Introduction
To the best of our knowledge, no one has ever suggested that it is “easy” to suffer
from intractable chronic pain, with some subgroups impacted more than others. This
burden has had a particularly strong impact in the United States, where the chronic
pain treatment system has demonstrated failings with respect to access to care1–8
Because chronic pain is so poorly treated in the United States, patients have struggled
not only with their pain and its sequelae but also with mounting frustration and downstream
psychological consequences. Depression and suicidality have been linked to poorly
controlled pain,9,10 and the authors of a recent study11 noted that these phenomena
are a concern within the context of opioid tapering. Similarly, Lembke has recently
acknowledged that even mention of tapering can trigger severe anxiety in chronic pain
patients,12 with data supporting the relationship between undertreated chronic pain
and anxiety.13,14 Although myriad investigations have supported the existence of a
reciprocal relationship between chronic pain and depression15–17 as well as between
chronic pain and anxiety,18–20 detailed discussion of causality is beyond the scope
of this analysis.
Personality Disorders and Chronic Pain
Although depression and anxiety have been the most investigated psychological sequelae
of chronic pain, they are hardly the only psychological conditions for which chronic
pain sufferers are overrepresented. Several early reports and studies suggested that
patients with personality disorders were significantly overrepresented in the chronic
pain patient population.21–24 However, these studies were not particularly methodologically-robust,
as clear issues of selection bias, small sample sizes, and reliance only upon semi-structured
psychiatric interviews detracted from their validities. It was not until Gatchel et
al25 published their prospective multi-site investigation of clinical predictors of
psychopathology as strongly relating to low back pain patient outcomes in 1995 that
more formidable scientific rigor was used to determine the incidence of personality
disorders in the chronic pain population. The authors used a combination of a structured
clinical interview and a 120-item patient questionnaire relating to the structured
interview in addition to the Minnesota Multiphasic Personality Inventory (MMPI) to
determine diagnoses for 324 chronic low back pain patients. Subjects were deemed either
“disabled” or “nondisabled” based upon their current vocational statuses, with 36.1%
of the disabled patients but only 22.3% of the nondisabled group identified as suffering
from a personality disorder.
Beyond the mere diagnosis of a personality disorder is the type of personality disorder
from which a patient suffers. Based on the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders (DSM),26 there are 3 “clusters” of personality
disorders. Cluster A personalities include the paranoid, schizoid, and schizotypal,
and these patients are often described as “odd or eccentric”. Cluster B personalities
include the antisocial, borderline, histrionic, and narcissistic, and patients with
such disorders are described as “dramatic, emotional, or erratic”. Finally, Cluster
C personalities include the avoidant, dependent, and obsessive-compulsive, and are
generally described as “anxious or fearful”. In pain management settings, it is the
Cluster B patients who have received the most attention and raise the highest level
of concern. In 1996, Elliot et al27 published the first study examining the prevalence
of personality disorders in chronic pain patients in an outpatient program using a
psychometric measure (the Millon Clinical Multiaxial Inventory (MCMI)) that had been
validated for the identification of the specific personality disorders. The MCMI profiles
yielded evidence of a personality disorder in 66% of the study’s sample, with 19%
identified as suffering from Cluster B personality disorders. Not surprisingly, higher
Narcissism Scale scores were associated with higher pain scale ratings at discharge,
with higher Borderline Scale scores associated with earlier discharge from the program.
Borderline Personality Disorder and Chronic Pain
Of great concern to pain clinicians is the dramatic over-representation of patients
with a comorbid Borderline Personality Disorder (BPD) (or even severe borderline personality
features without meeting the full diagnostic criteria for a BPD diagnosis) in the
chronic pain population. An excellent summary of the DSM-5 criteria for BPD can be
found at:
http://www.bpddemystified.com/what-is-bpd/symptoms/
. While data suggest a point prevalence of BPD in the general population of only 1.6%,28
figures as high as 62.5% among chronic pain patients have been identified in the empirical
literature.29 Little work has been published on the prevalence of BPD in specific
pain syndromes, although a 2012 study indicated that BPD patients are significantly
over-represented in the fibromyalgia population.30 It has been noted that the percentage
of patients with BPD in medical settings may be underestimated, as they are often
simply identified as “difficult patients” rather than being diagnosed with BPD.31
Further, it has been determined that patients with BPD’s pain complaints are more
difficult to medically substantiate than those without the characterological disturbance.32
Highlighting the issues that result in Cluster B Personalities’ presentations as challenging
patients, Sansone and Sansone33 authored a review in 2007, focusing on specific strategies
for treating chronic pain patients with comorbid BPD. The “paradox” of which they
wrote are findings that while those with BPD seem impervious to self-inflicted pain
(common among BPDs), their tolerance for non-self-inflicted pain has been found in
numerous studies to be considerably lower than in patients without this Cluster B
disorder. The authors also note challenges associated with findings of BPD patients’
higher prevalence of prescription opioid misuse, noting their tendency toward impulsivity
and difficulties with self-regulation. This emotional dysregulation has been determined
to contribute to pain sensitivity.34 Further, BPD patients are likely to report higher
levels of pain than patients with other personality disorders.35 Regarding treatment
of chronic pain patients with BPD, Sansone and Sansone33 emphasize the importance
of helping patients understand that analgesics are unlikely to fully treat their pain,
the benefits of non-opioid medications, the benefits of non-pharmacological approaches,
conservative use of opioid analgesics, and careful monitoring of all opioid prescriptions.
Frequent, brief appointments are suggested, along with the establishment of firm boundaries.
Not surprisingly, a 2013 study by Tragesser et al determined that BPD in non-pain
patients was associated with greater frequency and quantity of opioid abuse, higher
risk for misuse as measured by the Revised Screener and Opioid Assessment for Patients
with Pain (SOAPP-R), and more severe opioid-related consequences and dependence features.36
More severe borderline features were associated with an even greater risk of abuse.
An earlier study indicated that 15% of patients suffering from BPD had histories of
opioid abuse or dependence.37 Sansone et al came to similar conclusions among primary
care outpatients with histories of opioid prescription, determining that those with
BPD were at greater risk for abuse of prescription pain medications.38 The literature
has also addressed similar issues regarding demands for excessive opioid analgesics
in patients with BPD in palliative care settings.39 The authors of a recent investigation
in which patients with chronic pain with comorbid BPD were more likely to misuse prescription
opioids attributed this phenomenon to BPD sufferers’ unstable identities and self-harmful
impulsivity.40
In a later analysis, Sansone and Sansone41 suggest that BPD symptomatology is often
used to interpersonally engage others, with these symptoms, either consciously or
unconsciously, used to elicit caretaking from those around them. However, given their
tendencies toward unstable interpersonal relationships, extreme mood swings, and explosive
anger, these relationships with health-care providers are unlikely to be maintained.
This is consistent with Kalira et al's assessment,42 in which they note that patients
with BPD are prone to provoking anger and frustration in others, potentially resulting
in providers doubting the veracity of their symptoms.
Suicidality has been documented as quite prevalent in borderline personalities, with
an average of 3 suicide attempts during their lifetimes – primarily involving overdose.43
Further, other self-injurious behaviors (eg, superficial wrist cutting not intended
to result in death but rather to relieve emotional tension) are also common among
those with BPD,44 with these “parasuicides” too often resulting in unintended deaths.
Importantly, longitudinal data have suggested that up to 10% of those suffering from
BPD ultimately commit suicide.45 Unfortunately, a recent review concluded that there
are no evidence-based guidelines for suicide prevention in BPD.46 For purposes of
this analysis, it is important to consider a 2006 study that found that individuals
with chronic pain are 2–3 times more likely to commit suicide than those without chronic
pain47 – independent of personality disorder status. Similarly, Braden and Sullivan
determined in a 2008 investigation that borderline personality traits were predictive
of suicide among patients with self-reported chronic pain conditions.48 In 2015, the
initial investigation of the specific relationship between chronic pain, BPD, and
suicidality was published.49 BPD was associated with the utilization of higher dosages
of opioids, the use of benzodiazepines and antidepressants, and medication nonadherence.
Not surprisingly, those patients with BPD reported 6.6 times the likelihood of suicidal
ideation over the past 12 months and 7.9 times the likelihood of a past-12-month suicide
attempt compared to those without BPD.
Yet another concern regarding comorbid chronic pain and BPD are findings that chronic
pain sufferers with BPD are more likely to be receiving disability compensation than
are those without BPD. For example, early work by Burton et al50 determined that workers
compensation patients with BPD were less likely to return to work following functional
restoration. A small 2003 study51 also found a positive relationship between disability
and borderline personality symptoms, with the authors concluding from their finding
that the perception of greater disability in the borderline personality group as representing
an “unconscious tendency to reestablish their life roles as victims” (p. 442). Two
European studies52,53 similarly identified a strong positive association between the
use of disability benefits/pensions and BPD. Most recently, BPD features were associated
with a greater likelihood of receiving disability for chronic pain, even when the
authors controlled for anxiety, depression, and other aspects of patients’ pain.54
The authors offered 3 explanations for their findings. First, negative interpersonal
relationships can cause problems with maintaining employment. Second, that those with
BPDs have diminished social support networks that could provide a buffer to stress
may result in an inability to function at a sufficiently high level to maintain employment.
Most relevant to this analysis, the third explanation offered is that those with BPD
are more likely to find themselves in conflictual relationships with health-care providers,
thus interfering with the quality of care they receive and, consequently, less favorable
pain care outcomes.
“Diathesis-Stress”, Borderline Personality, and Chronic Pain
Many individuals who present at any given time with symptoms of BPD do not do so throughout
their lives. In fact, many may carry what are essentially “latent” features of BPD
until stress levels become so overwhelming that borderline personality features become
manifest. Despite the DSM-V’s26 characterization of the traits that define BPD as
“enduring”, there exists considerable disagreement regarding this concept. Crowell
et al,55 among numerous others, have suggested a purely psychosocial model of BPD,
while others, such as Perez-Rodriguez et al,56 have more recently focused on the neurobiological
underpinnings of the disorder. A biopsychosocial conceptualization of BPD could combine
these two positions, and numerous experts57–60 on the disorder have considered a biological
predisposition toward BPD to put certain individuals at greater risk for the onset
of the disorder and more severe manifestations of its symptoms when under considerable
psychosocial stress. A diathesis-stress model has also been proposed to help understand
why certain individuals will develop chronic pain while others will not do so. Among
the early proponents of such a model were Flor and Turk,61,62 who conceptualized chronic
pain as an interaction between biological and psychological predispositions (diathesis)
and the stress of injury and resulting disability. The copious body of empirical investigation
supporting the model has been reviewed in a textbook chapter by Weisberg and Keefe.63
Most relevant to this analysis is the work by Weisberg and Keefe,64 Weisberg,65 and
Weisberg et al66 on the possibility that stress of chronic pain and the losses associated
with it serving to “trigger” personality disorders to which a patient had been predisposed,
yet had not yet manifested themselves. These authors have posited the existence of
a bidirectional relationship between chronic pain and personality disorders, as well
as claiming that their model provides a rational explanation for the over-representation
of personality disorders in the chronic pain population that was discussed earlier
in this analysis. Supporting this explanation is their observation that descriptions
of many chronic pain patients’ premorbid personality functioning differ dramatically
from those observed following the development of their chronic pain. As discussed
earlier, whether the predisposing diathesis or diatheses are psychosocial, physiological,
or a combination of the two has yet to be firmly established empirically. More relevant
is the conceptualization of chronic pain as a “disease of the person” that affects
the sufferer beyond the physical sensation of pain itself. Rather, chronic pain affects
individuals’ qualities of life by causing potential deficits in function and can have
a dramatic impact on a patient vocationally, financially, legally, recreationally,
socially, sexually, emotionally, and even spiritually.
The COVID-19 Crisis, Chronic Pain, and Borderline Personality Expression: A Potentially
Bad Storm
To this point, we have elucidated the challenges associated with being a patient with
the comorbidities of chronic pain and BPD, as well as treating such patients under
normal circumstances. The worldwide COVID-19 crisis has greatly exacerbated these
challenges, which will be discussed in the remainder of this analysis.
Accepting the diathesis-stress model of chronic pain and BPD, the role of stress in
exacerbating pain symptoms cannot be understated. Whether infected with the virus,
living with loved ones who are infected or in a high-risk category, or fearing for
our lives and/or livelihoods, everyone is under a heightened sense of stress. Much
has been written about the levels of individual and societal stress associated with
the crisis, and detailed description of all of the related stressors is beyond the
scope of this analysis. What is important is the formidable body of literature unequivocally
supporting the notion that stress exacerbates chronic pain.67–69 Although the impact
of stress on chronic pain experience has been studied extensively, investigation of
the impact of societal stress on chronic pain has been limited.
Scientists have already begun to address issues of chronic pain treatment as affected
by the COVID-19 crisis. Eccleston et al70 have noted that the crisis and response
of social distancing have resulted in many having to postpone evaluation and the initiation
of treatment due to the misguided view that pain management is “elective.” As the
authors express concern that patients with pain will turn to the streets and seek
potentially deadly illicit opioids, they recommend that technologies such as telemedicine
and digital therapeutics emphasizing effective self-management should be used more
widely. Cohen et al71 have recently developed a best practices guideline for chronic
pain management during the COVID-19 pandemic and other public health crises. The authors
note that “Traditionally, pain management has not been considered a high priority
in austere environments or times of crisis” (p. 5). Like Eccleston et al,70 they support
telehealth, and opine that utilization of mobile approaches for psychological treatment
of chronic pain is perhaps even more compelling than such approaches for physical
treatment. Certainly to their credit, in discussing appropriate triage, Cohen et al
note the importance of assessing psychiatric considerations. Further, they cite the
empirical literature indicating that psychological stress increases the risk for opioid
abuse, noting that many patients consciously or unconsciously use opioids to reduce
psychological symptoms that may emerge or be exacerbated by the stress of a pandemic.
Unique stressors, including those associated with being quarantined, are outlined.
Overall, the body of literature on BPD and chronic pain strongly supports our concerns
regarding treating previously diagnosed BPD patients. Moreover, it is important to
be aware of the likelihood that those who are predisposed to the characterological
disturbance will manifest BPD in response to the severe stress of the COVID-19 crisis.
Social media has suggested that myriad patients were unable to find adequate pain
treatment prior to the onset of the pandemic, reporting that they were discharged
from multiple practices “without cause”. It is our sense that many of these patients
suffer from BPD, and as clinicians, we understand why physicians may not desire to
work with these individuals. However, we also believe that pain management should
be provided to all in need of such, and discrimination against these individuals presents
an ethical imbroglio. All patients suffering from chronic pain deserve a chance to
lead quality lives, even if they are at risk for impulsivity, suicidality, opioid
misuse, and disruptive or even violent behavior. While medical systems tend to place
the blame on patients for behaviors associated with their personality disorders,72
doing so is a violation of epistemic justice,73,74 and serves to further marginalize
an already stigmatized, vulnerable group of patients.
We conclude by recommending that at this particularly stressful time, the key to solving
the BPD and chronic pain dilemma is more routine screening for personality disorders
among all patients receiving pain management services. With progressive frequency,
physicians who treat patients with pain are administering screening measures for depression
and anxiety, with recent recommendations made for such screening among patients in
chronic pain management involving opioid therapy,75 prior to spine surgery,76 in cancer
care,77 and in primary care practice, generally.78–80 Further, some suggest that more
frequent urine drug testing (UDT) is actually an answer to the opioid misuse problem
in the pain management setting,81 with recommendations that all patients receiving
chronic opioid therapy undergo monthly UDT – not to exclude patients from treatment
– but rather to determine which patients require a higher degree of monitoring in
order to optimize treatment safety and efficacy. This approach is similar to one proposed
in a recent study of total hip and total knee arthroplasty patients, in which the
authors stress screening not as a deterrent to arthroplasty, but rather as a tool
to identify patients who would potentially benefit from a higher level of support
and to minimize unnecessary utilization of resources.82 Would routine of screening
for BPD for chronic pain patients seeking treatment not potentially result in similar
outcomes, with benefits to both the patient and physician practices?
Effective screening for depression and anxiety is not necessarily less time-consuming
than screening for BPD, although more numerous brief screening measures for depression
and anxiety have been validated. Undoubtedly, the choice of a BPD screening measure
is an important one. Although structured and semi-structured interviews are considered
the “gold standards” for the diagnosis of personality disorders, these approaches
require a considerable amount of training, expertise and physician time to administer.
Accordingly, they cannot be considered practical for use in the pain setting for screening
patients for BPD.
While a number of screening measures for personality disorders exist, we believe that
the most effective and practical for routine screening of BPD in the pain management
setting is the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD).83
Numerous screening measures for all of the DSM personality disorders have been published,84
yet as they screen for multiple personality disorders, they tend to be lengthy and
screen for disturbances that may not be particularly relevant to chronic pain management.
The MSI-BPD is a 10-item measure specific to BPD. Its balance of sensitivity (0.81)
and specificity (0.85) have been determined to be good.83 While not widely used in
investigations of the impact of BPD on chronic pain outcomes, the general psychometric
properties of the measure are sufficiently strong to justify it as a quick screener
for BPD. Positive scores on the MSI-BPD should never be used to exclude a patient
with pain from treatment. As it is merely a screener, the tool should be used to identify
patients who may likely benefit from psychological or psychiatric evaluation prior
to continuing with treatment. Screening should be provided to all patients in a pain
practice in order to 1) avoid stigmatizing those suspected of having a BPD, and 2)
identify those who potentially do suffer from a BPD yet have not manifested it in
their interactions with a practice, yet have the potential to manifest the symptoms
in response to high levels of stress. This is particularly important during the ongoing
COVID-19 crisis, as patients with chronic pain are dealing not only with their “normal”
pain-related stressors but also with remote treatment or a complete lack of treatment,
as well as concerns regarding medication shortages and lack of access to alternative
and multimodal care.70
Chronic pain patient advocates have expressed concern that identification of patients
with BPD will result in many not being able to receive treatment. This is hardly the
recommendation that we are making. Should a patient receive a diagnosis of a BPD,
he/she should be more closely monitored than non-characterologically-disturbed patients,
just as those with greater potential for prescription opioid misuse should be monitored
for such more closely than those at lower risk.85,86 Perhaps the analogy of patients
at higher risk for substance abuse can be taken further in considering those with
BPD. It has been recommended that patients at higher risk for substance abuse can
be effectively treated in outpatient pain clinic settings, provided that they work
concomitantly with a substance abuse counselor and/or an addiction medicine specialist.87
Accordingly, we recommend not that those with BPD are excluded from necessary treatment
that is often necessitated for patients to lead lives of reasonable quality, but that
they also receive concomitant mental health services (including Dialectical Behavioral
Therapy) in order to help them minimize the behaviors that have too often resulted
in their discharge from pain care and often futile efforts to find new pain management
specialists to treat them. A perusal of social media over the past 3 months is suggestive
of widespread psychological deterioration of many chronic pain patients, with evidence
of high levels of vitriol, frank paranoia, and threats regarding self-destructive
behaviors (eg, seeking illicit opioids on the streets, suicidality) and outward violence
more frequent than had been the case prior to the onset of the COVID-19 crisis. We
appreciate that several months of social media posts hardly represent empirical “data”,
and that changes in the social media environment may occur as the pandemic progresses,
stagnates, or diminishes. Irrespective, we find the trends in borderline types of
posts disturbing, and are concerned that many patients will experience difficulties
in finding and/or maintaining the relationships necessary to access reasonable-quality
pain management. Having made recommendations for screening, referral, and enhanced
monitoring, we understand that they will not be universally accepted. Further, we
recognize that there will undoubtedly be a degree of variance regarding how patients
with comorbid chronic pain and BPD are most effectively managed within individual
pain management practices. Irrespective, it would perhaps behoove pain management
physicians and their patients to ask themselves 1) are outcomes under the current
paradigm of treating all patients presenting for treatment satisfactory?, and 2) can
risks to both patients and their physicians be further mitigated by screening for
BPD?
BPDs are not “going away”, and it appears likely that the COVID-19 crisis is not going
to “go away” anytime soon. The stress of poorly managed chronic pain, according to
the diathesis-stress theory, is likely to result in increasing levels of stress and,
accordingly, increased emotional dysregulation and related behaviors among those suffering
from BPD as the COVID-19 crisis persists. Although not a panacea, the simple act of
screening all chronic pain patients for BPD may represent an important initial step
in identifying patients in pain practices that can benefit from further mental health
evaluation and increased monitoring. Perhaps we should have looked at such a paradigm
as prudent since the inception of the management of chronic pain. Irrespective, the
ongoing COVID-19 crisis gives us even more reason to institute a minor paradigmatic
revision in our assessment and treatment of patients with chronic pain.