Personality Disorders:
DSM-5 = 'an enduring pattern of inner experience and behaviour 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'
Cluster A = Odd = Paranoid (suspicious), Schizoid (detached), Schizotypal (eccentric)
Cluster B = Dramatic = Antisocial (disregard for others), narcissistic (self-important), borderline (emotionally unstable), histrionic (attention seeking)
Cluster C = Anxious = Dependent (submissive and clingy), avoidant (feels inadequate), obsessive-compulsive (perfectionistic).
Cluster C types are known to be at higher risk of persistent pain
(higher harm avoidant, and and lower self-directedness. These lead to fear-avoidance).
Cluster B types are known to be at higher risk for problematic substance abuse
(they often like the euphoric effects of opiates and Benzos)
Borderline personality disorder presents in up to 30% of patients presenting to pain clinic - higher than the 2-6% expected in general population
Treatment goals in BPD are the same: improve function and develop skills to reduce discomfort. The goals of therapy are based upon changing behavior in the face of intense and distressing emotional states. Dialectical behavior therapy is the most widely recognized treatment for borderline personality disorder. This treatment is based on validating strong emotions and negative experiences, while helping the patient choose healthier behaviors despite these feelings.
Consequences of chronic pain:
Increased risk of depression, anxiety, physical deconditioning, sleep distrurbance, poor self-esteem, social isolation and relationship breakdown
Stigmas associated with the pain
Lower productivity
Yellow flags
The belief that pain is harming or disabling
Family:
Overprotective spouse
Solicitous spouse behaviours
Socially punitive spouse issues
Negative attitudes from family members
Lack of support person
Beliefs or attitudes about pain
Belief that pain is harmful and fear-avoidance behaviours
Belief pain must be abolished before return to work
Expectation of worse pain if returns to work
Catastrophising
Belief pain is uncontrollable
Passive attitude to rehab
Behaviours
Extended rest
Reduced activity
Irregular boom-bust cycles of activity
Avoidance of normal activity
Severely high reporting of pain
Excessive reliance on aids
Sleep quality reduced
High alcohol or smoking or other substances
Compensation issues
Lack of financial incentive to return to work
Delay in accessing income support and dispute over eligibility
History of claims
Extended time off work
Previous back pain
Ineffective case management
Work
Belief that work is harmful
History of manual work
Low education or socioeconomic background
Unhappy environment
Diagnosis issues
Health professional sanctioning disability
Conflicting diagnoses
Unhelpful diagnostic language
Dramatisation of back pain and focus on passive treatment
Expecting a 'techno fix'
Advice to withdraw from job
Lack of satisfaction with treatment
Emotions
Fear of increased pain with work
Depression
Grief
Irritability
Anger
Anxiety
Social anxiety
Feeling unneeded or unwanted
Psychological focuses in chronic pain:
Reconceptualise his pain
Identify realistic and practical goals
Reinforce progress
Identify obstructive factors such as catastrophising
Develop coping skills
Relaxation training, breathing techniques, biofeedback, autogenic training
Red flags
Concerning features for possible physiologically harmful causes of pain
Essentials of pain Medicine - Summary
Somatoform disorders are now under somatic symptom and related disorders
Somatic symptom disorder
Undesired or unpleasant sensations are common - occurring in 60-80% of people in a given week
Patients may seek help when these are prolonged or they are associated with anxiety of serious illness
DDx:
Depression (mood is more prominent), panic disorder (more acute), GAD (worry about everything), Illness anxiety disorder (worry about health specifically), Conversion disorder (loss of function primarily not distress), organic disease, substance use, cog dysfunction
Conversion disorder (Functional Neurological Symptom Disorder)
Neurological symptoms incompatible with neurological pathophysiology
Can be sensory and/or motor
Symptoms may include seizures or convulsions or unconscious episodes
Diagnosis can only be made after appropriate medical investigation
Patients with a neurological condition can still have functional neurological symptom disorders
Factitious disorder (Munchausen syndrome)
Intentional production of physical or psychological symptoms
It requires proof that the person is falsifying symptoms in the absence of obvious rewards
Malingering
NOT a mental illness
Questions:
3. Critically discuss current views on the possible importance of personality and personality disorders in chronic pain and their implications for treatment outcome.
https://www.practicalpainmanagement.com/treatments/psychological/connecting-dots-how-adverse-childhood-experiences-predispose-chronic-pain https://www.practicalpainmanagement.com/treatments/psychological/optimizing-care-using-trauma-informed-approach
References:
Argoff, C. E., Dubin, A., Pilitsis, J., & McCleane, G. (2009). Pain management secrets E-Book. Elsevier Health Sciences.
FPM - Module 2
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