Studies have shown that mental health disorders and chronic pain are inextricably connected. There is a bidirectional relationship between these conditions stemming from common neurological processes. Research indicates that individuals suffering from chronic pain have greater incidences of depression, anxiety, substance misuse, and personality disorders. While there is documented evidence regarding mood disorders in chronic pain patients, personality disorders are not as well-studied in this population.
A new analysis by Shapiro, et al. highlights the challenges of medical management for those suffering from concomitant personality disorders and chronic pain, and the interplay of stress in this group. Pain clinicians have greater concern over managing these complex patients due to difficult patient behavior patterns.
According to the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), there are three clusters of personality disorders: A, B, and C. Cluster B personalities include borderline, anti-social, histrionic, and narcissistic personality disorders – and there is a documented higher prevalence of Cluster B traits among chronic pain patients. Among these, borderline personality disorder (BPD) poses unique difficulties for the therapeutic environment.
Borderline Personality Disorder, in particular, is characterized by dysregulation of behavior, mood, and self-image. Studies indicate that rates of BPD in the general population are around 2%, while among chronic pain patients the rate is around 30%. Those with BPD demonstrate a dichotomy between tolerance of self-inflicted pain (able to tolerate) versus non-self-inflicted pain (low tolerance). They also tend to have higher incidences of substance misuse – in particular, opioid misuse – leading to dependence, overdose, and other complications.
Research suggests that patients with co-existing chronic pain and BPD create challenges for therapeutic management due to a convergence of BPD personality traits, such as poor impulse control, disruptive behavior, increased suicide risk, and an inability to maintain interpersonal relationships. Chronic pain patients are at two to three times higher risk for suicide, and 10% of people with BPD have died by suicide.
Further data indicates that those with coexisting chronic pain and BPD are also more likely to be receiving disability benefits for chronic pain. Researchers suggest this may stem from a confluence of BPD characteristics resulting in individuals receiving less personal, professional, and social support. In addition, individuals with comorbid chronic pain and BPD often lack the ability to self-manage their condition leading to poor quality of life and inadequate medical care.
Several theories exist regarding the increased prevalence of personality disorders in chronic pain patients. Research indicates that in some individuals’ personality disorders may be an underlying characteristic prior to a pain diagnosis. One widely accepted model, the diathesis-stress model, suggests a combination of biological and psychological factors are at play. The model proposes stress from chronic pain may provoke personality disorder symptoms in those who were already predisposed.
Recently, the COVID-19 crisis has highlighted the significant damaging impact of stress on those with concurrent chronic pain and BPD. The current pandemic has underscored health disparities and problems with healthcare access for many disadvantaged populations. BPD patients already faced challenges obtaining medical care, with frequent discharges from medical practices due to “disruptive” or “challenging” behavior. The pandemic has added to condition-related stress stemming from infection risk, social isolation, poor self-management skills, and lack of readily available medical care worsening pain symptoms.
The combined aspects of social and psychological stress from the pandemic have increased concern among scientists for patients with chronic pain and BPD. These patients already face trouble accessing care, have poor treatment results, and the novel coronavirus pandemic has added to their biopsychosocial stress, further complicating management.
Experts feel it’s imperative to establish adaptive care guidelines during this crisis to address the unique needs of this vulnerable population. Toward this goal, specialists have developed best practice guidelines urging clinicians to increase use of telemedicine for assessment and treatment. One suggestion offered by the guideline is to triage patients into three categories (elective, urgent, emergent). Experts also recommend use of digital therapeutics for self-care in chronic pain patients to address the current situation.
In conjunction with increased use of telemedicine and digital medicine solutions, Shapiro, et al, encourage increased standard screening of chronic pain patients for personality disorders. They suggest that screening can improve medical access, use of resources, and treatment measures. Specifically, the authors recommend incorporating the McLean Screening Instrument for BPD (MSI-BPD) for reliability, and feasibility of use in busy pain practices.
One of the paper authors and editor of the journal where it was published (Journal of Pain Research), Michael Schatman, PhD, told PPM, “The MSI-BPD can be provided along with short anxiety and depression screens, and patients can be told that it will help the staff better understand how they can support them best.” He and co-authors emphasized that screening should never be used to deny treatment or discharge individuals from a practice based on scores. Schatman added, “It is important to recognize that there is no medicine available that can be used to treat BPD.”
Screening and monitoring, therefore, can be employed to identify patients who require additional mental health assessments and can help patients avoid care-related disruptions now and in the future. Incorporating routine screening for BPD in chronic pain patients can have a considerable positive impact on medical management and outcome measures.