Borderline Personality Disorder and Chronic Pain: Be a Therapeutic Optimist

LAS VEGAS—“Get the keys to the attic!” That's the advice Michael R. Clark, MD, MPH, MBA, provided to attendees during his evocatively titled and engaging presentation, “The Madwoman in the Attic: Pain and Personality Disorders.”

“The borderline patient is manageable,” said Dr. Clark, who is Vice Chair, Clinical Affairs, and Director, Pain Treatment Programs, Department of Psychiatry & Behavioral Sciences at Johns Hopkins Medicine, Baltimore, Maryland.

The “official” definition of personality disorders is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture.” This pattern is manifested in two or more of four areas: cognition, affectivity, interpersonal functioning, and impulse control.

Crucial considerations are that this pattern is stable and of long duration, with its onset traced back to at least adolescence or early adulthood; is not better explained as a manifestation or consequence of another mental disorder, and is not attributable to the physiological effects of a substance, such as a drug of abuse or a medication, or another medical condition, such as head trauma.

Treating personality disorders in chronic pain requires following pain management principles that include, “is the patient doing more?” “is the patient feeling better?” and “is there less focus on pain and emotional distress?” Dr. Clark said goals for borderline personality disorder and chronic pain are similar, which is to improve functioning, ability to tolerate discomfort, and coping skills for difficult situations and to emphasize behaviors based on thoughts rather than feelings.

He reviewed the underlying themes of treating patients with personality disorders, including “can't means won't,” “need means want,” and “think means feel.” Also emphasized was the need to explain the doctor-patient relationship, define consequences of “inappropriate” acts, and the importance of documenting if treatment is rejected.

The essence of “borderline” includes three types of patients: demanding, noncompliant, and high-utilizing. The demanding patient does not understand the word “no” and wants the clinician to “just fill my order.” The noncompliant patient won't or can't follow directions. The high-utilizing patient presents with high levels of distress, multiple unexplained symptoms, an overwhelming medical history, and extensive treatment failures.

He urged clinicians to “look for options to solve the problem” including asking colleagues for help. Comprehensive treatment is effective, and “team-based treatment prevents frustration,” he said.

Although the patient can always be discharged, “patients seeking medical care need help, and if you do not help, someone will hurt.”