Category Archives: Policy

Personality and Pain: Which Came First?

James N. Weisberg, PhD

This article is adapted from a chapter in a soon to be published text:
Weisberg, J.N., Paul, C. & Twyner, C. Personality and Personality Disorders in Chronic Pain.  In Incayawar, M., Clark, M. & Maldonado-Bouchard, S. (Eds.). Overlapping Pain and Psychiatric Syndromes-Global Perspectives. New York, NY: Oxford University Press

Chronic pain is a significant health care issue at epidemic proportions in the United States1 and there is a high incidence of both clinical psychiatric disorders2,3 and personality disorders (PD) in the chronic pain population.4 This article will briefly summarize some of the important points pertaining to the prevalence and interplay between personality disorders and chronic pain.

Personality and Pain

The relationship between personality and pain can easily be traced to ancient Greece. More recently, in the late 19th century psychodynamic theorists discussed the connection between emotional factors and the experience of chronic pain.5 George Engel maintained that, while physical pain may result from underlying pathophysiology, the interpretation of pain is a psychological phenomenon and also noted that certain diagnoses, including Depression, Hysteria and Hypochondriasis were relatively common in people experiencing chronic pain.6 In an attempt to further characterize personality characteristics, the use of Minnesota Multiphasic Personality Inventory (MMPI)7 and its successors (MMPI-2, MMPI-2-RF) led to a plethora of research seeking to use psychometric tests quantify these early theorists, help predict treatment outcome from multidisciplinary treatment8, spine surgery9, spinal cord  stimulators10as well as  and pain-related disability11.  However, despite the hundreds of studies using the MMPI and its successors, there continues to be controversy regarding the applicability and appropriateness of in the chronic pain population.12,13

A number of other psychological inventories have been used in an attempt to describe and characterize individuals with chronic pain and to predict treatment outcomes. Some, but not all of these measures include the NEO Personality Inventory (Neuroticism-Extroversion-Openness Personality Inventory-NEO-PI) and its revisions,14-16 the Millon Clinical Multiaxial Inventory and subsequent revisions (MCMI; MCMI-IV)17,18 and the Temperament and Character Inventory (TCI).19

While psychological inventories have investigated different personality characteristics as they relate to pain, relatively few studies have investigated personality disorders in chronic pain. 

Personality Disorders and Chronic Pain

Whereas personality refers to the constellation of non-pathological characteristics in an individual’s patterns of thought, emotion, and behavior the DSM defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”20 Thus, the essential difference between a trait and disorder is the degree of distress and disruption caused.

Personality and personality disorders are likely the combination of biological, developmental, and environmental factors that become impacted by state-dependent variables such as mood and anxiety. The Diathesis-Stress model purports that individuals have underlying genetic vulnerabilities and possibly early life experiences that interact with stressors the individual encounters later in life.21  Depending on the nature of the stressors and the individual’s ability to cope with such stressors, the underlying vulnerability may or may not become expressed as a disease process. The diathesis-stress model was first applied to explain schizophrenia21 and depression.22  It has also been applied to the development of chronic back pain23 and the development of depression in chronic pain patients.2 Similarly, this model has been proposed to apply to personality disorders in chronic pain patients.24 Thus, combined with underlying traits and situational stressors brought on by chronic pain, an individual’s underlying personality traits and characteristics may become magnified to the extent the individual meets criteria for a personality disorder.

Epidemiology of Personality Disorders:

In its most recent edition, the American Psychiatric Association cites data from a national epidemiologic survey suggesting approximately 15% of US adults meet criteria for at least one personality disorder.25 A large epidemiological study found prevalence estimates for the different clusters suggest 5.7% for disorders in Cluster A (Paranoid, Schizotypal and Schizoid Personality Disorder), 1.5% for disorders in Cluster B (Histrionic, Narcissistic and Borderline Personality disorders),  6.0% for disorders in Cluster C (Avoidant, Dependent, Obsessive-Compulsive Personality Disorders), and 9.1% for any personality disorder, indicating frequent co-occurrence of disorders from different clusters.26

To date, approximately 15 studies have investigated the prevalence of personality disorders in chronic pain.  Some of the more seminal studies are highlighted here.  The first published study using a semi-structured interview to diagnose DSM-III personality disorders in chronic pain found 37% of their sample met criteria for at least one personality disorder with the most common diagnoses being histrionic PD (14%), dependent PD (12%) and borderline PD  (7%).27  Fishbain et al,28 using a semi-structured interview to diagnosis both DSM-III axis I and Axis II disorders, found 59% of their chronic pain sample met criteria for a personality disorder with most common diagnoses being dependent PD (17%), Passive-Aggressive PD (15%) and histrionic PD (12%).   Weisberg et al29 used a combination of clinical interview, treatment notes and both patient and family self-report measures to assess personality disorders in 55 chronic pain patients who were evaluated and treated at a comprehensive outpatient pain management program. They found that 31% met criteria for at least one PD and an additional 27% met criteria for PD-NOS which is used when an individual meets incomplete criteria for two or more personality disorders.  Similar to other studies, the most common diagnoses were borderline PD (13%) and dependent PD (11%).  These researchers suggest that obtaining longitudinal information from both the patient and an individual with a longstanding relationship with the patient might provide a more thorough assessment of the impact of state factors such as mood, anxiety, and stress on the presentation of personality.29 More recently, Conrad et al30 found that 41% of their chronic pain sample met criteria for a personality disorder diagnoses compared to 7% of their control group.  Most common were Borderline PD (11%) and paranoid PD (12%). The authors found clinical disorders, such as depression at a equally high rate, lending more credence to the importance of assessing personality in context of state factors.

In summary, the relatively few studies that have investigated personality disorders in various samples of patiens with  chronic pain have found prevalence rates from 31% to over 80%. However, as has been noted by previous researchers, due to a variety of factors including state-dependent variables, stressors unique to chronic pain, genetic and developmental influences and other known and unknown factors, significant caution must be used when making a personality disorder diagnosis in the individuals with chronic pain.  In addition, knowing premorbid functioning is crucial in understanding the multifactorial nature of the observed behavior.  Nontheless, the presence of a personality disorder increases the liklihood of co-morbid conditions, such as substance misuse and abuse and makes treatment of chronic pain that much more challenging to the pain clinician.

The Nexus of Personality Disorders in Chronic Pain and Substance Use Disorders:

There has also been a paucity of research on the interaction between personality disorders and substance use disorders in chronic pain.  One study investigated psychological comorbidities, including personality disorders, in chronic pain sufferers presenting to either a university emergency department or an urgent care clinic requesting opioids.31 Pertinent results demonstrated 18% likely had a personality disorder diagnosis and found that personality disorder was significantly related to opioid abuse.31 A recent study found the incidence of personality disorders to be 52% in those with co-occurring chronic pain and substance use disorders.32 The most common personality disorder was antisocial PD (22%) followed by avoidant PD (19%) and paranoid PD (16%). Although there is little literature on this topic, both of these studies suggest that personality disorders may be a moderating variable in the incidence of substance use disorders in persons with chronic pain.                                                                                                                                         

Treatment of Personality Disorders in Chronic Pain

While working with people living with either chronic pain or personality disorders can prove to be daunting to the clinician separately, working with those with the co-morbid diagnoses of both personality disorders and chronic pain can pose unique challenges and opportunities in regard to treatment. Although maladaptive behaviors are, by definition, problematic in a variety of settings, legitimate concerns may be disregarded as secondary to the manifestations of personality disorders or simply attributed to being “difficult.”

The need for the pain clinician to screen for personality disorders is rooted in the understanding that the manifestations of a personality disorder in a person living with chronic pain can be exacerbated or unmasked by the individual’s pain condition according to the diathesis-stress model.24  In addition, the need for vigilance and awareness with these conditions is considerable as these patients are at higher risk for various adverse outcomes, including substance use disorders. 31 Attempting to detangle the personality disorder from the chronic pain state with the goal of treating one or the other may be difficult at best.

Cognitive-Behavioral Therapy for chronic pain (CBT-CP) has been well documented in the literature to be one of the most effective treatments for chronic pain.33-35 Acceptance and Commitment Therapy (ACT)36, has been shown to benefit patients with personality disorders that had failed in previous treatment with significant improvements in personality pathology and quality of life.37 ACT for chronic pain has also been effective at decreasing pain intensity, anxiety, and disability38 The use of CBT-CP and ACT may be a potential avenue for treatment, but research designed to investigate these interventions among people with coexisting chronic pain and personality disorders is lacking.

Dialectical Behavior Therapy (DBT), a current mainstay of treatment of borderline personality disorder, focuses on the development of coping skills with the ultimate goal of improving emotional regulation and control.39 However, as with other therapeutic modalities, there is minimal evidence for treatment for DBT in those with chronic pain and comorbid personality disorders.

Given the common elements between Cognitive-Behavioral Therapy and Dialectical Behavior Therapy, it stands to reason that a hybrid model combining elements of both CBT-CP with DBT might be a highly successful approach to maximizing treatment potential in patients with co-morbid chronic pain and personality disorders, especially borderline personality disorder.

Summary: 

In summary, it is important to assess patients not just for depression, anxiety and other clinical psychiatric disorders, but for personality traits and disorders in order to better understand the impact personality may have on the expression of their pain perception, medication use and coping styles.  Understanding the role personality disorders may play in the complexities of chronic pain should result in the tailoring of multimodal treatments for chronic pain that emphasize non-opioid medical management, cognitive-behavioral and physical therapies.

References

  1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC)2011.
  2. Banks SM, Kerns RD. Explaining the high rates of depression in chronic pain: A diathesis-stress framework. Psychological bulletin. 1996;119(1):95-110.
  3. McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain. 2003;106(1-2):127-133.
  4. Weisberg JN. Personality and personality disorders in chronic pain. Curr Rev Pain. 2000;4(1):60-70.
  5. Breuer J, Freud S. Studies on hysteria. Original work published 1893-1895 ed. New York, NY: Basic Books; 1957.
  6. Engel GL. Psychogenic pain and pain-prone patient. Am J Med. 1959;26(6):899-918.
  7. Hathaway SR, McKinley J. Minnesota Multiphasic Personality Inventory. Minneapolis, MN: University of Minnesota Press; 1943.
  8. Kleinke CL, Spangler AS, Jr. Predicting treatment outcome of chronic back pain patients in a multidisciplinary pain clinic: methodological issues and treatment implications. Pain. 1988;33(1):41-48.
  9. Block AR, Ohnmeiss DD, Guyer RD, Rashbaum RF, Hochschuler SH. The use of presurgical psychological screening to predict the outcome of spine surgery. The Spine Journal. 2001;1(4):274-282.
  10. Block AR, Marek RJ, Ben-Porath YS, Kukal D. Associations Between Pre-Implant Psychosocial Factors and Spinal Cord Stimulation Outcome: Evaluation Using the MMPI-2-RF. Assessment. 2017;24(1):60-70.
  11. Gatchel RJ, Polatin PB, Mayer TG. The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine. 1995;20(24):2702-2709.
  12. Fishbain D, Cole B, Cutler R, Lewis J, Rosomoff H, Rosomoff R. Chronic pain and the measurement of personality: Do states influence traits? Pain Medicine. 2006;7(6):509-529.
  13. Turk DC, Fernandez E. Personality assessment and the minnesota multiphasic personality inventory in chronic pain: underdeveloped and overexposed. Pain Forum. 1995;4(2):104-107.
  14. Costa PT, McCrae RR. The NEO Personality Inventory Manual. Orlando, FL: Psychological Assessment Resources; 1985.
  15. Costa PT, McCrae RR. Revised NEO Personality Inventory (NEO–PI–R) and NEO Five-Factor Inventory (NEO–FFI) professional manual. Odessa, FL: Psychological Assessment Resources; 1992.
  16. McCrae RR, Costa PT, Jr., Martin TA. The NEO-PI-3: a more readable revised NEO Personality Inventory. J Pers Assess. 2005;84(3):261-270.
  17. Millon T. Millon Clinical Multiaxial Inventory. Minneapolis, MN: National Computer Systems; 1977.
  18. Millon T, Grossman S, Millon C. Millon Clinical Multiaxial Inventory-IV: MCMI-IV. Bloomington: NCS Pearson; 2015.
  19. Cloninger C, Svrakic, DM., Przybeck, TR. A psychobiological model of temperment and character. Archives of general psychiatry. 1993;50:975-990.
  20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: Author; 2013.
  21. Meehl PE. Schizotaxia, schizotypy, schizophrenia. American Psychologist. 1962;17:827-838.
  22. Monroe SM, Simons AD. Diathesis-stress theories in the context of life stress research: implications for the depressive disorders. Psychological bulletin. 1991;110(3):406-425.
  23. Flor H, Turk DC. Etiological theories and treatments for chronic back pain. I. Somatic models and interventions. Pain. 1984;19(2):105-121.
  24. Weisberg JN, Keefe FJ. Personality disorders in the chronic pain population: Basic concepts, empirical findings, and clinical implications. Pain Forum. 1997;6(1):1-9.
  25. Grant BF, Hasin DS, Stinson FS, 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. 2004;65(7):948-958.
  26. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological psychiatry. 2007;62(6):553-564.
  27. Reich J, Tupin JP, Abramowitz SI. Psychiatric diagnosis of chronic pain patients. Am J Psychiatry. 1983;140(11):1495-1498.
  28. Fishbain DA, Goldberg M, Meagher BR, Steele R, Rosomoff H. Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain. 1986;26(2):181-197.
  29. Weisberg JN, Gallagher RM, Gorin A. Personality disorder in chronic pain: A longitudinal approach to validation of diagnosis. Paper presented at: 15th Annual Scientific Meeting of the American Pain Society; November 1996, 1996; Washington, DC.
  30. Conrad R, Schilling G, Bausch C, et al. Temperament and character personality profiles and personality disorders in chronic pain patients. Pain. 2007;133(1-3):197-209.
  31. Wilsey BL, Fishman SM, Tsodikov A, Ogden C, Symreng I, Ernst A. Psychological comorbidities predicting prescription opioid abuse among patients in chronic pain presenting to the emergency department. Pain Medicine. 2008;9(8):1107-1117.
  32. Barry DT, Cutter CJ, Beitel M, Kerns RD, Liong C, Schottenfeld RS. Psychiatric Disorders Among Patients Seeking Treatment for Co-Occurring Chronic Pain and Opioid Use Disorder. J Clin Psychiatry. 2016;77(10):1413-1419.
  33. Majeed MH, Sudak DM. Cognitive Behavioral Therapy for Chronic Pain-One Therapeutic Approach for the Opioid Epidemic. J Psychiatr Pract. 2017;23(6):409-414.
  34. Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153-166.
  35. Knoerl R, Lavoie Smith EM, Weisberg J. Chronic Pain and Cognitive Behavioral Therapy: An Integrative Review. West J Nurs Res. 2016;38(5):596-628.
  36. Cederberg JT, Cernvall M, Dahl J, von Essen L, Ljungman G. Acceptance as a Mediator for Change in Acceptance and Commitment Therapy for Persons with Chronic Pain? Int J Behav Med. 2016;23(1):21-29.
  37. Chakhssi F, Janssen W, Pol SM, van Dreumel M, Westerhof GJ. Acceptance and commitment therapy group-treatment for non-responsive patients with personality disorders: An exploratory study. Personality and mental health. 2015;9(4):345-356.
  38. McCracken LM. Learning to live with the pain: Acceptance of pain predicts adjustment in persons with chronic pain. Pain. 1998;74(1):21-27.
  39. Wilks CR, Korslund KE, Harned MS, Linehan MM. Dialectical behavior therapy and domains of functioning over two years. Behaviour research and therapy. 2016;77:162-169.

 

 

Disparities in Pain and Pain Care: Combating Bias in Practice

Jennifer L. DelVentura, Ph.D., ABPP
Jennifer L. Steiner, Ph.D., ABPP

In a post in a previous issue of this newsletter, titled “Gender disparities in Pain and Pain Care,” we explored the evidence that women are not only at higher risk for pain and pain conditions but that their pain appears to be underestimated and, in some cases, undertreated compared with men’s pain. Similar patterns are evident in diagnosis and treatment of pain in racial/ethnic/SES minority patients, ranging from differences in prevalence and severity of pain in these groups to differential access to resources and pain care.

While there are many factors operating at different levels (community, institutional/systemic, familial/social, individual) contributing to these disparities, the impact of provider biases on pain care is of particular interest for us, as clinicians.  Biases are ubiquitous, often unconscious, and a normal part of human cognition, but they are not innocuous.  They may even be inconsistent with conscious beliefs—e.g., one may deny having negative beliefs about minority groups, but still evidence presence of unconscious biases in decision-making.  But importantly, with awareness and effort biases are malleable.  It is our task as ethical, caring providers to strive to minimize the impact of harmful biases on patient care.   

Using measurement tools normed for minority populations

One approach to reducing impact of biases involves using pain assessment tools normed for minority patient populations.  Even seemingly unbiased tools may be interpreted and rated differently by minority groups.  Take for example the widely-used numerical pain rating scale with verbal anchors (e.g., “moderate,” “severe” or “worst pain imaginable”) to describe pain intensity.  While these scales appear bias-free, their use rests on the assumption that we all interpret pain descriptors in the same way.  Yet this may not be true, as is demonstrated in a study by Campbell and colleagues[1], comparing pain ratings to thermal stimuli in men vs. women and white vs. black participants.  Findings indicated that when using a generic numerical pain rating scale, women and black participants rated the stimuli as significantly more painful than their counterparts.  However, when participants were allowed to individualize the rating scale by moving the verbal anchors to reflect their subjective interpretation of pain, group differences in pain ratings were no longer significant[1] suggesting group differences in how these anchors were interpreted, perhaps attributable to culture, socialization, or other factors.

The Campbell et al [1] study points to the need for measures modified for or normed to different populations.  Indeed, a few measures with such norms do exist.  For example, for psychologists, the MMPI-II-RF and Millon Behavioral Medicine Diagnostic [2], offer a multitude of specific patient group norms divided by gender (but not ethnicity).  Additionally, several behavioral measures of functioning that are commonly used by physical therapists now have more extensive norms for different populations. The unipedal stance (UPST) now has norms for age and gender [3] and several other common tests such as the timed up-and-go test and single limb stance test have established significant differences based on age [4-6].  However, most measures lack norms specific to race/ethnicity, and thus this remains an important area of development for the field of pain management.  Because such minority group norms are not widely available, it is crucial to be aware of the inherent limitations of our commonly used measures.

Provider-level strategies for managing bias

But what else can providers do to reduce impact of bias on patient care?  Social psychology research offers valuable insights into strategies for addressing biases in our work.  Based on this research, Burgess and colleagues [7] put forth a multi-step, evidence-based framework for addressing biases in healthcare, parts of which we will briefly summarize here.

First, fostering providers’ internal motivation for change is foundational to this model and involves bringing awareness to the presence of biases in our work.  This can be done using techniques like the implicit association test (IAT, [8, 9], a measure of response latency that evaluates the strength of an association between pairs of contrasting concepts and is believed to tap into implicit connections between concepts in the brain. The IAT takes advantage of the brain’s inherent tendency to pair concepts together in service of faster processing, the more closely two concepts are linked together for an individual, the faster the person should be able to respond when one component of the pair is activated in the brain. It is a computer-administered task that has been used to highlight unconscious biases or preferences for people that belong to particular social groups (race, gender, religion., etc.), however, it is important to note that there is some debate as to what the IAT actually measures, and whether implicit bias is correlated with explicit bias and/or explicit behavior [10, 11]. Nevertheless, completing an IAT for a number of variables, i.e. gender, race, size, etc. (at projectimplicit.net)[1] may offer some insight into our own associations and may inform self-reflection.

To give an example of what such an exercise might look like we invite you to consider the following sentences (adapted from the group exercise described in Holm et al., 2017) and count how many are true for you:

  • I can feel confident that others feel that I am qualified upon first impression.
  • I can speak in a roomful of medical providers and feel that I am heard.
  • My age adds to my credibility.
  • When I report pain or physical symptoms to my doctor, I can feel confident that my race or gender identification will not work against me.
  • When I report pain or physical symptoms to my doctor, I can feel confident that others will take them seriously and not assume I am motivated by secondary gain.
  • I can feel confident that if a family member requires hospital or emergency treatment they would be treated with dignity and respect even if they don’t mention my connection with the hospital.

Consider what you notice here.  How many feel true for you? And how might this reflect privilege (or lack thereof) in a healthcare environment? The intention here is not to blame or shame individuals who carry privilege, but rather to consider how this privilege might impact our experience and the quality of care we receive [7, 12].

Now, we invite you to bring to mind a patient or acquaintance with minority group affiliations (race, gender, age, SES). Then with this patient in mind, read through and consider these sentences again from this person’s perspective.  How many of these might feel true to this person?  And in turn, how might this impact actual or perceived care?  The answers and experience might be rather different in this case, and may be uncomfortable for us to consider.  Indeed, it is common for exercises like the above to elicit some negative emotions and internal discomfort (e.g., cognitive dissonance).  However, when elicited in a safe, nonjudging environment, these negative emotions can serve to motivate behavior change.  

Other strategies and considerations for providers

Other steps in the Burgess et al [7] model include increasing contact and comfort with minority groups, and facilitating perspective-taking and empathy for minority group patients—e.g., imagining situations from the patient’s perspective.  However, empathy can suffer due to stress, burnout, and time (e.g., over the course of one’s career).  Even when great strides have been made in reducing the impact of biases and increasing awareness of one’s biases, as creatures of habit we tend to regress back into old patterns if not careful.  Thus, self-care and becoming attuned to our own needs is vital to reducing bias in our work.  It is important that providers practice recognizing signs of burn-out within themselves and routinely re-assess for potential biases. At a systems level, this perhaps highlights the need for greater resources, i.e. advocating for lighter patient caseloads, more time with patients, more time for education (such as seminars or experiential trainings) of this nature both during graduate-level training and at the post-licensure level, and more.

All considered, it is important to note that perfection is neither expected nor realistic in efforts to reduce negative impacts of biases.  Rather, we should strive to reduce biases through practice of empathy, perspective-taking, awareness, and seeing patients as individuals rather than through the lens of group membership.

References

  1. Campbell, T.S., et al., Relationship of ethnicity, gender, and ambulatory blood pressure to pain sensitivity: Effects of individualized pain rating scales. The Journal of Pain, 2004. 5(3): p. 183.
  2. Millon, T., et al., Millon Behavioral Medicine Diagnostic. 2001, Minneapolis, MN: NCS Assessments.
  3. Springer, B.A., et al., Normative values for the unipedal stance test with eyes open and closed. J Geriatr Phys Ther, 2007. 30(1): p. 8-15.
  4. Hirano, K., et al., Impact of low back pain, knee pain, and timed up-and-go test on quality of life in community-living people. J Orthop Sci, 2014. 19(1): p. 164-71.
  5. Bohannon, R., Single limb stance times: a descriptive meta-analysis of data from indivdiuals at least 60 years of age. . Topics in Geriatric Rehabilitation, 2006. 22(1): p. 70-77.
  6. Steffen, T.M., T.A. Hacker, and L. Mollinger, Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther, 2002. 82(2): p. 128-37.
  7. Burgess, D., et al., Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med, 2007. 22(6): p. 882-7.
  8. Greenwald, A.G., D.E. McGhee, and J.L. Schwartz, Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol, 1998. 74(6): p. 1464-80.
  9. Nosek, B.A., A.G. Greenwald, and M.R. Banaji, Understanding and using the Implicit Association Test: II. Method variables and construct validity. Pers Soc Psychol Bull, 2005. 31(2): p. 166-80.
  10. Lane, K.A., et al., Understanding and using the implicit association test: IV. Implicit Measures of Attitudes, 2007: p. 59-102.
  11. Hofmann, W., et al., A meta-analysis on the correlation between the implicit association test and explicit self-report measures. Pers Soc Psychol Bull, 2005. 31(10): p. 1369-85.
  12. Holm, A.L., et al., Recognizing Privilege and Bias: An Interactive Exercise to Expand Health Care Providers’ Personal Awareness. Acad Med, 2017. 92(3): p. 360-364.

[1] Projectimplicit.net is run by a non-profit organization and collects the data for scientific purposes.

[2] The Cultural and Linguistic Competence Health Practitioner Assessment (CLCHPA) through the Georgetown University National Center for Cultural Competence can be found at https://nccc.georgetown.edu/assessments/.  Please note that the assessment and website are temporarily out of service for revisions

President’s Message, July 2019

Ann Quinlan-Colwell, PhD, APN

As a result of the opioid crisis, during the last few years we have faced many changes that we never expected. Patients and families have been devastated. Some are dealing with Opioid Use Disorder, while others are dealing with pain and withdrawal after abruptly stopping prescription opioids. Shocking are notes posted on physician’s doors stating: “We do not prescribe opioids.” Shocking in a different way was the demise of the Academy of Integrated Pain Management and potential demise of the American Pain Society. These changes are both dreadful and sad.

Similarly, many in our region have been impacted by severe weather crises such as tornados, floods and hurricanes. As a result of hurricane Florence, families are dealing with changes ranging from loss of homes to financial burdens. The effects of the hurricane are dramatic in our local landscape. Many of the majestic tall pines are gone which has dramatically changed the day to day rides through the area. It has been very easy to lament their loss. This week, I realized that following the cleanup, where the tall pines used to stand, now small maples, azaleas, struggling magnolias, smaller pines, and a variety of plants and shrubs are flourishing. Importantly, the remaining tall pines, clearly have an important position. Ironically, they seem stronger where they stand. At the same time, we need to ensure that the emerging bamboo doesn’t indiscriminately overgrow all else.

Using the landscape as a metaphor, I encourage us to continue to explore and support the many pharmacologic and non-pharmacologic options for pain management. As members of the Southern Pain Society, we care for patients using multimodal approaches. We are in a unique position to advocate for optimal multimodal pain management that includes opioids when appropriate and necessary. Similar to the tall pines and bamboo, opioids need not be the dominant, and should not be the only or excessive treatment. Yet they certainly do have an important role for many patients in many situations. Our members are pain management experts with varied experiences, specialties and knowledge. We have a responsibility to share balanced, multimodal information, both clinical and scientific, with our membership as well as clinicians in our region.

Like the variety of flora that is now emerging in the sunlight in our region, our 2019 SPS conference will highlight a variety of integrative approaches to more effectively manage pain. Some presentations will focus on interventions that have at times in the past were overshadowed by opioid monotherapy practices, but now are growing stronger with greater light being shown on them. Others will be innovative options that are emerging through this new landscape. It seems very appropriate that our conference will be in NOLA where recovery from Katrina was so dramatic. We look forward to sharing the emerging landscape of integrative pain management with you in NOLA in September.

Is Compassion Fatigue the Adversary of Compassionate Pain Management?

Ann Quinlan-Colwell, PhD, RNC, AHNBC, DAAPM

In the last newsletter, compassion was discussed as the possible ghost of pain management.  Intrinsic in that possible relationship is the potential ingredient known as compassion fatigue which is described by Sinclair and colleagues (2017) as “a work-related stress response in healthcare providers that is considered a ‘cost of caring’ and a key contributor to the loss of compassion in healthcare.”   The stress response involved in compassion fatigue is believed to evolve while caring for patients, clinicians repeatedly experience, in a secondary manner, the traumatic events and/or suffering of patients.  Although, there is no identified theoretical basis, empirical validation or measurement, there is general consensus that compassion fatigue is real and does clinically exist internationally (Sinclair et al, 2017).  It is certain that for a clinician to experience compassion fatigue, the clinician must first have compassion and experience compassion with patients. Ironically, the terminal result of compassion fatigue is that such an originally compassionate caregiver, no longer feels empathic or nurturing toward others, and no longer feels energetic or enthusiastic about the profession once so loved.

The term was first used in 1992 by a nurse educator, C. Joinson, who coined the term compassion fatigue to describe the burnout she observed among healthcare providers.  Today, although compassion fatigue is at times considered a branch of burnout (Sabo, 2011), it is generally considered different from burnout (Lanier, 2017).  In 1995, Dr. Charles Figley (Tulane University) described compassion fatigue occurring as the result of secondary traumatic stress occurring among caregivers when caring for people who are suffering as a result of a traumatic event.  He described the secondary traumatic stress/compassion fatigue as being similar to the post traumatic stress disorder (PTSD) experienced by the traumatized person.  In fact, the symptoms attributed to PTSD and compassion fatigue are remarkably similar (See Table 1). 

Table 1

Post Traumatic Stress Disorder Symptoms

Compassion Fatigue Symptoms

   

Upsetting thoughts

Intrusive thoughts

Irritable

Irritability

Flashbacks

Traumatic memories

Upset by memories

Anger

Trouble sleeping

Insomnia or difficulty sleeping

Nightmares

Nightmares

Concentration difficulties

Difficulty concentrating or focusing

Jumpy

Startle reactions

Overly careful

Hypervigilant

Emotional distance

Patient/client avoidance

Overly careful

Self-doubt and questioning self

Loss of interest

Depressed mood

Avoid activities

Isolating self

Memory difficulties

 

Taken from:

Foa, Johnson, Feeny, & Treadwell, (2001).

Taken from:

Fidley, 1995; Fidley, 2002; Sabo, 2011; Sinclair, et al, 2017

Figley defined compassion fatigue “as a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e.g. anxiety) associated with the patients … a function of bearing witness to the suffering of others”  (Figley, 2002, p. 1435).  The Compassion Fatigue Self Test of Psychotherapists was developed by Figley and later adapted by others with one version adapted with the permission of Figley available via http://www.community-networks.ca/wp-content/uploads/2015/07/Self-Assessment-Tools-Compassion-Fatigue-Feb-22-2010.pdf   In his Compassion Stress and Fatigue Model, Figley (1995, 1997, 2002) described ten variables which combine to result in compassion fatigue and which can be modified to avoid or mediate the development or experience.  The ten variables are listed in Table 2 along with a brief description of each one.

Table 2 Variables of Figley Compassion Stress and Fatigue Model

Model Variable

Description  of variable

Empathic ability

The ability to appreciate pain in another person.

Empathic concern

The impetus to respond to the pain of another person.

Exposure to the patient

Directly being exposed to and experiencing the emotional energy of the suffering person.

Empathic Response

Using insight to share the perspective of the suffering person in an effort to ease the pain and suffering of the person.

Compassion Stress

The effect of the energy expending during the empathic response which can result in negative effects on the well- being of the caregiver.

Sense of Achievement

The satisfaction with compassionate efforts that are experienced by the caregiver who has clear boundaries and concepts of responsibility. 

This variable is protective against compassion fatigue and promotes compassion satisfaction.

Disengagement

The ability, between encounters, to put space between self and the suffering patient and let go of the qualities associated with the suffering experience.  It also involves the clinician in fully engaging in his or her own life. 

When utilized this variable also is protective against compassion fatigue. 

Prolonged Exposure

Over time the persistent belief of responsibility for the person and the associated suffering.  The more intense the exposure with limited interruptions the greater the compassion fatigue.

Traumatic Recollections

These are memories of other experiences or the experiences of other patients which trigger emotional and stressful reactions (i.e. anxiety or depression).

Life Disruption

The unanticipated events that necessitate change in routine or schedule which normally occur in life.  However, when combined with the other variables, the likelihood of compassion fatigue developing increases.

 

Taken from: Figley, 2002, pp. 1436 – 1438.

Although the concept descriptor, compassion fatigue, was only coined 25 years ago, compassion fatigue is now considered an occupational hazard of health care workers (Mathieu, 2012).  Estimates of prevalence range as high as 40% in Intensive Care Units (van Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015).  Not only is it a general occupational hazard, but among clinicians who strive not only to do well, but to at all times to do their best,  Figley noted it is a “disorder that affects those who do their work well” (Figley, 1995, p. 5).  Traumatologist Eric Gentry proposed that many who enter caregiving professions suffer from compassion fatigued prior to even starting their profession because they previously learned to care for others rather than learning to care for self (Lanier, 2017).

Equipped with this knowledge, it seems reasonable to conclude there is an ethical responsibility to educate those who are at greatest risk (i.e. all clinicians) to be able to empathically and compassionately care for patients while promoting compassionate satisfaction and preventing compassion fatigue.  As a first step in addressing this responsibility, the next segment of this series will address the concept of self-compassion and the final segment will discuss restoring compassion in the work of pain management.  Now that you have read about the dilemma, hopefully, you will return to read about viable resolutions.

 

References

Abendroth, M., (Jan 31, 2011) “Overview and Summary: Compassion Fatigue: Caregivers at Risk” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Overview and Summary. DOI: 10.3912/OJIN.Vol16No01OS01

Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge.

Figley, C.R. (1997). Burnout in families: The systemic costs of caring. Boca Raton: CRC Press

Figley, C. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Psychotherapy in Practice, 58(11), 1433-1441.

Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376-384.

Gentry, J. E..  Baranowsky, A. & Dunning,   (1997).  Compassion Fatigue Article: Accelerated Recovery Program (ARP) for compassion fatigue.  Traumatology Institute. Online Training for Trauma Professionals.

Joinson, C. (1992). Coping with compassion fatigue. Nursing 22(4), 116-122.

Lanier, J. (2017).  Running on empty: Compassion fatigue in nurses and non-professional caregivers. The Bulletin Indiana State Nurses Association, 44(1), 10-14.

Mathieu, F. (2012). The Compassion Fatigue Workbook. NY, NY: Taylor and Francis Group.

Sabo, B., (Jan 31, 2011) “Reflecting on the Concept of Compassion Fatigue” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 1. DOI: 10.3912/OJIN.Vol16No01Man01

Sinclair, S., Raffin-Bouchal, S., Venturato, L., Mijovic-Kondejewski, J., & Smith-MacDonald, L. (2017). Compassion fatigue: A meta-narrative review of the healthcare literature. International Journal of Nursing Studies, 69, 9-24.

Todaro-Franceschi V.  (2013). Compassion Fatigue and Burnout in Nursing New York, NY: Springer Publishing Company.  ISBN: 978-0826109774

van Mol, M. M., Kompanje, E. J., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PloS one, 10(8), e0136955.

President’s Message January 2017 – Mordecai Potash, MD

It is my great pleasure to author my first column as President of the Southern Pain Society. In trying to find some inspiration for this column, I went through my New York Times’ collection of articles about chronic pain. I have long been a print and then digital subscriber to the Times, and now have amassed a collection its articles about chronic pain, pain management, and palliative care issues (with thanks to my father-in-law, who dutifully sends to me any article that escaped my eye).

Looking at these articles chronologically, it shows the great arc of change that our field has been through during our professional careers. From one practice standard and swinging to another – pain management as a field and as a professional practice has experienced marked changes and intense scrutiny that few fields of medicine have undergone over the last thirty years.

Just looking at the headlines (not even the articles themselves) will give you a good taste of this:

  • August 26, 1985 – “Helping Families Deal With Chronic Pain”
  • March 28, 1993 – “Patients in Pain Find Relief, Not Addiction, in Narcotics”
  • July 29, 2001 – “The Alchemy of OxyContin”
  • December 21, 2001 – “Few States Track Prescriptions As Way to Prevent Overdoses”
  • November 25, 2003 – “The Delicate Balance Of Pain and Addiction”
  • October 19, 2004 “Doctors Behind Bars: Treating Pain Is Now Risky Business”
  • May 30, 2006 – “Doctors Struggle to Treat Mysterious and Unbearable Pain”
  • March 27, 2007 – “Trafficker or Healer? And Who’s the Victim?”
  • June 17, 2007 – “Doctor or Drug Pusher”
  • August 29, 2007 – “A Surplus of Treatment Options, Few of Them Good”
  • May 13, 2008 – “Back Pain Eludes Perfect Solutions”
  • November 05, 2009 – “Treating the Pain Epidemic”
  • April 09, 2012 – “Tightening the Lid On Pain Prescriptions”
  • May 21, 2016 – “Prescription Dip Seen as Advance in Opioid Battle”
  • March 16, 2016 – “New Standards for Painkillers Aim to Stem Overdose Deaths “
  • November 23, 2016 – “If the Doctor Orders Marijuana, Will Insurers Pay?”
  • December 29, 2016 – “Ethics and Pain: It’s Complicated”

See what I mean? From recognizing that many were languishing unnecessarily due to pain; to beginning to recognize the societal trade-offs that would stem from aggressive pain management; to re-evaluating the legitimacy of providers who treat patients’ pain zestfully; to recognizing that effective pain management treatments are often elusive or expensive (or both); to trying to craft new guidelines to stem prescription abuse; to grappling with the impact of the medical cannabis movement; and to finally recognizing that our field is inherently complicated and perennially chock-full of contradictions.

Many of these articles have the term “double-edge sword” in their text, either as an interview quote or as a journalistic conclusion. This term does capture the dichotomy of our work – the very treatments that can be nearly life-saving for one of our patients can be ineffective for another, or even life-destroying. This dichotomy is true whether our treatments include extended release opiates, nerve blocks, rhyzotomies, kyphoplasties, spinal stimulators, infusion pumps, mindfulness exercises, or any other treatment that we render.

I personally know patients that have had such positive responses to each of these treatments, the word ‘miracle’ tumbles out repeatedly as they describe their response. I also know patients that would describe each of these treatments as having ruined their lives, leaving them even more disabled and embittered than prior to treatment (well, truth be told, I don’t know anyone who would describe ‘mindfulness’ as ruinous – just a hippy-born, navel-gazing, fantastic waste of time).

As we start 2017, the arc of change continues. Many state legislatures and healthcare payers / insurers are considering tremendous regulatory changes in light of both the CDC’s recommendations on opiates for the treatment of chronic pain and the nation’s changing attitudes towards the use of cannabis for the treatment of pain. Several recent articles have suggested a “swap” of chronic opiates for chronic cannabis – suggesting that this would lead to less societal pain such as traffic accidents and overdose deaths [1]. Even as some authors suggest these changes, disturbing reports about dramatic increases in traffic accidents, accidental childhood exposure, intense side effects, and – yes – overdose deaths are appearing in medical [2] and legal reports [3].

I am not “poo-pooing” medical marijuana. Rather – if there is anything the last 30+ years has demonstrated to us over and over again – it is that there are no easy answers in pain management. An approach that may work wonders for one patient may fail miserably in another. What remains the truest ‘answer’ is the ethos that I have seen demonstrated over and over again from our colleagues, in our newsletters, and at our conferences. We treat our patients with zealous compassion, encouraging that they deserve to live a life free of intense daily suffering, and advocating to institutions about preserving and enhancing treatment options for people with chronic pain.

I guarantee you that 2017 will bring new challenges to this ethos. But I also guarantee you that we have together faced similar challenges in the past and that our organization will continue to educate and promote our highest healing ideals.

REFERENCES

[1] Eric Sarlin. Study Links Medical Marijuana Dispensaries to Reduced Mortality From Opioid Overdose. NIDA Notes, published 05/17/2016 and accessed at  https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose
[2] Howard S. Kim, et al. Cyclic Vomiting Presentations Following Marijuana Liberalization in Colorado. Academic Emergency Medicine. Volume 22, Issue 6, June 2015, Pages 694–699
[3] Rocky Mountain High Intensity Drug Trafficking Area. The Legalization of Marijuana in Colorado: The Impact. Volume 2 / August 2014. http://www.rmhidta.org/html/August%202014%20Legalization%20of%20MJ%20in%20Colorado%20the%20Impact.pdf

Categories