OBJECTIVE: This screening study assessed 1000 consecutive migraine patients
at one headache clinic for Axis II (Personality Disorder (PD)) pathology. The purpose was to
determine the prevalence of moderate or severe PD within a headache population.
BACKGROUND: The recoginition of PD is crucial for effective treatment. Certain types of
PD are dangerous to a medical clinic, and they tend to be the most difficult patients to treat.
They are underestimated and not readily recognized by healthcare professionals, and require a
different approach. Many patients with PD characteristcs display a spectrum of symptoms, not
easily categorized into one specific PD. In general, characteristics may include: lack of
insight, blaming, anger, poor response to therapy and non-compliance, demanding, sense of
entitlement, lack of resilience, etc... Each PD has differing features. They are often a
source of frustration for medical personnel, but once identified, limits may be set and
therapeutic goals altered.
METHODS: 1000 consecutive patients with HIS diagnosis of migraine (with or without
tension headache) were screened. The patients were 20 to 92 years old, 805 women and 195 men.
All patients had been assessed via interviews, as well as an intake psychiatric assessment form
adapted for headache patients. The patients were assessed by the same treating neurologist/psychopharmacologist,
who also did the chart review for this study. The diagnosis of PD was done in accordance with DSM-IV
criteria. The patients identified as PD fulfilled the criteria, and were also considered moderate or
severe; the PD Characteristics were pervasive, greatly influencing functioning and social interactions.
Patients with mild PD, or characteristics of PD, were excluded.
RESULTS: CLUSTER A PD:
PARANOID (suspicious, rigid, thin-skinned, angry, dangerous, doubt loyalty): 2(M) .2%
SCHIZOID (self sufficient, indifferent, detached): 1(F) .1%
SCHIZOTYPAL (eccentric, grandiose): 0
CLUSTER B PD:
ANTISOCIAL(exploitative, condescending, opportunistic, deceitful, impulsive, irritable, lack
remorse): 3 (2M, 1F) .3%
BORDERLINE: (instability, poor-self imagine, abandonment fears, impulsive, suicidal, splitting,
angry, depressed, dramatic): 12 (2M, 10F) 1.2%
HISTRIONIC: (expressive, attention-seeking, emotional, shallow, theatrical, needy,
seductive, childlike, exaggerated, body-oriented): 5(F) .5%
NARCISSISTIC: (grandiose, lacks empathy, needs admiration, condescending, sense of
entitlement, exploitative, envious, arrogant, selfish, uncaring, rageful, insensitive): 4 (2M, 2F) .4%
CLUSTER C PD:
AVOIDANT: (socially inhibited, inadequacy, hypersensitive, fearful, sad, hypervigilant): 11 (1M, 10F) 1.1%
DEPENDENT (submissive, clings, fear of separation, need reassurance, manipulative,
naïve, lack of confidence): 7 (7F) .7%
OBSESSIVE-COMPULSIVE: (rigid, preoccupied with orderliness, miserly, perfectionistic, indecisive, cold, hoarding,
controlling, anxious, workaholic, demanding): 7 (7F) .7%
TOTAL PD SPECTRUM (MODERATE OR SEVERE): 55/1000 (5.5%); women=46/805 (5.7%)
men=9/195 (4.6%)
CONCLUSIONS: In this study 5.5% of migraineurs had a moderate or severe PD. The most
commonly seen PD's were borderline (1.2%) and avoidant (1.1%). The recognition of PD greatly affects
our approach.
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