the following scenario: a 28 year old man, Bill, presents to the pain clinic with severe low back pain. He seems angry on the first visit and is very demanding with the front office staff. Bill tells the staff he is mistrustful of physicians. He openly states to the doctor, “I will go back to work when you give me the right amount of drugs that help take away my pain.” Bill is upset with his last two health providers.
Over the next few months, the clinic staff bends over backwards for Bill, even though at times he is verbally abusive to the staff with a sense of entitlement. This is demonstrated in instances such as when he calls and tells the staff: “I want to talk to Dr. Smith NOW, put me through!” The staff, out of fear, jumps and does what he orders. His behavior is manipulative. The physician feels as though he is in a subservient position, trying to appease Bill and end the confrontations.
When the physician recommends that Bill be evaluated by a psychotherapist, Bill laughs at the idea and refuses. Suddenly, after nine months of treatment, Bill is suddenly blaming the physician and clinic for all of his difficulties including his pain, obesity, and sexual dysfunction. Bill threatens to sue the clinic and reports the doctor to the state regulatory office. What happened here?
Bill was subsequently diagnosed with a paranoid personality disorder. The clinic employees did not recognize him as having that diagnosis and failed to set limits on Bill’s behavior. The disruptions in the usual activities of the clinic, the increased stress on the staff, and the monopolization of clinician time are difficult to quantify. In the remainder of this article features of personality disorders that should help with identification are discussed. Optimal care and management of the disorder begins with recognition.
Approximately 10-12% of people in the general population have features of a personality disorder.1 There are a number of personality disorders, and some are more serious and difficult to treat than others. In general, characteristics of personality disorders include: lack of insight, poor response to psychotherapy or other therapeutic interventions, difficulty with attachments and trust, a sense of entitlement, and chaotic relationships and distress with family, friends and co-workers. Comorbid personality disorder with substance abuse is common.
Personality disorders range from mild to very severe and patients with such disorders may take on different roles, including victim, rescuer or persecutor. When the persecutor role is assumed, the person who is the target may be in danger. Seeing a therapist for a long period of time, perhaps 5-7 years, can help to some degree. However, goals and expectations must be limited. Considering the plasticity of the brain is important, as some people can improve naturally over time, particularly among younger patients. The following section describes some of the more severe personality disorder types. However, many people do not fit neatly into any of these single categories, because they have features of two or three different personality disorders.
Paranoid Personality Disorder. People who are diagnosed with paranoid personality disorder tends to be non-trusting, suspicious, related to seeing the world as dangerous. They may seem secretive and reluctant to confide in others. In relationships, they view themselves as being constantly mistreated, doubt the loyalty of everybody around them, and believe they are being exploited or harmed. Patients diagnosed with this disorder bear severe grudges against others, often, become angry easily and have a sense of entitlement. People with paranoid personality disorders can become violent and dangerous, with many spree killers being diagnosed with paranoid personalities. Several notorious world leaders, including Joseph Stalin and Saddam Hussein, were most likely paranoid personalities.2
Antisocial Personality Disorder. People diagnosed with antisocial personality disorder characteristically have no regard for the rights of others. In demeanor, they tend to be irritable, impulsive, and exploitative. They tend to, see themselves as better or superior, and can be very opportunistic in getting what they want. People with this disorder have characteristics of being deceitful, stealing from people around them, and often having trouble with the law. They frequently engage in fraudulent activities and may be successful as scam artists. For example, a person with this disorder may take on the role of financial savior for a church, then end up stealing everything from the church. Generally, people with this disorder have no remorse for their actions. Conduct disorder in a child often morphs into antisocial personality disorder. Examples include fictional character Tony Soprano on the television show, and, in real life, the mafia’s “Dapper Don,” John Gotti.2
Borderline Personality Disorder (BPD). Characteristics of people with borderline personality disorder are instability of mood, poor self-image, pervasive abandonment fears, identity disturbance and major boundary issues. People with borderline personality disorders usually demonstrate impulsiveness, and very quick shifts from depression to anxiety to irritability. They usually have chronic feelings of emptiness or severe loneliness, plus anger volatile tempers and even suicidal behavior. Under stress, they can become somewhat paranoid. Coexisting problems with substance abuse or other addictive behaviors may occur, as well as sleep disorders with severe insomnia. People with severe borderline personality disorders will react with high drama and create chaos for everybody around them. They tend to have a split world view, which is, they see people as wonderful or terrible, with nothing in between. Borderline personality disorders can vary from mild to severe, nd become better or worse over time. Suicide becomes more likely as patients age into their upper twenties and thirties.3 Suicide is also more common within a week of discharge from a psychiatric unit. Examples of people reportedly diagnosed with borderline personality disorder include Adolph Hitler, Marilyn Monroe, and Glenn Close’s character Alex, in the movie, “Fatal Attraction.”
Narcissistic Personality Disorder. Narcissistic personality disorder is less common than those previously discussed and is typified by a personality in which the person sees him or herself as superior to others. People with this personality have characteristics of grandiosity, being vain, requiring admiration, lacking empathy, having a deep sense of entitlement, having strong belief of self-importance and acting to support those feelings of self-importance. They characteristically have behaviors which are envious, arrogant, exploitative, and can be very angry. Examples might include General George Patton, Nicole Kidman’s character in the movie, “To Die For,” Michael Douglas’ character, Gordon Gekko, in the movie, “Wall Street.”2
There are a number of other personality disorders which are not as dangerous for the people around them or for health care providers. Even though PD characteristics may seem extreme, they are often overlooked, and health care clinics may react by reacting to and treating these patients in a dysfunctional manner. The difficulties begin with not recognizing the personality disorder.
Pain and Personality Disorders
One study on people with borderline personality (BPD) concluded that BPD comorbidity with migraine is associated with increased disability from the headaches.4 In addition, in that study those people diagnosed with BPD, were more severely affected by headaches; more inclined to be refractory to treatment; had increase in medication overuse headache; headaches were more pervasive; there was a higher degree of depression; , more unscheduled visits for acute headache treatment; and less chance of adequate response of headache medications..4
Another study indicated the incidence of BPD was increased in migraineurs.5 My recent study of 1000 migraineurs indicated that 5.5% of patients had a moderate or severe personality disorder.6 There is ample evidence that transformed migraine is associated with more prevalent psychopathology, including personality disorder, than is episodic migraine. BPD can be considered the mental health equivalent of chronic pain. In my experience, the two most important prognostic indicators for those with PD are impulsivity and substance abuse.
Treatment for those with PD necessitates a caring, but stern, approach. Limits must be set on clinician contact, including telephone calls. Abuse of staff should not be tolerated. Referral to other health care providers, particularly mental health professionals, should be suggested. Psychotherapists and psychiatrists who are experienced with this population are vital if the patient is to be adequately managed. Many of the PD patients do not do well with traditional, insight-oriented therapy treatment, but are better managed long-term with dialectical behavioral approach. For a therapy to be beneficial, it must be consistent and long-term. A psychoeducational approach may also help. Unfortunately, even with encouragement and support many PD patients will not continue in therapy. Therapeutic goals for the PD patient are relatively modest.
It is easy to become drawn into the drama surrounding patients with PDs, particularly those with BPD. The patient with BPD may grant the clinician power, but then subvert the therapy. An example of this would be, “Doctor, you are the greatest, only you can help me. These headaches ruin my life, ….and I know that nothing is going to work!” Some clinicians are able to manage working with these patients without becoming involved in the drama and countertransference, but most do not do well working with them. If there are signs of a dangerous PD (i.e. abuse and anger being demonstrated), during the first visit or phone call to the clinic), rather than becoming enmeshed in the relationship, is better to refer the patient to someone experienced in working with patients with PD.
There are risks inherent in caring for people who are diagnosed with personality disorders. As compared to the general population, those with BPD are at increased risk for suicide, particularly as they progress into middle age. Identifiable risk factors for suicide among BPD patients include repeated hospitalizations (i.e. five or more), a recent psychiatric hospitalization, and, among adolescents, birth trauma.3 Certain types of PD (i.e. paranoid, narcissistic, antisocial and borderline) are more likely to become angry and vengeful with health care providers working with them; resorting to lawsuits or writing letters to the departments of regulation. Violence may be threatened. A patient with PD often presents as a victim, and then rapidly flips into the role of persecutor. Anger among these patients becomes intently focused, creating a stressful environment for healthcare workers. Setting limits and keeping careful documentation are important in these situations.
It does take a village to help a patient with a personality disorder, just as it does to adequately treat those with severe pain. It is important to recruit other clinicians, such as mental health providers, physical therapists, biofeedback therapists, etc., to aid in the treatment.
While there are no specific medications indicated for those with PD, the Axis I symptoms are more amenable to pharmacotherapy. Medications, though limited, may be beneficial for the impulsivity, aggression, self-mutilation, anxiety and depression components of PD.7 Antidepressants, mood stabilizers, and antipsychotics may ameliorate symptoms. Some of these medications may also lessen headache pain as well. PD patients with severe, chronic pain present additional challenges for treatment. It is important to limit and closely monitor addictive medications. Particularly with BPD, opioids and benzodiazepines are best avoided. The diagnosis of a moderate or severe personality disorder alters both goals and approach for pain management.
For patient care, it has become increasingly important to recognize those patients whose psychiatric problems complicate their treatment in a pain clinic. Patients with a personality disorder are more likely to abuse drugs, file lawsuits, or display abusive behavior toward the staff. With personality disorders, setting limits is vital.
Treating patients with chronic pain can be complex and challenging enough. When their patients who live with chronic pain also have psychological comorbidities, it is vital that the psychopathology be effectively attended to, as well as the pain.
- Lester G. Personality Disorders in Social Work and Health Care. Nashville: Cross Country University Press; 2002:28-79.
- Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:24-25.
- Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:15-19.
- Rothrock J, et al. Borderline Personality Disorder and Migraine. Headache. 2007; 47:22-26.
- Hegarty AM. The prevalence of migraine in borderline personality disorder. Headache.1993;33:271.
- Robbins L. The prevalence of personality in migraineurs. US Neurological Disease, 2007, Vol.4, Issue I.
- Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:88-91.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition. Washington D.C. American Psychiatric Association: 1994.
- Akiskal HS. Classification, diagnosis and boundaries of bipolar disorders. Bipolar Disorder. Edited by Maj M, Akiskal H, Lopez-Ibor J et al. London, Wiley, 2002, pp 1-52.
- Merikangas KR, et al. Comorbidity of migraine and psychiatric disorders. Neurol Clin. 1997;15:115-123
- Baskin SM, et al. Mood and anxiety disorders in chronic headache. Headache. 2006;46(suppl 3):S76-S87.
- Robbins L. Bipolar spectrum in Migraine, Cluster and Chronic Tension Headache. US Neurological Disease, 2007, Vol. 3, Issue II.
- McIntyre RS, et al. The prevalence and impact of migraine headache in bipolar disorder: Results from the Canadian community health survey. Headache. 2006;46:973-982.
- Low NC, et al. Prevalence, clinical correlates and treatment of migraine in bipolar disorder. Headache. 2003;64:53-59.
- El-Mallakh, et al. Antidepressants in bipolar depression, in El-Mallakh R, Ghaem S. Bipolar Depression. Washington DC, American Psychiatric Publishing, Inc.; pp149-153.
- Calabrese J, et al. A randomized, double-blind, placebo-controlled trail of quetiapine in the treatment of bipolar I or II depression. AM J Psychiatry. 2005;162:1351-1360.