My Account Menu

Newsletter Signup

Please register to the site before you can sign for a list.
No account yet? Register
 

PERSONALITY CHARACTERISTICS OF PATIENTS WITH PAIN

by Robert J. Gatchel, Ph.D., ABPP.


2 Credit Hours - $49
Last revised: 06/29/2017

Course content © Copyright 2009 - 2017 by Robert J. Gatchel, Ph.D., ABPP. All rights reserved.



PLEASE LOG IN TO VIEW OR TAKE THIS TEST

This test is only active if you are successfully logged in.


 

COURSE OUTLINE

 

Introduction and Course Overview

Learning Objectives

Personality Characteristics and Pain

MMPI “Pain Profile” Studies

The Conversion V Profile Type

The Neurotic Triad Profile Type

The Disability Profile Type

Other MMPI Profile or Cluster Types

Conclusions

Personality Disorders: The DSM-IV

The Diathesis-Stress Model of Psychopathology

Personality Assessment Instruments and Methods

Evaluating Personality to Help with Chronic Pain Treatment

The Stepwise Approach to Assessment

Pain Management Intervention Strategies

Summary and Conclusions

References

 

INTRODUCTION AND COURSE OVERVIEW

 

Historically, going back to the ancient Greeks, Aristotle and Plato viewed pain as being “outside” the five basic senses (sight, hearing, smell, taste and touch), and more among the emotions, specifically a “quality or passion of the soul.”  Thus, this “state of feeling” was viewed as setting pain apart from the limitations of a pure sensory state, and extended it also to other areas of “mental life.”  This perspective pre-dated the subsequent and prevalent biomedical models of pain that viewed it as a pure sensory or mechanistic phenomenon.  It has not been until recently that we have discarded this outdated, dualistic biomedical view of pain as either a mental or physical event.  With the introduction of the biopsychosocial model of pain during the last decade, pain (especially when it becomes chronic in nature) is viewed as a complex interaction among physical, psychological and social factors (Gatchel et al., 2007).  Therefore, psychosocial factors (including personality characteristics) play an important role in the reception, reaction and coping with pain.  How to evaluate these personality characteristics and integrate them into a treatment program will be a focus of the present course.

 

LEARNING OBJECTIVES

 

List three MMPI profile types that have been related to patients with chronic pain

 

Describe the DSM-IV personality cluster types especially related to chronic pain patients

 

Explain the prevalence of DSM-IV personality disorders in a chronic pain population

 

Discuss the evidence for or against the concept of a “pain prone personality” type

 

Describe the stepwise process of pain assessment and treatment

 

 

PERSONALITY CHARACTERISTICS AND PAIN

 

With the introduction and acceptance of the gate-control theory of pain (Melzack and Wall, 1965), came the realization that many diverse factors are involved in pain perception.  This theory’s major contribution was the introduction to the scientific community of the importance of central nervous system and psychosocial variables in the pain-perception process.  Indeed, it highlighted the potentially significant role of psychosocial factors in the perception of pain (Melzack, 1993).  Subsequently, the biopsychosocial model of pain was introduced which further emphasized the fact that pain is a complex, subjective phenomenon that consists of a host of factors, each of which can contribute to the interpretation of nociception as pain.  Pain is experienced uniquely by each individual, and the complexity of pain is especially evident when it persists over time as a range of psychological, social and economic factors can interact with physical pathology to modulate a patient’s report of pain and subsequent disability (Turk et al., 2002). 

 

Obviously, this biopsychosocial perspective of pain highlights the potentially significant role of psychosocial factors (including personality) in the pain-perception process. There is now a great amount of clinical research indicating the important role of personality in pain perception which can, in turn, have important clinical implications for treatment approaches.  Without a firm grasp of psychosocial/personality characteristics of patients, it becomes difficult to precisely “tailor” treatment programs to the specific characteristics of a pain patient.  In fact, the most treatment- and cost-effective pain management programs embrace an interdisciplinary approach, in which the unique interactions among biological, psychological and social factors of each individual patient is taken into account before specifically tailoring a treatment program to deal with these unique interactions.  The older, and ineffective perception that a single treatment program can be applied across all pain patients (i.e., “the one shoe fits all sizes” perception) is no longer accepted as valid.  Rather, tailoring the “shoe size” or treatment program to each specific foot or patient is the most useful and valid approach to take.  The major assessment techniques used to measure personality characteristics will be reviewed next.

 

MMPI “PAIN PROFILE” STUDIES

 

As a result of the acceptance of the importance of psychosocial factors in pain, a copious amount of clinical research was then stimulated in an attempt to isolate the specific psychological characteristics of patients with chronic pain.  One of the major assessment instruments used in this search was the Minnesota Multiphasic Personality Inventory (MMPI). The major scales of the MMPI are presented in Table 1. The early MMPI work attempted to differentiate functional from organic pain.  For example, one of the earliest studies was conducted by Hanvik (1951) in the evaluation of patients who were then considered to have either chronic pain with an organic cause, or to have a functional pain disorder without a clear-cut organic cause.  This study was based upon the earlier mentioned traditional biomedical reductionist view of pain that assumed that every “real” report of pain originated from a specific physical organic cause.  If such a physical cause could not be found, then pain was viewed as functional, or merely the result primarily of psychosocial factors which made it less “real” in nature.  Fortunately, even though this organic-functional distinction has been replaced with a more comprehensive biopsychosocial model, Hanvik’s (1951) early investigation provided the basis for numerous subsequent studies assessing the psychological profiles of patients with chronic pain, while primarily utilizing the MMPI in such investigations. 

 

It should also be mentioned that, even though Hanvik isolated 25 items on the MMPI to differentiate the organic versus functional pain groups, subsequent investigations were unable to replicate his initial results or any of the conclusions that he proposed.  Subsequently, the utility and validity of drawing a distinction between functional versus organic features of chronic pain have been challenged and has fallen into disrepute.  Rather, with the biopsychosocial perspective of chronic pain, it is now appropriately viewed as a complex interactive system which cannot be divided into distinct psychological or physical components alone.  It should also be noted that, although there have been additional efforts to try to identify various “pain prone personality” types with the use of the MMPI, such studies have been strongly criticized and this notion is no longer accepted as valid.  All of these studies, however, do not dispute the notion that the MMPI can be a useful method of assessing personality in pain patients.  However, it should be viewed as only one of a possible battery of tests to better understand the psychosocial functioning of an individual.  Indeed, as will be discussed next, there appears to be different MMPI profile types that are useful in better understanding the characteristics and coping abilities of chronic pain patients.

 

 

Table 1. MMPI-2 Scale Names and Descriptions

 

 

Scale

 

 

Abbreviation

 

Original Name

 

Description

 

 

L

 

Lie

 

This is rough indication of attempting to present oneself in a positive light and denying any faults.

 

 

F

 

Infrequency

 

This scale can show individuals that are attempting to exaggerate psychological symptoms and present themselves as more disturbed than they actually are. 

 

 

K

 

Defensiveness

 

The K scale is a more subtle measure of an attempt to present oneself positively. 

 

 

1

 

Hs

 

Hypochondriasis

 

A wide variety of vague and nonspecific complaints about bodily functioning are assessed. All the items on this scale deal with somatic concerns or with general physical competence.

 

 

2

 

D

 

Depression

 

Various symptoms of depression are assessed including poor morale, lack of hope in the future, and a general dissatisfaction with one's own life situation.

 

 

3

 

Hy

 

Hysteria

 

Items are of two general types: (1) reflecting specific somatic complaints and (2) showing that the client considers himself or herself well socialized and adjusted. Such people generally maintain a facade of superior adjustment and only when they are under stress does their proneness to develop conversion-type symptoms appear.

 

 

4

 

Pd

 

Psychopathic

Deviate

 

 

This scale is a general measure of rebelliousness including problems with authority, impulsiveness, troubled relationships, underachievement, and behaving outside social norms. 

 

 

5

 

Mf

 

Masculinity-

Femininity

 

 

High scores indicate that the individual is endorsing characteristics opposite of the gender stereotype (e.g. a male scoring high on Mf is endorsing stereotypical female traits and a lack of stereotypical masculine features).

 

 

6

 

Pa

 

Paranoia

 

This scale measures paranoid symptoms such as ideas of reference, feelings of persecution, grandiose self-concepts, suspiciousness, excessive sensitivity, and rigid opinions and attitudes.

 

 

7

 

Pt

 

Psychasthenia

 

This scale measures symptoms such as obsessive-compulsiveness, anxiety, excessive doubt, anger, and unreasonable fears.

 

 

8

 

Sc

 

Schizophrenia

 

This scale was originally developed to identify patients diagnosed as schizophrenic. Items assess a wide variety of content areas, including bizarre thought processes, peculiar perceptions, social alienation, poor familial relationships, difficulties in concentration and impulse control, lack of deep interests, disturbing questions of self-worth and self-identity, and sexual difficulties.

 

 

9

 

Ma

 

Hypomania

 

This scale assesses such things as elevated mood, accelerated speech and motor activity, irritability, flight of ideas, and brief periods of depression.

 

 

0

 

Si

 

Social

Introversion

 

This scale assesses a person's tendency to withdraw from social contacts and responsibilities. The items on this scale are of two general types: (1) deals with social participation and (2) general neurotic maladjustment and self-depreciation.

 

 

As noted above, the MMPI was one of the most widely used psychosocial measures of chronic pain.  However, with the subsequent introduction of the MMPI-2 and other tests designed specifically for populations with chronic pain, the utility of the MMPI has decreased over the years.  However, the extensive past research that used the original MMPI still provides valuable information into the various correlates of chronic pain and the personalities of individuals with chronic pain syndromes.  There have been two traditional MMPI profile types (the “Conversion V” and the “Neurotic Triad”), as well as a newer type (the “Disability Profile”) that have been found to be useful in better understanding the personality characteristics of chronic pain patients.

 conversionv

Figure 1: The Conversion V Profile

 

The “Conversion V” Profile Type

 

The Conversion V profile (Figure 1) represents a configuration of Scales 1 (Hypochondriasis) and 3 (Hysteria) that are significantly higher than that for Scale 2 (Depression).  This profile is produced when an individual endorses somatic symptoms, while also denying social anxiety and depressive symptoms.  Such individuals often react to stress with the development of physical symptoms, and also have limited insight into their feelings.  They also tend to be sociable, conforming, and passive-dependent.  The incidence of this Conversion V profile for a general medical patient population is roughly 5-15%, but is 35-60% for patients with chronic pain.  Although the individual with a Conversion V profile can share some of the symptoms of a person with the Neurotic Triad profile (to be discussed next), the Conversion V patient is more likely to report less psychosocial distress than is the Neurotic Triad profile patient.  This is most likely due to the fact that Conversion V profile individuals may be able to more effectively distract themselves from painful and distressing emotions by focusing on their physical symptoms.

 neurotictriad

Figure 2: The Neurotic Triad Profile

 

The “Neurotic Triad” Profile

 

Some chronic pain patients often have high scores on all three of the first clinical scales (Hypochondriasis, Depression and Hysteria).  This profile type (The Neurotic Triad: Figure 2) is frequently seen in individuals with the following characteristics:  somatic complaints; the presence of secondary gain (i.e., some financial or interpersonal gain for being “sick or in pain”); depressive feelings; and difficulty with sleep.  Moreover, such individuals are often hypothesized to have conflicted feelings about dependency, and they may also keep other people “at a distance” or interact with others in unpleasant or demanding ways.

disabilityprofile 

Figure 3: The Disability Profile

 

The “Disability” Profile

 

The Disability Profile (Figure 3), recently introduced by Gatchel, Mayer and Eddington (2006) for musculoskeletal pain patients, is comparable to what is called the “Floating Profile” in the psychiatric literature. This Floating Profile is defined as elevations of 4 or more of the clinical scales (T scores above 65). Overall, this profile has been associated with personality disorders (in particular, borderline personality disorder). Individuals with this particular profile do not have one particular defense mechanism to call upon in order to effectively cope with stressors in their lives and, therefore, often experience severe emotional distress.

 

Other MMPI Profile or “Cluster” Types

 

There have been numerous other profiles or cluster types developed in an attempt to classify chronic pain patients. The cluster groups were developed using a statistical technique called Hierarchical Clustering Analysis, which involves differentiation of subjects according to major clusters or patterns of MMPI profiles. One such cluster solution found in 10 separate studies used the P-A-I-N in order to describe the different typologies or clusters (Robinson, 2000). The Type P cluster consisted of elevations on most of the clinical scales, and it appears to be reflective of the most disturbed profile. It was associated with difficulty in the realms of psychosocial, educational, and vocational functioning. The Type A cluster was similar to the early discussed Conversion V profile. The Type I cluster appears to be a hypochondriacal profile associated with physical impairment of patients who had multiple medical procedures and multiple hospitalizations. Finally, the Type N cluster patients were characterized as relatively normal.

 

Conclusions

 

Because of the importance of psychosocial factors in chronic pain, it is not surprising that there would be MMPI profile and cluster types associated with how patients react to their pain or how patients may be predisposed to reacting to pain in particularly unique ways. There is no doubt that the first three clinical scales of the MMPI reviewed above have significant relevance to pain patients. Although these various profiles or clusters do not differentiate between the now outdated notion of functional versus organic pain patients, they can be used to indicate that physical symptoms may be used by certain patients to distract from painful emotions or to produce distressful affect. To date, though, none of these profiles or clusters have been found to support the presence of a single “pain prone personality type” or have they been able to predict treatment outcome effects. Again, though, it should be emphasized that these profile or cluster types should be used as only one piece of data in isolating psychosocial characteristics of patients with pain.

 

PERSONALITY DISORDERS: THE DSM-IV

 

In an attempt to increase the reliability of psychiatric diagnoses, the American Medical Association published a series of manuals that delineated specific criteria that had to be met before an individual could be given a particular diagnosis. As should be known, the DSM-IV (American Psychiatric Association, 2000) allows for diagnoses on five different axes, each corresponding to a different class of disorder. An Axis I diagnosis classifies major clinical disorders such as anxiety, depression, schizophrenia, etc. Axis II diagnoses consist of personality disorders, which will be the topic of the present discussion. In the DSM-IV, these personality disorders are included in Table 2.

 

 

Table 2. Major Personality Disorders

 

 

Overview

 

The DSM-IV lists ten personality disorders, grouped into three clusters (A, B, C) and these are coded on Axis II. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder (Personality disorder not otherwise specified).

 

 

Cluster A (odd or eccentric disorders)

 

Paranoid personality disorder: characterized by a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.   

 

Schizoid personality disorder: characterized by a pervasive detachment from social relationships and restricted range of expression of emotions in interpersonal settings.  (lack of interest in social relationships, seeing no point in sharing time with others, misanthropy, introspection)

 

Schizotypal personality disorder: characterized by a pattern of social and interpersonal deficits along with cognitive or perceptual distortions and eccentricities of behavior.

 

 

Cluster B (dramatic, emotional or erratic disorders)

 

Antisocial personality disorder: a pervasive disregard for and violation of the rights of others.

 

Borderline personality disorder: a pervasive pattern of instability in relationships, self-image, affect, identity and behavior.

 

Histrionic personality disorder: a pervasive pattern of excessive emotionality and attention-seeking behavior.

 

Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy.

 

 

Cluster C (anxious or fearful disorders)

 

Avoidant personality disorder: a pervasive pattern on social inhibition, avoidance of social interaction, feelings of inadequacy, and extreme sensitivity to negative evaluation.

 

Dependent personality disorder: a pervasive pattern of needing to be taken care of by others that leads to submissive and clinging behavior and fears of separation.   

 

Obsessive-compulsive personality disorder: characterized by a preoccupation with orderliness, rigid conformity to rules, and moral codes at the expense of flexibility, openness and flexibility.  

 

 

Although Axis II personality disorders may or may not be directly psychologically-troubling for any particular individual, they may contribute to deficits in interpersonal functioning, reality testing, coping, etc. Finally, there are also Axis III (which allows for the diagnosis of a physical disorder such as diabetes, heart conditions, etc), Axis IV which is used to denote a person’s psychosocial stressors, and Axis V which involves rating a patient’s overall level of functioning in the past year on a scale from 0 to 100. By using this classification system, it is believed that many of the difficulties in obtaining consistent and reliable diagnoses can be eliminated. The resultant diagnoses can then be used for more effective treatment planning, and can also be duplicated across clinicians who make these diagnoses. It should also be noted that, in order to make this an even more reliable system, a Structured Clinical Interview for DSM diagnosis (SCID) has been developed, which requires clinicians to use the same sequence of questioning and the rating of symptoms verbalized by patients. This SCID approach has been found to be associated with a high degree of inter-rater reliability across clinicians (Spitzer et al., 1988). The SCID I is used to evaluate Axis I disorders, while the SCID II is used to classify Axis II personality disorders.

 

In light of the earlier reviewed MMPI findings with chronic pain patients, it is not surprising that there has been a greater prevalence of Axis II disorders found for chronic pain patients, relative to the general population. It should also be noted that the DSM-IV includes a method to “cluster” these various Axis II personality disorders into three major personality clusters. Cluster A includes the social personality disorders, consisting of the paranoid, schizoid, and schizotypal personality disorders. Individuals with these cluster disorders often appear odd or eccentric. Cluster B consists of the “flamboyant” personality disorders, including the borderline, histrionic and narcissistic personality disorders. Individuals with these often appear dramatic, overly emotional or erratic. Finally, the Cluster C consists of the anxious personality disorders, including the avoidant, dependent, obsessive-compulsive, and passive-aggressive personality disorders. Individuals with these disorders often appear anxious or fearful.

 

Of course, these clusters are important to know because they will have potentially significant implications for treatment recommendations and tailoring of the treatment program for patients. For example, elevations in depression and anxiety are usually found in chronic pain patients, but can be effectively treated through the psychosocial component of a pain management program with the use of methods such as cognitive behavior therapy, as well as psychopharmacological approaches. In contrast, the treatment of severely personality-disturbed pain patients is more troublesome because of the various types that are often recalcitrant to any type of traditional therapeutic intervention. Cluster B personality type individuals are especially troublesome because of the more “traumatic” nature of their ingrained characterological attributes, such as being inflexible, erratic, being oblivious to their own problems, and lacking empathy for others.

 

There have been numerous studies demonstrating the high prevalence of Axis II personality disorders in chronic pain patients. For example, a study by Polatin et al. (1993), found a high occurrence of DSM-IV personality disorders (51%) in a population of chronic back pain patients. Even though there is much to be learned about the relationship between personality disorders and chronic pain, such studies clearly indicate that the effective evaluation and treatment of chronic pain patients needs to include an understanding of personality disorders in order to be therapeutically effective. Thus, of course, there is a real advantage of the accurate diagnosis of personality disorders. However, for ethical purposes, it is quite important to accurately diagnose such individuals and not just haphazardly “stick a label” on a patient. A reliable personality diagnosis serves many clinically beneficial functions as in Table 3 delineated below:

 

 

Table 3. Importance of Personality Diagnosis in Treatment

 

 

The treatment program can be better tailored to fit the individual’s unique personality characteristics, without disturbing the concurrent treatment of other patients in a group setting.  This will help to optimize the likelihood of a successful outcome. Because compliance with treatment is usually somewhat low in patients with personality disorders, tailoring the treatment to help maximize compliance to the treatment regimen will help improve therapeutic outcomes.

 

In cases in which a severe personality disorder is diagnosed, the treatment team will get a “heads up” in what to expect and be able to appropriately modify their initial reactions to the patients accordingly.

 

With an assessment of both premorbid and current personality disorders, changes that are attributed to the onset of pain may be accurately determined, and treatment can therefore be aimed at returning the individual to his or her previous style of functioning.

 

 

 

With the above points in mind, it should also be recognized that pain management programs are not developed to “change” the personality of an individual, but merely to help “manage” personality styles more effectively and to make the personality functioning of an individual more adaptive to the environment (through techniques such as learning new coping skills, more appropriate interpersonal interactions, better methods of dealing with stress, etc). It is very important to not “label” a person with a particular personality disorder that may remain in a patient’s chart and then subsequently “follow” that patient in the future. Loosely using labels that may follow a patient the rest of his or her life is an ethical consideration that needs to be very carefully considered. In my own practice, rather than using a personality disorder label, I merely use some of the personality characteristics that may be either adaptive or maladaptive and that our treatment program successfully addressed.

 

THE DIATHESIS–STRESS MODEL OF PSYCHOPATHOLOGY

 

In a conceptual model of how acute pain develops into chronic pain, Gatchel (2005) characterized this progression according to a three-stage model. In Stage 1 of this model (referred to as the acute phase), normal emotional reactions, such as fear, anxiety and worry develop subsequent to the patient’s perception of pain. This is viewed as a natural emotional reaction that often serves as a protective function by prompting the individual to heed the pain signal and, if necessary, to seek medical attention for it. However if the perception of pain exists beyond a two-to-four month period (which is usually considered a normal healing time for most pain syndromes), the pain begins to develop into a more chronic condition, leading to Stage 2 of the model.

 

During Stage 2 of this process, psychosocial and behavioral problems are often exacerbated or heightened. Anger, emotional distress, and depression are typical symptoms of patients in Stage 2. Frequently, the extent of these symptoms usually depends on the individual’s pre-existing personality and psychosocial structure, in addition to socioeconomic and environmental conditions. For example, depressive symptoms are greatly exacerbated during this Stage for an individual with a premorbid depressive personality who is seriously affected economically by the loss of a job due to pain and disability. Similarly, an individual who had premorbid hypochondriacal characteristics and who receives a great deal of secondary gain (e.g., sympathy from others) for remaining disabled will most likely display a great deal of pain and distress.

 

The model itself proposes a diathesis-stress perspective, in which the stress of coping with pain can lead to the exacerbation of the individual’s underlying psychosocial characteristics. The model does not propose that there is a pre-existing pain-prone personality but, rather, patients bring with them certain predisposing personality and psychological characteristics (i.e., they have a diathesis) that is exacerbated by the stress of attempting to cope with the now chronic nature of the pain. Indeed, the relationship between stress and the exacerbation of mental health problems has been well documented in the scientific and clinical literature. This is not to say that predisposing factors make chronic pain a “psychogenic disorder” in that it is all in the “person’s head.” Again, the chronic problem represents a complex interaction between physical factors and psychosocioeconomic variables.

 

 

Table 4. Three Stage Diathesis-Stress Model (Gatchel, 2005)

 

 

Stage 1

 

This is characterized by normal emotional reactions including such things as fear, anxiety and worry that develop subsequent to the patient’s perception of pain.

 

 

Stage 2

 

In this phase, psychosocial and behavioral problems are often exacerbated or heightened. Anger, emotional distress, and depression are typical symptoms of patients in the transition from the Acute phase to Acceptance of the Sick Role.

 

 

Stage 3

 

The progression to complex interactions of physical, psychological and social processes consolidates leading to abnormal illness behavior.  This is the chronic phase of the model in which there is an acceptance of the sick role.

 

 

Finally, the progression to complex interactions of physical, psychological and social processes characterizes Stage 3, which represents the chronic phase of the model. As the result of the chronic nature of the pain experienced, and the stress that it creates, patients’ lives begin to revolve around the pain and behaviors that maintain it. The patient begins to adopt a “sick role,” in which any excuse from social and occupational responsibilities become routine. As a consequence, the patient now becomes accustomed to the avoidance of responsibility, and other reinforcers maintain such maladaptive behavior.

 

With the above diathesis-stress model in mind, clinicians should be aware that the personality characteristics being displayed by a particular pain patient may be an exacerbation or amplification of their “normal” personality if the pain has become chronic in nature. That is to say, before the onset of chronic pain, the personality style of a particular individual may not have been maladaptive or interfering with his or her activities of daily living. However, after the exacerbation, many of the characteristics of that individual’s personality may be more prominently displayed (e.g., the inability to deal with stressors that normally would not have been problematic to deal with before the chronic pain). It will then be important for the clinician to help the patient to develop better coping skills to deal with this now higher than usual level of stress. It should be kept in mind that some of the basic characteristics of individuals with personality disorders include those listed in Table 5.

 

 

Table 5.  Features of Patients with Personality Disorders

 

 

they usually have poor coping strategies and are not flexible in changing them

 

these coping styles result in them being extremely vulnerable under conditions of stress

 

their style of perceiving and reacting to significant challenges is maladaptive, which then tends to perpetuate or intensify preexisting difficulties.

 

 

Thus, the presence of a personality disorder or cluster, in general, and not necessarily a specific type of personality disorder, may significantly impair coping abilities and could be related to problems with chronic pain and disability. One key hallmark of individuals with personality disorders is a failure of, or inadequate, coping skills. Indeed, the DSM-IV explicitly defines personality disorders in terms of traits or styles that are “inflexible and maladaptive and cause either significant functional impairment or subjective distress” (APA, 1994). Again, this has major clinical implications for how to best manage chronic pain patients.

 

PERSONALITY ASSESSMENT INSTRUMENTS AND METHODS

 

We have already discussed two major approaches to the assessment of personality disorders –the MMPI and Axis II diagnoses of the DSM-IV. However, it should be kept in mind that, for approaches such as these (which are categorical in nature; i.e., either the disorder is present or not present), they are susceptible to many of the limitations associated with a categorical system in terms of not taking into account overlap between diagnoses. In fact, many investigators frequently cite multiple personality diagnoses for the same patient when assessment is based upon a structured, categorical approach.

 

Various studies have revealed that, on average, 85% of patients diagnosed with a personality disorder receive multiple Axis II diagnoses, with the average degree of overlap between any two specific pairs of personality disorders being 10% (ranging from 0% to 45%; Gatchel and Weisberg, 2000). Thus, such data raise questions about the distinct boundaries assumed to exist between specific Axis II diagnostic categories. This is one reason why many clinicians use a cluster approach when utilizing the DSM-IV. Likewise, it suggests that, for finer grade distinctions of personality disorders, it is helpful to use other assessment instruments and approaches to supplement one another in coming up with a more confident understanding of personality characteristics of a particular individual. Fortunately, there are several other instruments that have been developed to assess personality disorders. Some of these are listed in Table 6 and have been reviewed by Gatchel and Weisberg (2000).

 

 

Table 6: Assessment Instruments for Personality Features

 

 

     Personality Assessment Schedule

     Personality Interview Questionnaire

     Millon Clinical Multi-axial Inventory (MCMI-III)

     Schedule for Non-Adaptive and Adaptive Personality (SNAP)

     NEO Big 5 Factor Personality Inventory

     Multidimensional Pain Inventory (MPI)

 

 

EVALUATING PERSONALITY TO HELP WITH

CHRONIC PAIN TREATMENT

 

There can be no doubt that based on their individual experiences, people develop unique ways of interpreting information and coping with stress. These patterns, in turn, affect pain perceptions and responses to the presence of pain, and, if they are maladaptive, then one would expect more difficulty in coping. As discussed earlier, individuals with a personality disorder in general would be expected to display an inability to cope with a major stressor such as chronic pain. Likewise, we earlier discussed the fact that individuals with personality disorders often have maladaptive coping skills. As such, one would expect independent evaluation of coping skills to further document these deficits in individuals with personality disorders. Indeed, there is growing demonstration of a relationship between ineffective pain-coping strategies and chronic pain (Gatchel et al., 2007; Gatchel, 2005). In fact, one instrument that directly addresses the issue of personality and coping is the Multidimensional Pain Inventory (MPI), also previously known as the West Haven-Yale Multidimensional Pain Inventory (Kerns et al., 1985). This instrument was developed to measure three psychosocial dimensions of pain: patients’ self-reported pain and the effects of pain; responses of significant others to the communications of pain patients; and level of daily living activities. Turk and Rudy (1988) subsequently developed a classification system using the MPI which categorized patients according to three subgroups that predict response to treatment: dysfunctional, interpersonally distressed, and adaptive copers.  Brief descriptions of these groups can be found in Table 7.

 

 

Table 7.  Characteristics of MPI Cluster Groups

 

 

Dysfunctional

 

The dysfunctional profile patients have a tendency to perceive the severity of their pain to be high, and to report that the pain interferes with much of their life. They also report a high degree of emotional distress because of their pain.

 

 

Interpersonally Distressed

 

The interpersonally distressed patients are similar to the dysfunctional patients, but they also perceive that their “significant others” are not very understanding of their conditions. They perceive that they have no good social support to help them with their pain problems.

 

 

 

Adaptive Coper

 

The adaptive coper patients report a high level of social support and relatively low levels of pain or perceived interference with their lives. They usually respond well to pain management programs.

 

 

According to their system, the dysfunctional subgroup patients were hypothesized not to respond as well to intervention as would patients in the other two subgroups. There have been a number of studies supporting this hypothesis, as well as other findings related to the MPI profiles. Some of these findings, as reviewed by Gatchel (2005), include the following:

 

Chronic pain patients who were classified as dysfunctional reported more pain-specific fear and avoidance than did patients in the other two subgroups. Such characteristics, in turn, are related to poor coping abilities and treatment outcomes in these dysfunctional chronic pain patients.

 

Pain patients with dysfunctional and interpersonally distressed profiles display more indications of acute and chronic personality differences relative to adaptive coper profile patients.

 

Patients with an adaptive coper profile demonstrate greater positive treatment outcomes when administered a pain management program.

 

There has been a great deal of other clinical research demonstrating the utility of the MPI with various chronic pain conditions, including low back pain, headache, and temporomandibular jaw pain. Needless to say, the assessment of such MPI profiles provides a great help in tailoring the needs for treatment strategies to account for the different personality and coping characteristics of patients. For example, patients with an interpersonally distressed profile may need additional clinical attention addressing interpersonal skills to perform effectively in a group-oriented treatment program. Pain patients with a dysfunctional coping profile may require more intensive clinical management.  In contrast, patients coming in with an adaptive coping style may be less emotionally distressed, already have some requisite coping skills, and require less intensive treatment. Thus, some specific treatment modalities are more likely to be needed than others for each profile type. 

 

An important issue to consider is whether there are certain biopsychosocial profiles that are more or less responsive to different treatment modalities.  For example, variables that are likely predictors of pain-related disability outcomes, such as catastrophizing, fear of movement/activity, poor coping skills, emotional distress, and their interactions with environmental factors (such as work place satisfaction, and health care system variables) need to be more closely evaluated whenever possible.  How do we go about doing this?  This will be discussed next.

 

The Stepwise Approach to Assessment

 

In previous publications, I have provided an example of a stepwise approach to the assessment of a patient who was referred to treatment for low back pain (Gatchel, 2001; 2005).  Of course, for the evaluation of a pain patient, it is incumbent to have a comprehensive physical examination conducted by a physician.  For a patient with low back pain, this examination could consist of assessment and documentation about the following:  range-of-motion; straight-leg raising; documentation of areas of tenderness; neurological signs; gait and posture evaluation; and Waddell non-organic signs.  This initial physical examination will provide valuable information concerning possible functional deficits and anatomical/neurological problems.  If needed, additional diagnostics can then be ordered.  Also, signs of potential neuromuscular inhibition and motivational problems will usually become apparent during this physical evaluation, which can then be further validated with information garnered from the psychosocial assessment data.  Once it is decided that this low back pain patient can be safely functionally tested, a more comprehensive functional capacity evaluation should be requested in order to obtain the baseline data needed to individually tailor a physical rehabilitation program for that patient.

 

In terms of the ideal approach to the assessment of possible psychosocial problems and issues, one then must decide which psychosocial and/or personality assessment tools should be used.  In doing so, one should be aware of the issue presented in Table 8.

 

Table 8.  Choosing Assessment Tools

 

 

No single psychosocial device can be used reliably in all personality assessments.

 

One cannot assume that one instrument can be used as a sole method for descriptive purposes.  Such data should be viewed as just one source of information to be considered, along with other forms of data.

 

One must also know about a patient’s history of social relationships, the presence or absence of social support networks, degree of life satisfaction and success, the history of coping with stressors, and so on, in order to make a probability statement concerning the prediction of some behavior such as response to pain (e.g., a person with a history of coping well with stressors has an 80% probability of not displaying a great deal of pain behaviors).  It is extremely rare that a totally accurate prediction of some behavior based on a single psychosocial or personality assessment instrument can be made.

 

Multiple sources of data should be used to provide a comprehensive evaluation of a patient’s biopsychosocial functioning.

 

 

With the above in mind, the following is a chart (Figure 4) of the stepwise process initially described by Gatchel (2001, 2005) for the low back pain patient. 

 stepwisefigure

Figure 4: Stepwise Approach to Assessment

 

As can be seen, after the comprehensive physical examination, there is an initial screening process to “flag” obvious psychosocial distress which can be performed efficiently by utilizing tests such as the Beck Depression Inventory (which captures symptoms of depression), the SF-36 (which captures the overall physical and mental health functioning), and then a more specific low back pain type of instrument, such as the Pain Disability Questionnaire or the Oswestry Questionnaire.  After this initial psychosocial screening, if there are elevations in the measures, then the patient can be directly sent for rehabilitation treatment. If there are elevations, then a more comprehensive psychological interview can be conducted, as well as the administration of additional tests such as the MMPI-2 and/or the SCID for DSM-IV.  If there are no elevations or “red flags” on these psychosocial screening measures, then the patient can be referred to a comprehensive pain rehabilitation program.  In both cases, when the patient is entered into a treatment program, then the comprehensive physical examination, along with the comprehensive psychosocial evaluation (what we call the biopsychosocial evaluation), can be used to prescribe the specific treatment program for each individual.  Moreover, the MPI is also administered at this point in time in order to evaluate the patient’s overall coping style.  With this information on hand, the treatment staff can usually be prepared to deal with any unusual behaviors or barriers to recovery.

 

Pain Management Intervention Strategies

 

In the past, for many pain management programs, there was an unfortunate “disconnect” between the assessment that was administered to patients and the subsequent treatment program administered to those patients.  This was due to the fact that there was a tendency to apply a “one shoe size fits all” treatment strategy philosophy.  The more recent interdisciplinary pain management programs emphasize the need to carefully utilize the comprehensive assessment data in order to tailor a specific treatment program for each individual.  This has been emphasized throughout this present Course.  Because of this need, interdisciplinary pain management programs have been developed, and have been unequivocally demonstrated to be treatment – and cost-effective (See Gatchel and Okifuji, 2006, for a review of the literature supporting this conclusion).

 

At the outset, distinctions among primary, secondary and tertiary pain management care need to be highlighted because they suggest that the type of interdisciplinary pain management required for each is substantially different. For example, primary care is usually applied to acute cases of pain of limited severity. Basic symptom-control methods are used in relieving pain during the normal early healing period. Most often, only some basic psychological reassurance that the acute pain episode is temporary, and will soon be resolved, is quite effective at this stage of care.

 

Secondary care represents “reactivation” treatment that is administered to patients who do not improve simply through the normal healing process of primary care. It is administered during the transition from acute (primary) care to the patient’s eventual return to work or normal activities of daily living. This treatment has been designed to promote a return to productivity before advanced physical deconditioning and significant psychosocial barriers to recovery occur. At this phase, more active psychosocial intervention may need to be administered to patients who do not appear to be progressing. It is at this stage that an initial brief biopsychosocial evaluation can be administered to “flag” whether potential psychosocial issues or personality characteristics are present that may interfere with normal recovery. The earlier discussed initial screening process to “flag” obvious psychosocial distress factors can be administered at this point in time to hopefully capture such psychosocial/personality barriers to recovery, as well as any lingering physical functioning problems.

 

Finally, tertiary care requires a more comprehensive and intensive treatment approach. It is intended for patients suffering the effects of both physical deconditioning and chronic pain and disability. Basically, it differs from secondary care in regard to the intensity of the rehabilitation services required, including psychosocial and pain management. As reviewed by Gatchel (2005), the critical elements of interdisciplinary care can be found in Table 8.

 

 

Table 9.  Critical Elements of Interdisciplinary Care

 

 

In order to deal with any physical deconditioning problems, formal and repeated quantification of physical deficits are performed in order to help guide, individualized, and monitor the physical training progress of patients.

 

Psychosocial and socioeconomic assessments are conducted, again to guide, individualize and monitor pain and disability behavior-oriented interventions and outcomes.

 

A multi-model disability management program is utilized, which involves a wide array of cognitive-behavioral approaches, such as relaxation training, stress management, biofeedback, coping skills, etc.

 

Psychopharmacological interventions are available if detoxification and psychosocial management (of anxiety, depression, etc.) is needed.

 

An interdisciplinary, medically-directed team approach with formal staffing is conducted on a weekly basis, along with frequent team conferences in a low staff-to-patient ratio.

 

There is also an ongoing outcome assessment of physical and psychosocial variables at pretreatment, post treatment, and follow up periods, utilizing standardized objectives criteria.

 

 

As stated above, such an interdisciplinary biopsychosocial assessment-treatment program has been shown to be extremely effective in successfully managing chronic pain patients, relative to less intensive, single-modality treatment programs of the past.

 

SUMMARY AND CONCLUSIONS

 

In this Course, a brief overview was provided concerning how the outdated dualistic biomedical approach to the assessment and treatment of pain has been replaced during the past decade by a more effective biopsychosocial model of chronic pain. In this model, along with basic physical variables, psychosocial factors (including personality characteristics) play an important role in the reception, reaction and coping with chronic pain. Evaluation of these psychosocial-personality characteristics, and how to integrate them into a treatment program, was presented.

 

The early and most widely used assessment method for evaluating personality characteristics of pain patients has been the MMPI. The early work in this area attempted to differentiate functional from organic pain. However, much of the early clinical research demonstrated that there was no utility or validity of drawing a distinction between functional versus organic features of chronic pain. Rather, with the biopsychosocial perspective of pain, it is now appropriately viewed as a complex interactive system which cannot be divided into distinct psychosocial or physical components alone. It was also emphasized that, although there have been additional efforts to try to identify various “pain prone personality” types with the use of the MMPI, such studies have been strongly criticized, and this notion is no longer accepted as valid. In all of these clinical studies, though, there is no dispute about the notion that the MMPI can be useful for assessing personality in pain patients. However, MMPI results should be viewed as only one of a potential battery of tests to better understand the psychosocial functioning of an individual with pain.

 

Using the MMPI, three major profile types have been identified as useful in better understanding the personality characteristics of chronic pain patients: the Conversion V Profile type, the Neurotic Triad Profile type, and the Disability Profile type. In addition, a number of other profiles or cluster types have been developed in an attempt to classify chronic pain patients. For instance, in 10 separate studies the P-A-I-N grouping has been found useful to describe the different typology or clusters. Although such a clustering has been found to be useful, it should again be emphasized that these profiles or cluster types should be used as only one piece of data in isolating psychosocial and personality characteristics of patients with pain.

 

In an attempt to increase the reliability of psychiatric diagnoses, the American Psychiatric Association published the DSM-IV which allows for diagnoses on five different axes, each corresponding to a different class of disorder. For our purposes, Axis II diagnoses consist of personality disorders which included the following: paranoid personality disorder; schizoid personality disorder; schizotypal personality disorder; antisocial personality disorder; borderline personality disorder; histrionic personality disorder; narcissistic personality disorder; avoidant personality disorder; dependent personality disorder; obsessive-compulsive personality disorder; and personality disorder “not otherwise specified”. Furthermore, the structured clinical interview for DSM diagnoses (SCID) has been developed, which requires clinicians to use the same sequence of questioning in the rating of symptoms verbalized by patients. This SCID approach has been found to be associated with a high degree of inter-rater reliability across clinicians. The SCID I is used to evaluate Axis I disorders, while the SCID II is used to classify Axis II personality disorders. As discussed, in light of the earlier reviewed MMPI findings, it is not surprising that there has been a greater prevalence of Axis II disorders found for chronic pain patients, relative to the general population. Finally, the DSM-IV includes a method to “cluster” these various Axis II personality disorders into three major personality clusters: Cluster A, Cluster B and Cluster C. Of these three clusters, Cluster B personality type individuals are especially troublesome because of the more “dramatic” nature of the ingrained characterological attributes, such as being inflexible, erratic, being oblivious to their own problems, and lacking of empathy for others.

 

An understanding of psychosocial and personality disorders in patients with pain is extremely important in order to become aware of developing a therapeutically effective pain management program. This will allow the better “tailoring” of the treatment program to fit the individual’s unique personality characteristics, and thus helping to optimize the likelihood of a successful outcome. A diathesis-stress model of psychopathology was introduced to highlight how psychosocial and personality disorder problems may arise as patients progress from acute to chronic pain stages. With this diathesis-stress model in mind, clinicians need to become aware of the fact that the personality characteristics being displayed by a particular pain patient may be an exacerbation or amplification of their “normal” personality if the pain has become chronic and stressful in nature. That is to say, before the onset of chronic pain, the personality style of the particular individual may not have been maladaptive or interfering with his/her activities of daily living. However, after the exacerbation, many of the characteristics of that individual’s personality may become more prominently displayed, resulting in the inability to deal with the stressors that normally would not have been problematic to deal with before the onset of chronic pain. A number of additional personality assessment instruments/methods were introduced, as well as how practitioners can evaluate personality in order to help manage patients with chronic pain using a “stepwise approach” to assessment. Finally, the close connection between the assessment process and the treatment tailoring process was emphasized in discussing primary care, secondary care and tertiary care approaches using an interdisciplinary biopsychosocial model for patient management.

 

REFERENCES

 

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: APA.

 

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, Text Revision. Washington, DC: American Psychiatric Association.

 

Gatchel RJ. (2001). A Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders. LaGrange, IL: North American Spine Society.

 

Gatchel RJ. (2005). Clinical Essentials of Pain Management. Washington, DC: American Psychological Association.

 

Gatchel RJ, Mayer TG, Eddington A. (2006). The MMPI "Disability Profile": The least known, most useful screen for psychopathology in chronic occupational spinal disorders. Spine, 31, 2973-2978.

 

Gatchel RJ, Okifuji A. (2006).  Evidence-based scientific data documenting the treatment- and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. Journal of Pain, 7(11), 779-793.

 

Gatchel RJ, Peng Y, Peters ML, Fuchs PN, Turk DC. (2007). The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions.  Psychological Bulletin, 133, 581-624.

 

Gatchel RJ, Weisberg IN. (2000).  Personality Characteristics of Patients with Pain. Washington, DC: American Psychological Association Press.

 

Hanvik LJ. (1951). MMPI profiles in patients with low back pain. J. Consult. Psychology, 15, 350-353.

 

Kerns RD, Turk DC, Rudy TE. (1985). The West Haven-Yale Multidimensional Pain Inventory. Pain23, 345-356.

 

Melzack R, Wall PD. (1965).  Pain mechanisms: A new theory. Science, 50, 971-979.

 

Melzack R. (1993).  Pain: Past, present and future. Can. J. Exp. Psychology, 47(4), 615-629.

 

Polatin PS, Kinney RK, Gatchel RJ, Lillo E, Mayer TG. (1993). Psychiatric illness and chronic low-back pain. The mind and the spine--Which goes first? Spine, 18(1), 66-71.

 

Robinson RC. (2000). Psychometric testing: The early years of the MMPI. In Gatchel and Weisberg (eds). Personality Characteristics of Chronic Pain Patients. Washington, DC: American Psychological Association.

 

Spitzer RL, Williams JB, Gibbon M, First MB. (1988). Structured Clinical Interview for DSM-Ill-R. New York, NY: New York State Psychiatric Institute.

 

Turk DC, Monarch ES. (2002). Biopsychosocial approaches on chronic pain (pp. 3-29). In: RJ Gatchel and DC Turk (eds). Psychological approaches to pain management: A practitioner's handbook. New York: Guilford Press.

 

Turk D, Rudy T. (1988). Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. J. Consult. Clinical Psychology, 56:233-238.

 

 

 



PLEASE LOG IN TO VIEW OR TAKE THIS TEST

This test is only active if you are successfully logged in.




Additional information