Chronic Pain and Personality Disorders: Implications for Rehabilitation Practice.

The relationship between personality characteristics and chronic pain, especially chronic muscular pain, has long been recognized. William James (1890) suggested that there were two general personality types: hypoactive and hyperactive. According to this formulation, the hypoactive personality characterized individuals who tended to be relaxed and calm, with little or no indications of tension and rigidity. Those with the hyperactive personality, on the other hand, tended to be excitable, tense, and more prone to becoming angry. Alexander (1950) proposed that an inability to handle anger and aggressive impulses was at the root of many chronic and degenerative disorders, such as arthritis. Since the advent of psychoanalysis, nearly a hundred years ago, a number of studies have attempted to predict the connection between personality traits and a tendency tot developing chronic muscle pain (Alexander, 1961; McCreary, 1985; Rimon, Huhmar and Stenback, 1971). The evidence, however, remains inconclusive.

The Psychoanalytic model of chronic pain states that persistent pain is the result of underlying and often unconscious conflicts (Sternbach, 1974; Turk and Flor, 1984). Aronoff and Rutrick (1985) suggested that pain may be conceptualized as a compromise between inner drives and external demands. This suggests that pain may actually protect the individual from experiencing inner sources of conflict that may be overwhelming. The ego defenses, which have a particular influence on the musculature by increasing tension, prevent the conscious experience of such intrapsychic turmoil to reach conscious awareness. The experience of chronic somatic symptoms, however, is likely to be the price for such avoidance. Blumer and Heilbronn (1984) postulated that pain prone individuals tended to deny emotional and interpersonal distress, experienced guilt and depressed mood, and showed an inability to deal with anger and hostility.

A number of authors in the field of psychosomatic medicine have noted that patients with musculoskeletal disorders tended to sacrifice themselves masochistically to serve others. Alexander (1961), who is often acknowledged for his extensive study of the psychodynamics of medical disorders, suggested that parental restrictions prevented the child from expressing frustration freely by random motor discharge. When such preventions against aggressive expressions are turned inward, a psychological "straight jacket" results. The consequent increase in muscle tone is believed to aggravate or precipitate arthritis. French and Shapiro (1949) noted that these patients expressed their repressed impulses through their skeletal systems in their dreams.

Reich, Tupin, and Abramowitz (1983) evaluated a group of chronic pain patients at a multidisciplinary treatment program. Patients were extensively assessed over a l-year period. Medical records, evaluations, and reports from social workers were reviewed. Furthermore, patients were administered the MMPI and underwent a semistructured psychiatric interview. Their findings suggested that 37% of the patients presented with at least one axis II diagnosis. The most prevalent personality disorders in their sample were histrionic and dependent.

Gatchel, Polatin, and Kinney (1995), in a prospective study, conducted a comprehensive assessment of the various psychosocial variables in classifying patients with acute low back pain who eventually developed disability due to chronic pain. The results of their investigation suggested that disability due to chronic pain is a complex phenomenon which encompasses physical, emotional, psychological, and socioeconomic factors. The authors concluded that among the various variables studied, the most useful determinants of disability were the presence of an Axis II personality disorder, high analog pain scores and Scale 3 (Hysteria) elevations on the MMPI. Similarly, Gentry, Shows, and Thomas (1974) concluded that preexisting personality variables and dependency in relationships may be important contributing factors in chronic low back disability. This further supports the notion that "... psychosocial variables can interact with physical symptoms to contribute to disability" (Gatchel, Polatin & Kinney, 1995, p.419).

Reich and Thompson (1987) explored the prevalence of personality disorders in the chronic pain population. Their findings suggested that over 37% of chronic pain patients presented with discernable personality disorders, when compared against two groups of psychiatric patients. A structured psychiatric interview, based on the DSM-III criteria (APA, 1980), was utilized to generate axis I (clinical symptoms) and axis II (personality disorders) diagnoses. The authors concluded that there is a clinically significant prevalence of personality disorders in the chronic pain population, especially those with anxiety-related features such as avoidant, dependent, obsessive compulsive, and passive aggressive personality disorders. Fishbain, Goldberg, Meagher, Steele, and Rosomoff (1986) used a similar approach to assess a group of 283 patients suffering from chronic pain. Their findings showed that nearly 60% of the patients presented with a personality disorder with avoidant, obsessive-compulsive, and histrionic personality disorders being the most common. The authors suggested that there is a need for further exploration of the relationship between chronic pain and personality disorders. Similar findings with regard to Axis II diagnosis was reported by Polatin, Kinney, Gatchel, Lillo, and Mayer (1993) who found a high occurrence of personality disorders (51%) in a population of chronic low back pain sufferers. While there is much to be learned about the relationship between personality disorders and chronic pain, the above studies clearly suggest that the evaluation and treatment of chronic pain patients can be improved by acknowledging and understanding personality disorders.

Millon (1996) defined personality "... as a complex pattern of deeply embedded psychological characteristics that are largely unconscious and not easily altered, expressing themselves automatically in almost every facet of functioning" (p.4). Persons diagnosed with a personality disorder are those who manifest chronic signs of rigidity and maladaptive patterns of perceiving and thinking about their environment and themselves (APA, 1994). Such rigidity precipitates impairment in functioning and results in the experience of significant levels of distress (Widiger and Frances, 1987). The fourth edition of the Diagnostic and Statistical Manual of Mental Health (APA, 1994) defines l0 personality disorders. In this paper, four personality disorders which especially appear to present themselves in the chronic pain population will be discussed (See Fishbain, Goldberg, Meagher, Steele & Rosomoff, 1986; Reich and Thompson, 1983).

The Dependent Personality Disorder 

The essential features of patients with the dependent personality disorder are compelling others to assume responsibility for major areas of their lives and subordinating their own needs to others (APA, 1994). These individuals also lack self-confidence and experience intense discomfort when alone for brief periods. Patients with this diagnosis appear overly submissive and show a strong fear of separation (Millon, 1981). It is as if they have never resolved the separation-anxiety stage of development, hence they tend to experience significant levels of anxiety and fear when they consider the mere thought of abandonment. From a psychosomatic standpoint, these individuals may develop medical conditions that require significant involvement by others in their daily care (Alexander and French, 1948). Plagued with self-doubt and insecurity, these individuals require a great deal of support and patience on the part of the clinicians and therapists. Their inability to be decisive can at times be most trying. Finally, it needs to be noted that patients with serious medical disorders may develop and manifest characteristics similar to those suffering from this disorder (Cooper, Frances and Sacks, 1986).

Case Example:

Fred is a 39-year-old man who is often accompanied by his wife and daughter. He presents with a history of back pain, gastrointestinal distress, and headaches that last for days. Fred has been hospitalized on several occasions for severe depression and panic attacks. He is currently seeing a number of specialists who have prescribed various medications. The patient exhibits a restricted range of affect. His primary affective tone is that of helplessness. Fred constantly emphasizes that there is nothing he can do to help the pain and that nothing seems to have made a "real difference" so far, but he trusts that you can make him better. He tearfully states his willingness to do anything you suggest.

A Brief Summary of Clinical Features:

Patients with the diagnosis of dependent personality disorder often present with the following characteristics (See DSM-IV criteria, APA, 1994; Greenberg and Bornstein, 1988):

* Tendency for strong depressive features

* Tendency to suffer from adjustment disorder 

* Anxiety or panic caused by new responsibilities

* Tendency to belittle themselves

* Constant preoccupation with the fear of rejection

* Independence is synonymous with annihilation

* Tendency to overly idealize their therapists

Treatment Suggestions:

While working with these patients consider working on small goals. Incorporate as much structure as possible in your sessions, which will help to contain their anxiety. Provide them with active guidance and use modeling in order to get them involved in various tasks. Due to their regressive, childlike tendencies, at times you must "hold" their hand as you proceed with the task of therapy, but keep in mind that your task is that of empowering and not enabling (See Spitzer, Gibbon, Skodol, Williams, and First, 1994). Hence, the prolonged use of passive forms of therapy is not recommended because of these individuals insatiable desire to have things done to them instead of learning to take care of themselves. They may easily become dependent on passive, physical modalities such as massage and may develop symptoms of withdrawal if treatment is discontinued. Remember, if it is left up to them, they always prefer to use a wheelchair than to learn to walk.

The Avoidant Personality Disorder 

Patients with this diagnosis tend to be quite shy and withdrawn. A hallmark of this disorder is that of hypersensitivity to criticism, which is translated as a prelude to rejection. As a result, they tend to avoid relationships in order to safeguard themselves from the overwhelming pain of rejection (APA, 1994). Ironically, these individuals are "starved" for attention and human contact although it appears that they literally go out of their way to avoid relationships (Millon, 1981). They tend to repeatedly test those who promise uncritical acceptance, hence they often seem vigilant and guarded (Lion, 1981).

Case Example:

Jane is a 51-year-old woman who tends to arrive late for her appointments and appears disheveled. She presents with a history of chest pain, neck pain, and constant pain in her shoulders. She has been seen at the emergency room on several occasions because of severe chest pain and heart palpitations. These attacks were attributed to anxiety. She is currently being seen by a cardiologist who confirms this finding, although she is convinced that there is something wrong with her heart. She often makes self-deprecating remarks such as, "... but who am I to question anybody'?" Jane appears sad, shy, quiet, and preoccupied. At times, it seems as if she is not paying attention to what you are saying. She relates to you that she lives alone and does not like to be in crowded or "loud" places.

A Brief Summary of Clinical Features:

Patients with the diagnosis of avoidant personality disorder tend to manifest the following characteristics (See DSM-IV criteria, APA, 1994; Cooper, Frances and Sacks, 1986: Millon, 1996: Widiger, 1992):

* Inability to tolerate anything that hints of criticism

* Tendency to be very self-critical and self-deprecating

* Tendency to become overwhelmed with anxiety in social situations

* Live in a fantasy world where they are loved

* Appear distracted and uninterested in the task at hand

* Tendency to develop agoraphobia 

* Tendency to view themselves as interpersonally incompetent

Treatment Suggestions:

In working with patients with avoidant personality disorder, it is imperative that you realize that they expect you to reject them. Therefore, you need to be reassuring and supportive. Avoid criticism at all costs even if it is constructive and is meant for educational purposes. Instead, try to focus on their positive qualities with supportive coaching (Benjamin, 1996). Because of their self-deprecating and vigilant tendencies, they may be resistant to being directly touched. Hence, at least initially, it is prudent to gain their cooperation and trust by offering explicit explanations of the treatment and how it is to be administered. Also, since they tend to become easily distracted, it is best to make sure you have their attention before sharing new information with them. Finally. remember that they are starved for affection, therefore your gentleness means a great deal to them. These are individuals who often can better interact with animals than with people. Their pets are their best friends--often their only friends.

The Obsessive-Compulsive Personality Disorder 

The preoccupation with perfectionism is perhaps one of the most salient hallmarks of this diagnosis. Patients with this disorder exhibit restricted ability to express warm and tender emotions (APA, 1994). These are pedantic persons who are often preoccupied with matters of rules, order, organization, efficiency, and detail (Othmer & Othmer, 1989). They often show excessive devotion to work and productivity to the exclusion of pleasure. Their everyday relationships have a conventional, formal, and serious quality to them. They often lack imagination and a sense of humor. Although they tend to be quite resistant when subjected to the will of others, they adamantly insist in having others submit to their way of doing things. Since they cannot tolerate making mistakes, they often struggle with decision making and become overwhelmed with anxiety. As a result they often struggle with procrastination (Millon, 1996).

Case Example:

Bob is a 31-year-old program analyst who ,,vas referred to you for the evaluation and treatment of his back and neck pain. During the initial session, he emphatically states his disagreement with the diagnosis which was recently rendered by a rheumatologist. He believes that his problem is due to "faulty ergonomics". Bob suggests several interventions that should resolve the problem. He admits that he tends to do things his own way and, at times, he aggravates his pain by "overdoing it". On several occasions, the patient reminds you that he has time constraints and wants the treatment to be focused and to the point. The patient's affect is flat and he appears formal and "businesslike". At times, however, he tends to openly express his anger and irritation, especially when he disagrees with your treatment approach.

A Brief Summary of Clinical Features:

Patients with the diagnosis of obsessive-compulsive personality disorder tend to manifest the following characteristics (See DSM-IV criteria, APA, 1994; Jenicke, 1983; Pollack. 1987: Saltzman, 1973):

* Need to dominate

* Tendency to be argumentative

* Appear cold, distant, and judgmental

* Immobilized by the fear of making a mistake

* Fearful of addressing issues of anxiety

* Tend to use words as a way of hiding their feelings

* Do not want others to know them (especially their imperfections)

Treatment Suggestions:

Working with patients with the obsessive-compulsive personality disorder can be most exhausting. It is therefore crucial that you conserve your emotional resources. Do not be overly enthusiastic. Your efforts may go unnoticed, at least initially. It is best to meet them within the domain where they feel most comfortable, that is the intellectual level (Also see Benjamin. 1996). These individuals tend to expect "results" and may question passive and or "gentle" forms of physical treatments. They often respond favorably to detailed and specific exercises for home practice that will ultimately make them self-sufficient. Also, avoid placing too much emphasis on exploring feelings, since this tends to overwhelm them. They need to be in control, therefore it is only prudent to include them in some decision making with regard to your treatment plans. Finally, do not take their criticism personally.

The Histrionic Personality Disorder

This is a disorder with the most visible manifestations. Patients who present with histrionic personality disorder tend to be overly dramatic and "showy" in terms of mannerism and speech (McWilliams, 1994). They tend to be overly reactive and are perceived by others as extremely shallow, superficial, and insincere. These individuals often have chaotic interpersonal relationships. While they tend to be seductive, they have poor sexual adjustment (APA, 1994). They draw attention to themselves by exaggerating feelings and emotions to the point that they cannot go unnoticed. Furthermore, they demand praise, reassurance, and approval from others and are willing to do anything to be loved by others. Deep down, they constantly struggle with the desire to be dependent and, at the same time, fear being perceived as vulnerable (Mueller and Aniskiewicz, 1986). This often causes therapists to become confused and frustrated while working with them.

Case Example:

Betsy is a 45-year-old woman who presents with primarily chronic left-sided pain, numbness and tingling in her legs, throbbing headaches, and shortness of breath. She often dresses attractively and is well-groomed. During the initial visit, she greets you warmly and states that she has heard "wonderful things" about you. Betsy's speech and gestures are quite dramatic and her expressions can quickly shift from laughter to tears. Your frequent attempts at keeping her focused tend to fail. Meanwhile, she constantly apologizes for being "all over the place". The patient reluctantly admits that she has had difficulties in her relationships in the past and that she has been treated for depression and suicidal ideations. She is "convinced" that you are going to help her.

A Brief Summary of Clinical Features:

Patients with the diagnosis of histrionic personality disorder tend to manifest the following characteristics (See DSM-IV criteria, 1994; McWilliams, 1994; Millon, 1981; Mueller and Aniskowitz, 1986; Slavney, 1978):

* Often preoccupied with physical attractiveness

* People often label them as "actors" and don't take them seriously

* Tendency to become furious if their genuineness is questioned

* Live in a fantasy world and avoid dealing with real issues

* Tend to act out sexually

* Desire to be the center of attention

* May appear overly dependent

Treatment suggestions:

Histrionic patients constantly try to cover up enormous sources of intrapsychic and interpersonal anxieties. They may go on talking for hours, often with no sense of direction, without allowing you to express a single thought. Ironically, they may end up blaming you for tiring them (Spitzer et al., 1994). Structure your sessions and have well defined goals. At times you need to be gentle but firm in order to motivate them to pay attention to the task at hand. Be aware of their tendency to punish you if you don't pay enough attention to them. Do not reinforce their acting out behaviors--be gentle, but firm and consistent. They tend to forcefully resist working with equipment instead of people. Remember, they tend to need to be the center of attention and, as far as physical forms of therapies are concerned, may demand "hands on" treatments. Again, long term use of passive modalities is not recommended due to their tendency to become dependent (Slaveny, 1978). Finally, remember that beneath an excited, animated mask, there lives a lonely and frightened person.

Conclusions

There is growing evidence that a large majority of patients who present with chronic pain may also meet the criteria for personality disorders. The purpose of this paper is not to necessarily aid therapists and clinicians to diagnose personality disorders, but to assist them with providing more effective care by understanding some of the characteristics of patients with personality disorders, their tendencies, behaviors, and how to effectively work with them. Since it is always prudent for the therapist to develop an effective alliance with the patient in order to improve treatment outcome, a more expanded knowledge of the patient, not only in terms of physical symptom manifestations, may prove to be helpful and highly desirable. This objective is most expediently achieved by recognizing certain personality tendencies and by creating the appropriate, supportive atmosphere to provide the patient with the most effective treatment approach. It is also hoped that the reader will find the information presented here helpful enough so as to desire to increase his or her knowledge through additional study and research.

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Michah R. Sadigh

Good Shepherd Rehabilitation Hospital