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14 Articles in Volume 18, Issue #2
Ask the Expert: Is there evidence to prescribe cyclobenzaprine long-term?
Challenging the Chronic Pain Personality Profile
Designer Peptide May Prevent Chemo-Induced Neuropathy
Inside the Cancer Pain Research Consortium
Intrathecal Drug Therapy for Cancer-Related Pain
Managing Cancer Pain in an Era of Modern Oncology
Mapping Complex Pain: A Case Study
Medication Overuse Headache: Inaccurate and Overdiagnosed
Pain and Fall Risk in the Elderly
Reporting Quality of Care in Cancer Pain Management
Sharing the Risk: An Update to DEA & Doctors Working Together
The Intensifying Conflict Between Opioid Control and Pain Control
Two Mobile Apps Aim to Target Patient Compliance & Safety
Why Prescribers Need to Adopt Abuse-Deterrent Opioids

Challenging the Chronic Pain Personality Profile

March 2018 PPM Letters to the Editor from practitioner peers and patients

Dear Dr. Cosio,

I’d like to respond to your article “Understanding the Role of Personality Disorders in the Treatment of Chronic Pain,” published in the January/February 2018 issue. Here in Canada, 16% to 41% of the population suffers from chronic pain. Much like in the United States, chronic pain exists in epidemic proportions and continues to be managed poorly. When dealing with such a wide swath of the population, healthcare providers are absolutely going to see a lot more than chronic pain. Some patients will indeed suffer from mental illness, and we know that a common symptom of post-traumatic stress disorder is chronic pain as well.

Chronic pain is a sure-fire way to disrupt one’s mental health and perhaps lead to a change in character. It will change moods, behaviors, and personality characteristics, and it will not take long. Consider putting your own body into a position wherein you feel severe, relentless chronic pain and imagine letting that pain go untreated…

Notice how it feels as you lose the ability to maintain employment and watch your financial resources drift away as you use them up to get by. Notice the ensuring hardship as you lose your home and end up on a small, fixed, disability income. Notice how your hard-earned credentials no longer have meaning, and what the pain does to your mental wellness as you lose out on life’s opportunities.

At the same time, you may notice how the pain leads to relationship breakdown. Friends with whom you used to enjoy socializing fade away. Family members try at first to help, but as time passes, are unable to understand how you feel. Notice your mental health suffer as your life continues to grow isolated. As role after role slips away, this loss of self can manifest in many ways. Instead of a productive, hard-working, earning individual, you may feel that you have become a burden to others.

Try as you might to regain your health, notice how you feel lost in a healthcare system as there is no solution for your pain, combined with the constant awareness of the betrayal of your body. Some physicians may discredit you, leaving you confused and hurting even more. As you experience impaired or reduced function, sleep and appetite disturbances, helplessness and hopelessness become unwanted visitors. They won’t take long to invite in depression and anxiety.

Your mental health adapts to all of this, and if the pain goes on long enough, your mind will inevitably drift to the only solution you can see through a blur of suffering. We certainly know the risk of suicide greatly increases among chronic pain patients.

Did your character or personality change? Are you the same intelligent, vital, productive individual without any sign of a disorder?

In one of our western provinces last year, a citizen was in terrible pain. I will spare the personal details but his doctor did not treat his pain. The days and weeks dragged on. One night, out of desperation, he managed to get to the emergency ward of his local hospital. The ward offered no treatment and again he was sent home with terrible pain in tow. Sadly, he took his life that night. Immediately, and without hesitation, the hospital staff transformed this man from someone in horrific pain, begging for help, into a psychiatric patient. The conversation turned quickly to how sad it was, and that there needed to be a push for more and faster psychiatric resources to ensure this didn’t happen in the future.

However, this man was not a psychiatric patient. He was a human being with intolerable, inescapable, and interminable pain that was left untreated. His basic human right to have his suffering eased was violated.

If we deemed all chronic pain patients as having a psychiatric diagnosis, we could offer them all psychotropic medications and pat ourselves on the backs for a job well done. And when anyone attempts or commits suicide, society could pretend that it was due to mental illness, never just excruciating pain. That person might be gone forever, but we can sleep at night knowing we did our job to the best of our ability because the perception is that it’s very difficult to treat some mental illnesses.

The American Psychiatric Association’s Diagnostic and Statistic Manual of Mental Disorders is indeed a wonder. In its evolution, it has taken us from about 100 disorders in the 1950s to more than 500 today. We are also fortunate to have all of those pharmaceutical companies developing the medications we need. Let’s face it, our brain pathologies are becoming really hard to keep up with. We may even be told when we’re not grieving as per the standard, or that we suffer from a caffeine-related mental illness. That’s good to know so that we can get the correct medication.

Of course I am being facetious. I am angry, shocked, and confused. In today’s climate, chronic patients are taking quite the beating. It’s almost effortless because this group is already down. They never used to be dismissed as addicts, but they are now. Those who have the most severe pain have been yanked off of their medications and sent spiraling into more suffering, disability, and even death from medical collapse or suicide. Their treatment now comes from political policy rather than medical fact. So now, not only can we tick them off in the DSM as addicts, perhaps we can also soon label them as them having a personality disorder.

It seems as though humanity and perspective are being lost. Shipping pain patients off to rehab clinics and filling them with psychotropic drugs does not treat their pain. When did chronic pain become a social ill that must be denied or twisted into another illness altogether? There is a great travesty disguised as care occurring along with an over-reaching of efforts and excuses not to treat pain. What happened to pain being the fifth vital sign? Pain is pain is pain, whether it’s caused by a car accident, chronic illness, or cancer.

Maybe there is a better way. Imagine a world where pain got the respect it deserved? Where more money and resources were allotted to not only research and education but also to treatment? Make no mistake. We have a pain crisis that is out of control and no amount of dismissing it as addiction or inventing new mental pathologies will heal these individuals. Let’s collectively tap into the humanity we all have left and treat pain in a way that is necessary and helpful.

Ann Marie Gaudon, MSW
Registered Social Worker, Psychotherapist, Chronic Pain Sufferer, 33 years and counting


Dear Ms. Gaudon,

Thank you for writing. I can tell that you have a lot of passion and concerns related to chronic pain, and I want to address them.

In the United States, and I presume in Canada as well, we recognize that chronic pain is not a simple phenomenon, but rather a holistic one. We also know that different psychopathologies are comorbid with chronic pain, and if they are not addressed, they may have a negative impact in the patient’s recovery process. As a mental health professional, I assume you would agree that it is important to assess, educate, and treat these diseases in addition to addressing the chronic pain needs of the individual. This multidisciplinary approach is important as the majority of mental health cases go unrecognized in primary care settings. In fact, about 60% of previously undetected depression cases could have been recognized if the patients had been evaluated for a mental health disorder.

When someone has an untreated mental health condition that goes unaddressed, it tends to affect the outcome of treatment overall. Therefore, we felt it was important to educate frontline providers about these disorders, how they are defined, and how the definitions have changed with the new DSM-5.

There is no cure for chronic pain, so the goal is to make patients feel better. It is a matter of coping. In terms of the personality disorder article you reference, the intention was not to diagnose people with pain as having a personality disorder, but rather to educate providers about pre-existing characteristics that could affect a certain individual’s ability to cope. If healthcare providers are able to identify these patients, then we can better address the whole patient, treating any mental issues in conjunction with a comprehensive pain management plan.

The overall purpose of my Mental Health column in the journal is to focus on the potential comorbid psychological, emotional, and cognitive issues that may affect individuals living with chronic pain conditions so that readers—clinicians—can continue to apply the best, most well-rounded strategies and practices in their care. As a result, it is hoped that patients may achieve the most effective long-term outcomes.

Again, thank you for writing and providing feedback.

David Cosio, PhD, ABBP
Anesthesiology/Pain Clinic
Jesse Brown VA Medical Center, Chicago, IL
Author of PPM’s Mental Health series

Last updated on: April 12, 2019
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