Pain clinics attract patients with higher levels of psychopathology than is characteristics of chronic pain patients in general (DeGood, 2000). While pain and depression are expected among patients in pain centers and can be managed with appropriate consultation, severe character pathology (Cf. personality disorders) represents an extreme challenge.
In a study (Burton et al., 1997), found that 25% of the patients in a traditional multidisciplinary pain center had symptoms of borderline personality disorder, 26% had symptoms of histrionic personality disorder and 22% had symptoms of narcissistic personality disorder.
A further complication of treatment in pain centers is the finding (Polatin et al, 1993) that 5% of the patients in these settings are antisocial, having a pervasive pattern of disregard for, and violation of, the rights of others. Deceit, violence and a pattern of job, marital and legal problems are typical of this group.
These are referred to as _Cluster B_ or _dramatic_ personality disorders.
Most health care providers dread interaction with borderline patients who tend to be impulsive, have unregulated emotions, and are unstable in their relationships with pain clinic staff. Histrionic patients in these centers are attention seeking, markedly overly emotional and melodramatic. Narcissistic patients lack empathy for those around them, have endless need for attention and admiration and see themselves as special with a strong sense of entitlement.
Psychological methods of coping which were barely adequate prior to injury become grossly maladaptive in the presence of pain and the attention provided by others.
Compliance is spotty at best with Cluster B personalities. Equally as problematic is that dramatic personality disorders are disruptive and damaging to the therapeutic setting. The antisocial has a continuous potential for violence, and the histrionic_s aggressive demand for attention can never be adequately met. The narcissist needs to remain disabled to generate attention and will fly into a rage when they are forced to comply with rules (that they insist do not apply to them). The bordeline_s create an atmosphere of chaotic moods and demand narcotics to attempt to achieve emotional stability.
These Cluster B personalities will not only disrupt other patients but will fatigue and deplete professional and support staff.
These individuals with dramatic personality disorders are often better treated in individualized (solo practitioner) settings where they are more isolated from other patients and a large staff. In that setting, they are best treated by a pain medication specialist with no attempts to integrate broad interdisciplinary teams.
The key, of course, will always be to recognize these personality disturbances as having existed for almost all of the patient_s life and not mislabel them as the result of pain itself.