Disability and borderline personality disorder in chronic pain patients

1Department of Psychiatry and Internal Medicine, Wright State University School of Medicine, Dayton; 2Department of Psychiatry Education, Kettering Medical Center, Kettering, Ohio; 3Private practice as an independent consultant for the management of chronic noncancer pain, Seattle, Washington; 4Division of Psychology, Department of Human Relations, Columbia College, Columbia, South Carolina, USA Correspondence: Dr Randy A Sansone, Sycamore Primary Care Center, 2115 Leiter Road, Miamisburg, Ohio 45342, USA. Telephone 937-384-6850, fax 937-384-6938, e-mail randy.sansone@khnetwork.org Borderline personality disorder is a personality dysfunction that is characterized by chronic self-regulation difficulties (eg, eating disorders, drug/alcohol abuse and pain regulation difficulties) and long-standing self-harm behaviour. Patients with this particular personality disorder have specific psychodynamics and behaviours that can potentially compromise overall psychosocial and occupational functioning. For example, Kroll (1) discussed the crucial psychodynamic theme of victimization in these patients and emphasized that this victim theme is essential in understanding the psychopathology of these patients. Kroll states that individuals with borderline personality disorder engage others to “...act upon [them], usually in a negative, rejecting, or aggressive way, but sometimes in a caretaking...way”, and emphasizes that the behaviours of helplessness and incompetence are, at times, intended to coerce others to “take over ordinary adult functions and decision-making activities”. This theme of victimization can readily interface with various medical issues to promote a position of helplessness and incompetence, leading to the role of “medical victim” (2). In turn, chronic medical victimhood lends itself to ongoing psychosocial dysfunction and impairment, and the gravitation toward medical disability. Few studies have explored the relationship between medical (not psychiatric) disability status and borderline personality symptomatology (BPS). Burton et al (3) examined individuals with work-related upper extremity pain and found that BPS was a predictor for poor return to work. In an internal medicine sample (4), we found that disabled participants who were unable to work were significantly more likely to meet the criteria for BPS than nondisabled counterparts. However, in a second internal medicine sample (5), we did not find any relationship between medical disability and BPS. In summary, the relationship between medical disability and BPS remains empirically unclear, despite indications in the clinical literature that such relationships are likely. In the present study, we examined the relationship between medical disability and BPS in a unique clinical sample – an insured chronic pain population. We hypothesized that the presence of BPS would be associated with medical disability, based on the preceding clinical impressions and available empirical literature.

Few studies have explored the relationship between medical (not psychiatric) disability status and borderline personality symptomatology (BPS).Burton et al (3) examined individuals with work-related upper extremity pain and found that BPS was a predictor for poor return to work.In an internal medicine sample (4), we found that disabled participants who were unable to work were significantly more likely to meet the criteria for BPS than nondisabled counterparts.However, in a second internal medicine sample (5), we did not find any relationship between medical disability and BPS.In summary, the relationship between medical disability and BPS remains empirically unclear, despite indications in the clinical literature that such relationships are likely.In the present study, we examined the relationship between medical disability and BPS in a unique clinical sample -an insured chronic pain population.We hypothesized that the presence of BPS would be associated with medical disability, based on the preceding clinical impressions and available empirical literature.

Methods
Participants in the present study were chronic noncancer pain patients who were consecutively recruited during their initial BAckgRound And oBJective: Few studies have examined the relationship between disability and borderline personality symptomatology, and, among those that have, findings have been inconsistent.In the present study, the relationship between medical disability and borderline personality symptomatology was examined in a sample of chronic pain patients.Methods: In a consecutive insured sample of male and female chronic pain patients (n=117), who were being initially evaluated by an outpatient pain specialist, the criterion of having "ever been on medical disability" and features of borderline personality disorder were examined using the borderline personality scale of the Personality Diagnostic Questionnaire-4.Results: While 35% of participants acknowledged having ever been on medical disability, there was no statistically significant difference between those with a history versus those without a history of medical disability with regard to the prevalence of borderline personality symptomatology.conclusions: Findings suggest that among chronic pain patients, there may be no meaningful relationship between having ever been on medical disability and borderline personality symptomatology.MÉthodologie : Dans un échantillon consécutif de patients de sexe masculin et féminin assurés ayant des douleurs chroniques (n=117) qui ont été initialement évalués par un spécialiste de la douleur en consultations externes, les chercheurs ont examiné le critère d'« incapacité médicale antérieure » et les caractéristiques de troubles de la personnalité limite au moyen de l'échelle de personnalité limite du questionnaire diagnostique de la personnalité-4.RÉsultAts : Tandis que 35 % des participants ont reconnu avoir déjà eu une incapacité médicale, il n'y avait pas de différence statistiquement significative entre ceux qui avaient de tels antécédents et ceux qui n'en avaient pas pour ce qui est de la prévalence de symptomatologie de la personnalité limite.conclusions : D'après les résultats, chez les patients ayant des douleurs chroniques, il n'y aurait peut-être pas de lien significatif entre le fait d'avoir déjà eu une incapacité médicale et la symptomatologie de la personnalité limite.clinical evaluation.After an introduction to the project, in which the recruiter explained the purpose, design, anonymity, risks and benefits of the study, each qualifying patient was invited to participate.Each participant completed a research booklet that explored demographics, disability history ("Have you ever been on medical disability?"), Workers' Compensation status and BPS as measured by the borderline personality scale of the Personality Diagnostic Questionnaire (PDQ)-4 (6), a self-report version of the diagnostic criteria for the disorder as listed in the Diagnostic and Statistical Manual of Mental Disorders, 4 th edition (7).Earlier versions of the PDQ have been confirmed as useful screening tools for borderline personality disorder in both clinical (8,9) and nonclinical samples (10), including the use of the free-standing borderline scale (11).Completion of the research booklet was assumed to function as consent to participate.The project was approved by an institutional review board.
In terms of disability status, 41 (35.0%) participants reported ever having been on medical disability.The mean score on the PDQ-4 did not differ significantly between those respondents who had been on medical disability (n=41, mean 1.68±1.90)and those who had not (n=76, mean 1.61±2.01)(t [1,115]=0.20,P<0.85).The proportions of respondents who exceeded the cut-off score of 5 on the PDQ-4, indicating an increased likelihood of borderline personality disorder, was examined.The proportions of such clinically positive respondents in the disability group (7.3%) and nondisability group (10.5%) were not statistically significantly different (c 2 =0.32,P<0.60).
A total of 32 (27.4%) of the respondents were undergoing evaluation for Workers' Compensation.The mean score on the PDQ-4 did not differ significantly between those respondents who had undergone evaluation for Workers' Compensation (n=32, mean 1.53±1.97)and those who had not (n=85, mean 1.67±1.97)(t [1,115]=0.34,P<0.75).The proportions of respondents who exceeded the cut-off score of 5 on the PDQ-4, indicating an increased likelihood of borderline personality disorder, were also examined.The proportions of such clinically positive respondents in the evaluation group (9.4%) and nonevaluation group (9.4%) were not statistically significantly different (c 2 =0.00,P<1.00).

discussion
The findings from the present study suggest that there is no relationship between medical disability and BPS.From a statistical perspective, even though there appears to be no relationship between medical disability and BPS among the participants in the present study, we cannot be sure that the study data provided sufficient evidence to reject the null hypothesis.If our hypothesis is actually correct, but statistically unproven, then the findings from the present study might indicate that such a relationship is highly dependent on the sample under study and, perhaps, not particularly statistically robust in an insured sample of chronic pain patients.If so, this interpretation would be particularly relevant for clinicians in the area of pain management because they might anticipate potentially greater management difficulties in uninsured or governmentinsured chronic pain populations.If the null hypothesis is actually valid, we might interpret that underlying BPS is not necessarily the predominant explanation for the types of management challenges that clinicians encounter in patients with chronic pain.Indeed, there may be other competing psychiatric explanations including comorbid Axis I disorders such as depressive and anxiety disorders, as well as various Axis II disorders such as antisocial or dependent personality disorders.
The limitations of the present study include the small sample size, use of self-report measures and lack of information about pain status (eg, years in pain and location of pain).Additional research with larger samples, comparisons by insurance type and use of more than one measure of BPD is warranted.