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Chronic Pain and Borderline Personality Disorder: It's Not All in Your Head
Chronic Pain and Borderline Personality Disorder
Several studies since the early '90s have shown a strong correlation between the mental illness, borderline personality disorder, and chronic pain syndromes. Those with BPD experience higher levels of pain, on average, and a high percentage of chronic pain patients are BPD-sufferers. But why? First it's important to understand BPD and exactly what it is.
What is borderline personality disorder?
As described by the NIMH (National Institute of Mental Health), borderline personality disorder is a serious mental disorder that was first listed in the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) as a diagnosable illness in 1980. That makes it fairly new, and not very well-understood by the population in general, and even misunderstood by many psychologists today.
Part of this misunderstanding is due to its name; borderline personality disorder got its name because psychiatrists at the time believed it was atypical, or on the "borderline" of several different psychoses and neuroses. That belief has since been well-debunked. In reality, BPD is a form of emotional PTSD, in most cases, stemming from early life trauma. In some cases, it is a result of genetic predisposition or other factors.
The typical symptoms of borderline personality disorder are:
- Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
- A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
- Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
- Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
- Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
- Intense and highly changeable moods, with each episode lasting from a few hours to a few days
- Chronic feelings of emptiness and/or boredom
- Inappropriate, intense anger or problems controlling anger
- Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.
Chronic Pain and BPD
Here's where it get's complicated. About 2% of the overall population has BPD. Then, about 30% of chronic pain patients have BPD. That is a drastic difference, essentially meaning that more people with BPD experience chronic pain than not, by a wide margin.
According to an article in Innovations in Clinical Neuroscience, eight studies had been done to relate chronic pain syndromes to borderline personality disorder since 1994, when the article was published in 2012. Of the subjects in one study, all of whom suffered from chronic pain, 30% reported the symptoms of borderline personality disorder. Additionally, those with borderline personality disorder actually reported higher levels of pain, and those in remission from borderline personality disorder used less pain medications than they had before. The results of this and the other studies underline the fact that BPD and chronic pain are certainly linked, but don't assert a complete picture about why.
Instead, the general take-away is that people with this disorder experience pain as more severe than those without BPD.
However, the reason why is likely to be a more complicated combination of factors, including a real decline in health caused by emotional distress, as well as a decline in emotional health due to physical distress.
Which presents the question:
Physical Pain and Emotional Distress: The Chicken or the Egg?
When talking about borderline personality disorder (and other personality disorders or emotional disorders) and chronic pain, an issue arises:
Which comes first?
While emotional distress can cause your body to experience pain more frequently and more severely, for several reasons, severe and frequent pain can also lead to an emotional response. Pain over a long period of time that is unrelenting can even cause PTSD and changes in stress hormones that effect the way your brain regulates your moods--the hallmark of borderline personality disorder.
Whether or not a study about borderline personality disorder and pain takes into account that the pain syndrome could have occured first is very important. It seems that the easiest and most frequent conclusion is that a person starts out with BPD, and therefore experiences pain in a distorted way. However, a person with BPD may have this disorder due to trauma with a pain disorder or illness.
The two are comorbid, meaning that one does not necessarily cause the other in every instance. Rather, they work together symbiotically, spurring each other on and perpetuating each other in the brain.
Chronic Pain in Family Members of Those with BPD
According to Medline Plus, with the U.S. National Library of Medicine, first-degree family members of those with borderline personality disorder also tend to experience higher levels of pain. This pain is described as "somatoform."
Somatoform Pain Disorder
From the U.S. National Library of Medicine:
- Somatoform pain disorder is pain that is severe enough to disrupt a person's everyday life.
- The pain is like that of a physical disorder, but no physical cause is found.
- The pain is thought to be due to psychological problems.
- The pain that people with this disorder feel is real.
- It is not created or faked on purpose (malingering).
"No physical cause is found."
Again, whether the pain came first or it is caused by a psychological issue is unclear. While family members tend to be diagnosed with "somatoform pain disorder," this disorder is similar in symptomology to syndromes like fibromyalsia and migraine, which run in families. No physical cause can be found for these syndromes, either, yet they are not considered psychological.
Fibromyalsia in BPD-Affected Families
Possible causes of fibromyalsia, according to Mayo Clinic:
- Genetics. Because fibromyalgia tends to run in families, there may be certain genetic mutations that may make you more susceptible to developing the disorder.
- Infections. Some illnesses appear to trigger or aggravate fibromyalgia.
- Physical or emotional trauma. Post-traumatic stress disorder has been linked to fibromyalgia.
In a family where one person has BPD -- for example, the father -- the children are likely to suffer from similar fibromyalsia pain as the father experiences, even though they do not have BPD. In this scenario, the children are likely to be assumed to have "somatoform pain disorder," simply because their father suffers from borderline personality disorder.
However, it is entirely possible that the fibromyalsia came first, since it can be inherited or triggered by illness. The children and the father are likely, in this scenario, to be diagnosed with only psychological issues, since that could explain their physical symptoms. But it is just as likely the opposite: a genetic illness has caused this family to experience pain, which is now going undiagnosed and misdiagnosed. If this pain is severe, such as chronic migraines, and it goes undiagnosed for long periods of time due to a misguided assumption about a psychological disorder, this could cause trauma to those suffering in constant pain, and even cause borderline personality disorder.
That is not to say that BPD does not regularly cause fibromyalsia, migraines, and other pain disorders. As in the Mayo Clinic overview of fibromyalsia, PTSD, which is similar to BPD in many ways, can cause the widespread pain known as fibromyalsia. Often, treating the underlying psychological problems improves pain levels. But the possibility of physical, genetic illness should never be overlooked due to psychological factors in the family or in the individual.
The Immune System Response to Borderline Personality Disorder
The immune system, the mechanism in our body that keeps us healthy, has a very real response to emotional stress. Acute stress -- a single stressful event, such as a big presentation -- has little effect on the immune system. However, long-term stress has a very marked effect on the function of the human immune system. When a person is under moderate to severe levels of stress for long periods of time, the immune system is suppressed, and illness can thrive.
This is what's known as a "physiological change." According to Suzanne C. Segerstrom and Gregory E. Miller in their article, Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry, the immune system evolved in humans alongside the "fight-or-flight" mechanism in our brains. When faced with danger, such as a predator, our brain sends oxygen and blood to the extremeties, signaling this reaction to either fight or to run away. At the same time, the immune system reacts to this temporary physical threat by increasing its defence, having evolved to recognize that injury, and therefore infection with pathogens, can happen during these fight-or-flight moments.
However, the immune system responds to the stressors of today very differently. When faced with a predator, immune response may have increased, because injury and infection were iminent. However, the immune system has a very different response to the types of stressors that we humans face in modern times -- stressors that do not threaten injury, infection, or other physical damage.
Segerstrom and Miller, in their analysis of nearly 300 studies of health and stress, found that there is an undeniable connection between modern-day stressors and the supresssion, or reduced responce, of the immune system. Stress can also cause the body's natural immune defences to misfire, meaning that they could do more damage than good.
Types of Stressors
The immune system also responds noticably differently depending on the type of modern stressor we face, such as whether it is temporary or long-lasting, as mentioned above. The different kinds of stressors are extremely important to understand when trying to figure out how borderline personality disorder causes chronic pain and illness.
According to Elliot and Eisdorfer’s (1982) stressor taxonomy, the different kinds of stressors are essentially as follows:
- Acute time-limited stressors: brief challenges, such as public speaking.
- Brief naturalistic stressors: a person confronts a real-life short-term challenge, such as an exam.
- Stressful event sequences: the loss of a spouse, or a natural disaster; the people affected do not know when the challenge will be over, but they have a sense that it will end.
- Chronic stressors: unlike the previous three; usually extend throughout one's life and force him or her to restructure his/her identity or social roles.
- Distant stressors: traumatic experiences that happened in the past, but have the ability to continue affecting immune system function because of long-term cognitive and emotional consequences.
Chronic and Distant Stressors
As previously discussed, borderline personality disorder is predominantly caused by childhood or early in life trauma, such as sexual assault or abuse. This is a distant stressor, a stressor happened in the distant past, but it continues to affect the immune system, and therefore, damage the individual's health.
Borderline personality disorder also usually includes chronic stressors. Simply the ongoing treatment, and the daily struggles of borderline personality disorder are chronic stressors in themselves. Borderline personality disorder, in all of its symptoms, is a chronic stressor, which creates a vicous cycle of stress, immune response, pain, and more stress.
Once a person is so overwhelmed by these chronic and distant stressors, the others (numbers 1 through 3) can become heightened and pack much more of a punch, both emotionally and physcially. Their affect on the immune system, since your body and emotions are already so overcome with stress, will be greateer.
Pain and the Immune System
Not only can emotional distress cause immune system supression, but prolonged pain can do the same, by increasing the level of cortisol, which is the body's primary stress-induced hormone. Increased cortisol can lead to fatigue, as well as depression and mood problems - just what someone with borderline personality disorder does not need.
This connection between increased cortisol and mood/ emotional disturbance is a key point in the chicken or the egg debate: could physical pain have been a pivotal factor in creating an environment where borderline personality disorder could develop? It is definitely possible.
How do you break out of the cycle of borderline personality disorder, pain, and immune system supression? The answer is: you approach it from all angles. You are less likely to experience pain if you go into remission from borderline personality disorder, but you are more likely to go into remission from borderline personality disorder if you can rid yourself of physical pain and illness related to the immune system.
Emotionally, work on your illness, but only as much as you can handle physically. Physically, work on your illness as much as you can handle emotionally. Your doctor should be aware of your cortisol levels, as well as other stress hormones and how they may be affecting your health, and your psychiatrist and therapist should know you suffer from pain and immune supression. It's all a delicate balance, but not one that can't be reached.