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Psychiatry 2007 [ A P R I L ]40

ABSTRACTClinical observations and empirical

studies indicate that patients withborderline personality are bothsensitive and insensitive to pain. Thisdichotomy may be explained by thecontext of the pain. For acute self-induced pain, borderline patientsseem to experience attenuated painresponses. For chronic endogenouspain, borderline patients appear painintolerant. In this paper, we explainthis unusual paradox. We then discussthe psychiatric assessment of chronicpain, emphasizing the importance ofinitially determining the patients

status with regard to borderlinepersonality disorder. For those chronicpain patients who have comorbidborderline personality disorder, werecommend a specific pain-management strategy that addressesthe self-regulation difficulties of thesepatients and minimizes the risks oftreatment.

INTRODUCTIONChronic pain syndromes and pain

management are being increasinglyemphasized throughout all fields ofmedicine. Research indicates that,using the formal definition of chronicpain (i.e., pain duration of at least 3months), between 10 and 20 percentof the general US population suffersfrom a pain syndrome.1 In 2001, therewere approximately 3,800 specialtypain programs in the US.1Accordingto Loeser,2 chronic pain is the primarycause of healthcare consumption and

disability during ones working years.

BORDERLINE PERSONALITY

and the Pain Paradox

[ R E V I E W ]

by RANDY A. SANSONE, MD; and LORI A. SANSONE, MD

Dr. R. Sansone is a Professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in

Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; and Dr. L. Sansone is a civilian family

medicine physician at Wright-Patterson Air Force Base in Dayton, Ohio.

DISCLAIMER: The views expressed in this article are those of the authors and do not reflect the

official policy or position of the US Air Force, Department of Defense, or US government.

ADDRESS CORRESPONDENCE TO: Randy A. Sansone, MD, 2115 Leiter Road, Miamisburg, Ohio,

45342; Phone: (937) 384-6850; Fax: (937) 384-6938; E-mail: [email protected]

KEY WORDS: borderline personality disorder, pain, management, psychotherapy

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[ A P R I L ] Psychiatry 2007 41

In support of this, Gatchel andcolleagues1 found that chronic painsyndromes cost the US public around$70 billion a year.

The preceding observations areparalleled by an empiricallyconfirmed increase in the prescriptionof opioid analgesics. Data from theDrug Abuse Warning Networkindicates that between 1990 and1996, there were prescriptionincreases of 59 percent for morphine,1,168 percent for fentanyl, 23 percentfor oxycodone, and 19 percent forhydromorphone.3According to the USMedicaid database, the prescription of

opioids increased by 309 percentbetween 1996 and 20024 and nearlydoubled between 1998 and 2003.5

These data indicate that in the US,

pain is prevalent and the painmanagement industry is exponentiallyincreasing. In this article, we focus onthe relationship between borderlinepersonality disorder (BPD) and pain,and how this Axis II disorder affectspain assessment and management.

PAIN CLASSIFICATION: ANOVERVIEW

Pain is a difficult symptom tocategorize because it is present in so

many different contexts (i.e., diseasestates) and is a subjectivephenomenon. Despite theselimitations, acute pain may be definedas a prompt protective phenomenonthat alerts the individual of acutephysical compromise. On the otherhand, chronic pain is typically definedas pain of three or more monthsduration, has no acute physiologicalrole, and persists beyond the timerequired for the body to heal. Various

pain classifications specify body

region or system, intensity, etiology,somatic versus visceral origins,nociceptive versus neuropathicfeatures, and so forth. However,acute versus chronic pain is acommon clinical division based onpain duration, even though thesubjective experience of the painmay be similar. Despite these varioustypes of pain, the implicatedneurotransmitters entail the opioid,noradrenergic, and serotonergicsystems. Whether similarneurotransmitter afflictions relate tothe borderline disorder remainsunknown.

THE PAIN PARADOXThe intersection of BPD and pain

is a complex one. On the one hand,patients with BPD appear to be

impervious to acute pain, which iscommonly reported during episodesof self-mutilation, such as cutting.On the other hand, clinicalexperiences and empirical findingswith chronic pain suggest just theoppositethat patients with BPDare more sensitive to pain thanindividuals without this Axis IIdisorder.

Pain tolerance in patients

with BPD.As noted previously,

patients with BPD appear to be fairlyimpervious to self-inflicted pain.Indeed, mental health clinicians whotreat patients with BPD are wellaccustomed to the seemingly hightolerance to pain reported by manyindividuals during acute acts of self-injury. During these acts, manypatients claim to feel nothing, as ifthey are seemingly immune to thebodys experience andacknowledgement of tissue

destructioni.e., pain.

In support of these clinicalobservations, during acute acts ofintentional self-injury, a number ofempirical studies confirm theexistence of pain attenuation inpatients with BPD.615 Researchershave examined individuals with BPDthrough the use of study designs thatentail the introduction of noxiousstimuli to the subject. Typically, themethodology of these endeavorsentails the acute exposure of theparticipant to intense levels of heat orcold, with the subsequent assessmentof the individuals discomfort ortolerance. The data from these studies

confirm the presence of attenuatedpain responses in the majority ofindividuals with BPD.6,8,11,13,15 Indeed,investigators estimate that an

attenuated pain response to acute self-inflicted injury may occur in up 80percent of individuals who arediagnosed with BPD.6,15

Why the majority of individuals withBPD exhibits high tolerances to painduring acute acts of self-injury remainsunexplained. However, a number oftheories have been proposed, whichmay provide some insight into thisperplexing phenomenon. For example,McCown and colleagues16 posit that

such responses are the result of stress-induced analgesia. Russ andcolleagues12 indicate that borderlineindividuals may actually re-interpretthe pain on a psychological level, aprocess that may be mediated bydissociation.12 Kemperman andcolleagues8 describe the possibility ofinherent neurosensory abnormalitiesas well as underlying attitudinal and/orpsychological abnormalities.9 Otherresearchers have suggested the release

of endogenous opioids at the time of

On the one hand, patients with BPD appear to be impervious to acutepain, which is commonly reported during episodes of self-mutilation,

such as cutting. On the other hand, clinical experiences and empiricalfindings with chronic pain suggest just the oppositethat patients withBPD are more sensitive to pain than individuals without this Axis IIdisorder.

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self-injury.17 If the opioid theory isvalid, then it is possible that self-harmbehavior might actually be self-reinforcing.

As is evident, some of thepreceding hypotheses are difficult toempirically confirm or discount. Forexample, how does one accuratelymeasure an individuals ability todissociate? Likewise, how does onedetermine precisely how and whattype of psychological re-interpretation occurs? Regardless ofthese empirical dilemmas, duringacute acts of self-injury, there appearto be genuine psychophysiologicalchanges that occur. As an example,during acts of self-injury,investigators11 have found increasedtheta-wave activity in theelectroencephalogram tracings ofpatients with BPD who report beinghighly pain tolerant. This suggeststhat some type of reflexivepsychophysiological process isoccurring at the moment of self-harm.

As for the theory regarding therelease of endogenous opioids duringacute acts of self-harm, researchershave examined the effects of opioidantagonists in patients with BPD.Theoretically, these drugs shouldblock the analgesia as well as

reinforcing effects of endogenousopioid release. However, the findingsof these studies have beeninconsistent,11,18 and the role ofendogenous opioids in theattenuation of pain responses remainsunclear.

To summarize the preceding data,it appears that the majority ofpatients with BPD reportexperiencing minimal pain duringacute acts of self-injury. The reasonsfor this phenomenon remainunknown, but a number of theories

are posited in the literature and

electroencephalogram studiessupport the presence of some sort ofreflexive psychophysiologicalresponse.

Pain intolerance in patients

with BPD. Clinical observations andseveral empirical studies indicate thatsome patients with BPD are actuallyintolerant of chronic pain. Harper19

effectively summarized these clinicalimpressions by stating, it [is]particularly difficult for[theborderline patient]to endureprolonged acute pain (p. 196); theborderline patients tolerance ofdiscomfort will typically be of shorterduration than other individuals (p.197).

In support of the preceding clinicalconclusion, there are several areas ofresearch that suggest or indicate painintolerance among those with BPD.While empirical data are scant, onearea of study is the prevalence ofBPD among patients with chronicpain. We examined a sample ofprimary care outpatients with chronicpain and found that 50 percent ofparticipants met the diagnosticcriteria for BPD using asemistructured interview fordiagnosis.20 Merceron, Rossel, andMatthey21 also confirmed BPD

features among chronic pain patientsthrough the use of projectivepsychological testing.

A second area of research is theprevalence of opioid misuse amongthose suffering from BPD. Opioidmisuse, or the excessive use of

narcotic analgesics by borderlinepatients, might be a practicalindicator of pain intolerance. Whilefew in number, several studiesspecifically confirm the existence ofopioid abuse in a substantial minorityof patients with BPD. In this regard,

Dulit and colleagues22

found that 15

percent of patients with BPD hadhistories of opioid abuse ordependence. In a Greek study ofyoung adult inpatients with BPD,Hatzitaskos and colleagues23 foundthat five percent acknowledged opioidmisuse. Frankenburg and Zanarini24

compared BPD patients in symptomremission to those with continuingsymptoms and found that the moresymptomatic subsample reported thesustained use of pain medications.Finally, Kaplan and Korelitz25 foundan association between BPD and oralnarcotic use among patients withinflammatory bowel disease. Theseempirical data support the clinicalobservations that some patients withBPD are unable to tolerate ongoingpain and subsequently overutilizepain medications, including opioidanalgesics.

What might explain an intoleranceto persistent pain in patients withBPD? We very strongly suspect thatthis phenomenon is the manifestationof a broader psychodynamic theme inpatients with BPDthe inability toeffectively self-regulate.26Accordingto theDiagnostic and Statistical

Manual of Mental Disorders,

Fourth Edition, Text Revision

(DSM-IV-TR),27 BPD is characterized

by, marked impulsivity beginningby early adulthood and present in avariety of contexts. The presence ofimpulsivity affirms that individualswith BPD are unable to effectivelyself-regulate or to modulatethemselves. The DSM-IV-TR27

exemplifies impulsivity, or self-regulation difficulties, in the areas ofspending, sex, substance abuse,reckless driving, and binge eating. Insupport of the DSM-IV-TR27 clarifier,variety of contexts, we believe thatself-regulation difficulties might also

manifest in the inability of these

What might explain an intolerance to persistent pain in patients withBPD? We very strongly suspect that this phenomenon is the

manifestation of a broader psychodynamic theme in patients withBPDthe inability to effectively self-regulate.

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individuals to effectively regulate ormodulate pain. As a result, theafflicted individual would seeminglyover-experience pain, appear painintolerant, and/or be prone to usingexcessive amounts of analgesics in anattempt to control pain.

Context and the pain paradox.

Through the preceding discussion, itappears that individuals with BPD areboth insensitive to and over-sensitiveto pain. What might explain thisseeming paradox? We stronglysuspect that the answer resides in thecontext of the pain experience itself.26

Pain that is self-inflicted, of shortduration, and directly under theindividuals personal control appears tobe excessively well tolerated. Thisintense but brief experience may beaccompanied by a variety ofpsychological maneuvers, such asdissociation, to enable pain toleration.

On the other hand, pain that isendogenous, continuous, and notunder the individuals control may bevery poorly tolerated. Indeed, it maybe that the continuous nature of thistype of pain reveals the borderlinepatients inability to effectively regulatethe sensation. In other words, theseindividuals seem compromised in theirinnate ability to modulate, control, or

manage their experience of pain.Importantly, we believe that thisinability to effectively regulate pain ismediated by a number of variables,including comorbid mood and anxietydisorders, which are very prevalentamong patients with BPD; childhoodhistories of trauma with the resultingclinical features of post-traumaticstress disorder (i.e., hypervigilance orhyperarousal), which may result in anintense focus on internal or body

sensations; and complex interpersonaldynamics in which eliciting caringresponses from others throughsymptoms is paramount.28

THE INTERPERSONAL DYNAMICSOF PAIN

In our opinion, the interpersonalfunction of pain is a strong reinforcerfor continued symptoms, but is likelyto be a secondary event thatconsolidates over time in the lives of

these patients. Once established,

however, the vehicle of pain offers thepatient the legitimate opportunity tosolicit care and support from others,without the complex task of buildingrelationships and/or experiencing

vulnerability. This elicitation of supportextends to healthcare professionals aswell. Chronic pain symptoms naturallyincrease the patients contact withhealthcare providers, which mayexplain the observation of higherhealthcare utilization amongindividuals with BPD in primary caresettings.2931

Pain also effectively establishes anidentity through the role of victim,enabling borderline individuals to re-

enact their legacy of childhoodvictimhood (i.e., early developmentaladversity or abuse), which many haveexperienced.26 In this way, self-regulation difficulties (i.e., pain)unintentionally facilitate thedevelopment of a distinct social rolethat of medical victim. If the pain issufficiently disabling, the patient mayseek and secure disabilitycompensation. For some of theseindividuals, disability compensation

may function as societys affirmation,

albeit unintentional, of medicalvictimhood.

CLINICAL IMPLICATIONS OF THEPAIN PARADOX

As we have discussed, ameaningful proportion of chronic painpatients suffer from comorbid BPD.These Axis II patients are frequentlyover-sensitive to or intolerant ofendogenous chronic pain, which maybe explained by their inherentdifficulties with self-regulation.

Pain assessment. Unfortunately,the clinician in the medical setting isfaced with the complex task of painassessment in order to determine

appropriate treatment options. Toassess the severity of pain thatpatients are experiencing, clinicians inthese settings often utilize visualanalog scales. These scales arepurported to have reasonable validityand reliability.32

There are several types of visualanalog scales for pain assessmentsome have faces that progress from asmile to increasing distress; some usenumber ratings of 0 (no pain) to 10

(worst pain imaginable); and others

BORDERLINE PERSONALITY AND THE PAIN PARADOXCASE EXAMPLE (FICTITIOUS)

Mrs. N. was an obese, 46-year-old, Caucasian, married woman with ahistory of fibromyalgia, chronic fatigue syndrome, irritable bowelsyndrome, panic disorder, recurrent major depression, dysthymia,

generalized anxiety disorder, binge eating disorder, and partner-relationshipproblem who presented to her family physician four months following anautomobile accident. Following the accident, the patient had initially undergonex-rays in the emergency room because of neck pain, but now presented withright-sided upper abdominal pain.

During the encounter with her primary care physician, Mrs. N. wascontinuously crying. She explained that she was prescribed tramadol (Ultram),acetaminophen/hydrocodone (Vicodin), clonazepam (Klonopin), morphine,cyclobenzaprine (Flexeril), three antidepressants (?) (sertraline, bupropion,venlaxine extended release), topiramate (Topamax), and valproic acid(Depakote). She alluded to her care by a pain specialist, nutritionist, familytherapist, and psychiatrist. On physical examination, she demonstrated anexaggerated response to light touch. She was sent for chest x-rays to evaluatefor a possible rib fracture. Mrs. N. was supposed to return to the clinicimmediately following her x-ray. She was unable to be located for three hourseither in the lobby or by cellphone. At the end of the day, she approached thereception desk and vociferously complained that she had been abandoned in thelobby all afternoon and had suffered in pain all alone.

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are variations of these basic formats(i.e., different number sequences,different accompanying text).33

Regardless of styling, all of these self-report methods for pain assessmentrequire the patient to estimate along arange of graded responses theseverity of their pain. Using thisapproach, the pain assessment isentirely subjective.

While the use of visual analogscales may be a reasonable approachin patients without BPD, there areinherent difficulties with these scalesin patients with BPD. Given theborderline patients inherent self-regulation difficulties and exquisitehypersensitivity to their own internalenvironment from childhood trauma,their perception of endogenous painis likely to be unnaturally augmented.Because of this, their responses onvisual analogue scales are typicallyartificially inflated. Therefore, it isgenuinely challenging to accuratelydetermine pain levels in patients withBPD based upon self-reportmeasures. Unfortunately, at thepresent time, there are no knownalternatives for more accurate painassessment.

The dilemma of prescribing

pain medication. In recent years, a

clinical mantra has evolved aroundpain managementthat patients havethe right to have their pain treated.Indeed, pain is described as a vitalsign in some settings and must beroutinely assessed by the medical

clinician at each patient encounterregardless of the chief complaint. Yet,how can the clinician in the generalmedical setting accurately determinepain severity in patients with inherentself-regulation difficulties andpsychological stylings (i.e., medicalvictim dynamics) that profoundly

compromise pain assessment? In turn,

how can the clinician feasiblyprescribe appropriate doses of painmedication without a preciseaccounting of pain severity?

A SUGGESTED APPROACH TO PAINMANAGEMENT IN PATIENTS WITHBPD

We believe that an initial step in theevaluation of the chronic pain patientis the determination of the individualsBPD status. Because many clinicians inmedical settings may not be familiarwith the diagnosis and dynamics ofBPD, it is essential for mental healthprofessionals to provide consultationand/or educational guidance withregard to diagnosis. This guidancemust be from a broadly informedperspective, with the realization thatpatients with BPD may present withdifferent symptoms in differenttreatment settings.34 Specifically, inpsychiatric settings, borderlineindividuals tend to present withtraditional symptoms, including self-harm behaviors and suicide attempts,whereas in medical settings they maypresent with chronic pain syndromesas well as other somatic syndromes.26

While the surface symptoms appeardivergent (i.e., psychologicalsymptoms versus physical symptoms),

the psychodynamics and interpersonaldynamics remain unchanged.

If the diagnosis of BPD isconfirmed, we suggest the followingstrategy in the general medical settingfor chronic pain management: 1)

ongoing clarification with theborderline patient that analgesicmedications are unlikely to fully treattheir pain; 2) the liberal use ofnonaddicting analgesics (e.g., non-steroidal anti-inflammatory drugs); 3)the recommendation of and supportfor non-pharmacological approaches to

pain (e.g., cognitive-behavioral

strategies); 4) the highly conservativeuse of opioid analgesics; and 5) carefulmonitoring by the clinician of allnarcotic prescriptions. The monitoringof prescriptions may entail intermittentcontact with the pharmacy to ensurepatient adherence as well as touncover additional providers ofnarcotic prescriptions, if they exist.

In this recommended approach topain, note that the clinician in thegeneral medical setting fully assumesthe responsibility for carefullyregulating the patients use ofanalgesics, not the patient. In addition,it is not the patients level of pain thatdetermines analgesic prescription, butrather the clinicians best estimate ofthe patients pain. This approach needsto be reinforced through multiple,regular, brief appointments with theborderline patient.

Because the preceding approachmight be misperceived as withholdingeffective treatment from the patient,we believe that it is essential forclinicians in the general medicalsetting to document in the medicalrecord the patients diagnosis ofborderline personality traits ordisorder. This diagnosis justifies thepreceding conservative approach tochronic pain management and also

infers the patients potential risks ofaddiction, medication misuse/abuse,and overdose (i.e., the patient suffersfrom BPD). This approach to chronicpain in patients with BPD is essentiallygrounded on the dictum, Do no harm

(i.e., avoid unnecessary narcoticintoxication and addiction in thepatient).

Note that in this consultationmodel, the role of the mental healthprofessional is to do the following: 1)assist with BPD diagnosis as well asthe treatment teams understanding of

the disorder; 2) broach and/or

Because many clinicians in medical settings may not be familiar withthe diagnosis and dynamics of BPD, it is essential for mental healthprofessionals to provide consultation and/or educational guidance withregard to diagnosis.

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reinforce the preceding conservativestrategy for pain management; 3)evaluate and treat the patient for anyunderlying mood and/or anxietysyndromes, which tend to intensify theexperience of pain symptoms; and 4)

consider referral for cognitive-behavioral intervention for thosepatients who might be able to benefit.

For the psychiatric consultant, BPDcan be a difficult disorder to brieflyexplain to non-mental healthprofessionals with various levels ofpsychiatric knowledge. However, inour experience, a practical way toefficiently describe this disorder is tohighlight the three fundamentalelements of the working definition ofBPD. All patients with BPD have: 1) aseemingly intact social faade orveneer, which tends to erode understress; 2) longstanding difficulties withself-regulation (e.g., eating disorders,

substance abuse, promiscuity, chronicpain syndromes); and 3) chronic self-destructive behavior (e.g., cutting self,suicide attempts). In the case ofindividuals with chronic pain, it may bethat the resulting self-defeatinglifestyle functions as the means of self-destructive behavior.

When educating the treatmentteam, it is important to broach thedynamic of splitting. When variousprofessionals interface with the

individual with BPD, there is alwaysthe risk that the patient will engage insplitting. It is essential to advise clear,succinct, and well-organizeddocumentation of treatmentsuggestions in the medical record andto communicate these directly to keyproviders. In addition, it may behelpful to have team membersroutinely cross-check amongthemselves any suspiciousmanagement statements from the

patient (e.g., They said I could

increase the Vicodin as needed; i.e.,consider such statements as possiblyerroneous until proven otherwise).

Overall, it is important to appreciatethat the diagnosis of BPD will typicallyhinder efforts at effective pain

management. For example, theinherent self-regulatory difficulties ofthese patients may culminate inprescription misuse, abuse, anddependence. Their unrelenting needsto engage others may result inmultiplestatus quo appointments,escalating pain complaints, requestsfor unusual or medically unacceptableapproaches or procedures, andrequests for questionable disabilitycompensation. Likewise, thepsychiatric diagnosis itself tends tostigmatize patients and may result indistancing of the individual by thephysician and staff; this may furtherstimulate the patients attempts for

engagement. Because these patientsmay be continually demanding, there

is always a risk ofcountertransference on the behalf ofthe medical team. The treatmentteam may act out these feelings byindulging the patient with analgesics,withholding all pain-managementprescriptions, removing the patientfrom the practice, and/or tamperingwith the directives of the pain

management specialist. It is important

for the psychiatric consultant toemphasize structure and boundaries(clarify who is doing what) as well asto do no harm to the patient.

CONCLUSIONPatients with BPD seem to have

very dichotomous responses to theexperience of pain. On the one hand,they appear highly pain tolerant. Onthe other hand, they appear very painintolerant. This seeming paradox canbe readily explained by the context ofthe pain. From a pragmaticperspective, we believe that it iscritically important to determine theBPD status of the chronic pain patient,because such a diagnosis affects theclinicians subsequent assessment andmanagement of the pain syndrome. Inthose individuals with BPD, werecommend a very conservativeapproach to pain management, withcareful monitoring of analgesicmedications by the prescribingclinician. Mental health professionalscan be invaluable in training providersin general medicine settings and painclinics to initially screen patients forBPD, and to be aware of the frequentassociation between BPD and chronicpain. If the patient has BPD, themental health clinician may then

recommend and/or reinforce thesuggested conservative treatment

strategy. In this unique role, themental health professional canhopefully exert a positive impact onhealthcare utilization in medicalsettings, which benefits all of society.

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This diagnosis [BPD] justifiesthe...conservative approach [described in thisarticle] to chronic pain management and alsoinfers the patients potential risks of addiction,medication misuse/abuse, and overdose (i.e.,

the patient suffers from BPD).

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