Chronic pain clinic as a haven for difficult patients: the role of projective identification
DOI:
https://doi.org/10.5935/0104-7795.20150010Keywords:
Chronic Pain, Pain, Intractable, Projection, Identification (Psychology), Personality Disorders, Physician-Patient RelationsAbstract
Difficult patients - or those with difficult personalities - are frequently encountered in the treatment of chronic non-oncologic pain, overburdening the doctor-patient relationship far beyond the complexities of their illness and treatment. The present review/experiential report discusses the role that projective identification, as a psychological process of communication, puts the doctor-patient relationship in within the multi-professional chronic pain team. The concepts of projective identification are reviewed both in their benign and their malignant forms. Two clinical vignettes exemplify each of them. Some situations in the setting of doctor-patient communication are presented in which projective identification appears and complicates the therapeutic relationship. Some recommendations are offered regarding the handling of patients that communicate mainly by means of projective identification, and some ideas are offered to the multi-professional team. In our chronic pain clinic, difficult patients as a whole seem to prefer to communicate by means of a malignant form of projective identification and present with immature types of personality organizations. Within the chronic pain teams, doctor-patient relationships (as well as relations among the professionals) can be enriched if projective identification is detected early and appropriately handled. Long-term psychotherapy is the treatment that should be chosen for such patients.
Downloads
References
Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159(10):1069-75. DOI: http://dx.doi.org/10.1001/archinte.159.10.1069
Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994;47(6):647-57. DOI: http://dx.doi.org/10.1016/0895-4356(94)90212-7
Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11(1):1-8. DOI: http://dx.doi.org/10.1007/BF02603477
Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134(9):897-904. DOI: http://dx.doi.org/10.7326/0003-4819-134-9_Part_2-200105011-00014
Wasan AD, Wootton J, Jamison RN. Dealing with difficult patients in your pain practice. Reg Anesth Pain Med. 2005;30(2):184-92. DOI: http://dx.doi.org/10.1097/00115550-200503000-00009
Gabbard GO. Patients who hate. Psychiatry. 1989;52(1):96-106.
Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-7. DOI: http://dx.doi.org/10.1056/NEJM197804202981605
Klein M. Inveja e gratidao e outros trabalhos (1946-1963). Rio de Janeiro: Imago; 1946.
Aguayo J. On understanding projective identification in the treatment of psychotic states of mind: the publishing cohort of H. Rosenfeld, H. Segal and W. Bion (1946-1957). Int J Psychoanal. 2009;90(1):69-92. DOI: http://dx.doi.org/10.1111/j.1745-8315.2008.00115.x
Bion WR. Estudos psicanalíticos revisados (second thoughts). Rio de Janeiro: Imago; 1994.
Segal H. A Obra de Hanna Segal. Rio de Janeiro: Imago; 1982.
Rosenfeld H. Impasse e interpretaçao. Rio de Janeiro: Imago; 1987.
Goretti GR. Projective identification: a theoretical investigation of the concept starting from notes on some schizoid mechanisms. Int J Psychoanal. 2007;88(2):387-405.
Laplanche J. Vocabulário da psicanálise/Laplanche e Pontalis. 3 ed. Sao Paulo: Martins Fontes; 1998.
Goldstein WN. Clarification of projective identification. Am J Psychiatry. 1991;148(2):153-61.
Böhmer MW. "Communication by impact" and other forms of non-verbal communication: a review of transference, countertransference and projective identification. Afr J Psychiatry (Johannesbg). 2010;13(3):179-83.
Ramchandani D. The concept of projective identification and its clinical relevance. Am J Psychother. 1989;43(2):238-47.
Kernberg OF. Projection and projective identification: developmental and clinical aspects. J Am Psychoanal Assoc. 1987;35(4):795-819. DOI: http://dx.doi.org/10.1177/000306518703500401
Clarke S. Projective Identification: From Attack to Empathy? [text on the Internet]. London: Kleinian Studies Ejournal [cited 2014 July 7] Available form: http://www.psychoanalysis-andtherapy.com/human_nature/ksej/clarkeempathy.html
Ogden TH. On projective identification. Int J Psychoanal. 1979;60(3):357-73.
Gabbard GO. Splitting in hospital treatment. Am J Psychiatry. 1989;146(4):444-51. DOI: http://dx.doi.org/10.1176/ajp.146.4.444
Forward S. Emotional blackmail. New York: Harper; 1997.
Waska RT. Projective identification, countertransference, and the struggle for understanding over acting out. J Psychother Pract Res. 1999;8(2):155-61.
Solano JPC. Fracasso crônico no tratamento da dor crônica? A influência silenciosa da personalidade e seus transtornos. Acta Fisiatr. 2014;21(2):93-100.
Weisberg MB, Clavel AL. Why is chronic pain so difficult to treat? Psychological considerations from simple to complex care. Postgrad Med. 1999;106(6):141-2.
Mason P, Kreger R. Stop Walking on eggshells: taking your life back when someone you care about has borderline personality disorder. Oakland: New Harbinger; 1998.
Kreger R. The essential family guide to borderline personality disorder. Center City: Hazelden; 2008.
Poppe C, Crombez G, Devulder J, Hanoulle I, Vogelaers D, Petrovic M. Personality traits in chronic pain patients are associated with low acceptance and catastrophizing about pain. Acta Clin Belg. 2011;66(3):209-15.
Edwards RR, Cahalan C, Calahan C, Mensing G, Smith M, Haythornthwaite JA. Pain, catastrophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol. 2011;7(4):216-24. DOI: http://dx.doi.org/10.1038/nrrheum.2011.2
Turk DC, Wilson HD. Fear of pain as a prognostic factor in chronic pain: conceptual models, assessment, and treatment implications. Curr Pain Headache Rep.2010;14(2):88-95. DOI: http://dx.doi.org/10.1007/s11916-010-0094-x
McShea M. The failure to contain: How persecutory anxieties contribute to noncompliance in adult patients with congenital chronic pain conditions. Psychoanalytic Social Work. 2008;15(2):132-57. DOI: http://dx.doi.org/10.1080/15228870802086975
Segal H. Introduçao à obra de Melanie Klein. Rio de Janeiro: Imago; 1975.
Ogden T. Os sujeitos da psicanálise. Sao Paulo: Casa do Psicólogo; 1996.
Clarkin J, Yeomans F, Kernberg O. Psychotherapy for borderline personality. Arlington: American Psychiatric; 2006.
Kalira V, Treisman GJ, Clark MR. Borderline personality disorder and chronic pain: a practical approach to evaluation and treatment. Curr Pain Headache Rep. 2013;17(8):350. DOI: http://dx.doi.org/10.1007/s11916-013-0350-y
McWilliams LA, Higgins KS. Associations between pain conditions and borderline personality disorder symptoms: findings from the National Comorbidity Survey Replication. Clin J Pain. 2013;29(6):527-32. DOI: http://dx.doi.org/10.1097/AJP.0b013e31826ab5d0
Frankenburg FR, Zanarini MC. The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. J Clin Psychiatry. 2004;65(12):1660-5. DOI: http://dx.doi.org/10.4088/JCP.v65n1211
Keuroghlian AS, Frankenburg FR, Zanarini MC. The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up. J Psychiatr Res. 2013;47(10):1499-506. DOI: http://dx.doi.org/10.1016/j.jpsychires.2013.06.012
Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality. Innov Clin Neurosci. 2012;9(1):10-4.
Sansone RA, Whitecar P, Meier BP, Murry A. The prevalence of borderline personality among primary care patients with chronic pain. Gen Hosp Psychiatry. 2001;23(4):193-7. DOI: http://dx.doi.org/10.1016/S0163-8343(01)00148-7
Sansone RA, Sansone LA. Borderline personality and the pain paradox. Psychiatry (Edgmont). 2007;4(4):40-6.
Kernberg OF, Yeomans FE. Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis. Bull Menninger Clin. 2013;77(1):1-22. DOI: http://dx.doi.org/10.1521/bumc.2013.77.1.1
Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364(9432):453-61. DOI: http://dx.doi.org/10.1016/S0140-6736(04)16770-6
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(6):922-8.
Newman A. As idéias de D.W. Winnicott: um guia. Rio de Janeiro: Imago; 2003.
Gabbard GO. On 'doing nothing' in the psychoanalytic treatment of the refractory borderline patient. Int J Psychoanal. 1989;70(Pt 3):527-34.
Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harv Rev Psychiatry. 1998;6(4):201-7. DOI: http://dx.doi.org/10.3109/10673229809000330
Downloads
Published
Issue
Section
License
Copyright (c) 2015 Acta Fisiátrica
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
