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BORDERLINE PERSONALITY
and the Pain Paradox
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.

ABSTRACT
Clinical observations and empirical studies indicate that patients with borderline personality are both sensitive and insensitive to pain. This dichotomy may be explained by the context of the pain. For acute selfinduced pain, borderline patients seem to experience attenuated pain responses. For chronic endogenous pain, borderline patients appear pain intolerant. In this paper, we explain this unusual paradox. We then discuss the psychiatric assessment of chronic pain, emphasizing the importance of initially determining the patients status with regard to borderline personality disorder. For those chronic pain patients who have comorbid borderline personality disorder, we recommend a specific painmanagement strategy that addresses the self-regulation difficulties of these patients and minimizes the risks of treatment.

INTRODUCTION
Chronic pain syndromes and pain management are being increasingly emphasized throughout all fields of medicine. Research indicates that, using the formal definition of chronic pain (i.e., pain duration of at least 3 months), between 10 and 20 percent of the general US population suffers from a pain syndrome.1 In 2001, there were approximately 3,800 specialty pain programs in the US.1 According to Loeser,2 chronic pain is the primary cause of healthcare consumption and disability during ones working years.
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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: Randy.sansone@kmcnetwork.org KEY WORDS: borderline personality disorder, pain, management, psychotherapy

In support of this, Gatchel and colleagues1 found that chronic pain syndromes cost the US public around $70 billion a year. The preceding observations are paralleled by an empirically confirmed increase in the prescription of opioid analgesics. Data from the Drug Abuse Warning Network indicates that between 1990 and 1996, there were prescription increases of 59 percent for morphine, 1,168 percent for fentanyl, 23 percent for oxycodone, and 19 percent for hydromorphone.3 According to the US Medicaid database, the prescription of

region or system, intensity, etiology, somatic versus visceral origins, nociceptive versus neuropathic features, and so forth. However, acute versus chronic pain is a common clinical division based on pain duration, even though the subjective experience of the pain may be similar. Despite these various types of pain, the implicated neurotransmitters entail the opioid, noradrenergic, and serotonergic systems. Whether similar neurotransmitter afflictions relate to the borderline disorder remains unknown.

In support of these clinical observations, during acute acts of intentional self-injury, a number of empirical studies confirm the existence of pain attenuation in patients with BPD.615 Researchers have examined individuals with BPD through the use of study designs that entail the introduction of noxious stimuli to the subject. Typically, the methodology of these endeavors entails the acute exposure of the participant to intense levels of heat or cold, with the subsequent assessment of the individuals discomfort or tolerance. The data from these studies

On the one hand, patients with BPD appear to be impervious to acute pain, which is commonly reported during episodes of self-mutilation, such as cutting. On the other hand, clinical experiences and empirical findings with chronic pain suggest just the oppositethat patients with BPD are more sensitive to pain than individuals without this Axis II disorder.
opioids increased by 309 percent between 1996 and 20024 and nearly doubled between 1998 and 2003.5 These data indicate that in the US, pain is prevalent and the pain management industry is exponentially increasing. In this article, we focus on the relationship between borderline personality disorder (BPD) and pain, and how this Axis II disorder affects pain assessment and management.

THE PAIN PARADOX

The intersection of BPD and pain is a complex one. On the one hand, patients with BPD appear to be impervious to acute pain, which is commonly reported during episodes of self-mutilation, such as cutting. On the other hand, clinical experiences and empirical findings with chronic pain suggest just the oppositethat patients with BPD are more sensitive to pain than individuals without this Axis II disorder. Pain tolerance in patients with BPD. As noted previously, patients with BPD appear to be fairly impervious to self-inflicted pain. Indeed, mental health clinicians who treat patients with BPD are well accustomed to the seemingly high tolerance to pain reported by many individuals during acute acts of selfinjury. During these acts, many patients claim to feel nothing, as if they are seemingly immune to the bodys experience and acknowledgement of tissue destructioni.e., pain.

PAIN CLASSIFICATION: AN OVERVIEW

Pain is a difficult symptom to categorize because it is present in so many different contexts (i.e., disease states) and is a subjective phenomenon. Despite these limitations, acute pain may be defined as a prompt protective phenomenon that alerts the individual of acute physical compromise. On the other hand, chronic pain is typically defined as pain of three or more months duration, has no acute physiological role, and persists beyond the time required for the body to heal. Various pain classifications specify body

confirm the presence of attenuated pain responses in the majority of individuals with BPD.6,8,11,13,15 Indeed, investigators estimate that an attenuated pain response to acute selfinflicted injury may occur in up 80 percent of individuals who are diagnosed with BPD.6,15 Why the majority of individuals with BPD exhibits high tolerances to pain during acute acts of self-injury remains unexplained. However, a number of theories have been proposed, which may provide some insight into this perplexing phenomenon. For example, McCown and colleagues16 posit that such responses are the result of stressinduced analgesia. Russ and colleagues12 indicate that borderline individuals may actually re-interpret the pain on a psychological level, a process that may be mediated by dissociation.12 Kemperman and colleagues8 describe the possibility of inherent neurosensory abnormalities as well as underlying attitudinal and/or psychological abnormalities.9 Other researchers have suggested the release of endogenous opioids at the time of
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self-injury.17 If the opioid theory is valid, then it is possible that self-harm behavior might actually be selfreinforcing. As is evident, some of the preceding hypotheses are difficult to empirically confirm or discount. For example, how does one accurately measure an individuals ability to dissociate? Likewise, how does one determine precisely how and what type of psychological reinterpretation occurs? Regardless of these empirical dilemmas, during acute acts of self-injury, there appear to be genuine psychophysiological changes that occur. As an example, during acts of self-injury, investigators11 have found increased theta-wave activity in the electroencephalogram tracings of patients with BPD who report being highly pain tolerant. This suggests that some type of reflexive psychophysiological process is occurring at the moment of self-harm. As for the theory regarding the release of endogenous opioids during acute acts of self-harm, researchers have examined the effects of opioid antagonists in patients with BPD. Theoretically, these drugs should block the analgesia as well as reinforcing effects of endogenous opioid release. However, the findings of these studies have been inconsistent,11,18 and the role of endogenous opioids in the attenuation of pain responses remains unclear.

electroencephalogram studies support the presence of some sort of reflexive psychophysiological response. Pain intolerance in patients with BPD. Clinical observations and several empirical studies indicate that some patients with BPD are actually intolerant of chronic pain. Harper19 effectively summarized these clinical impressions by stating, it [is] particularly difficult for[the borderline patient]to endure prolonged acute pain (p. 196); the borderline patients tolerance of discomfort will typically be of shorter duration than other individuals (p. 197). In support of the preceding clinical conclusion, there are several areas of research that suggest or indicate pain intolerance among those with BPD. While empirical data are scant, one area of study is the prevalence of BPD among patients with chronic pain. We examined a sample of primary care outpatients with chronic pain and found that 50 percent of participants met the diagnostic criteria for BPD using a semistructured interview for diagnosis.20 Merceron, Rossel, and Matthey21 also confirmed BPD features among chronic pain patients through the use of projective psychological testing. A second area of research is the prevalence of opioid misuse among those suffering from BPD. Opioid misuse, or the excessive use of

percent of patients with BPD had histories of opioid abuse or dependence. In a Greek study of young adult inpatients with BPD, Hatzitaskos and colleagues23 found that five percent acknowledged opioid misuse. Frankenburg and Zanarini24 compared BPD patients in symptom remission to those with continuing symptoms and found that the more symptomatic subsample reported the sustained use of pain medications. Finally, Kaplan and Korelitz25 found an association between BPD and oral narcotic use among patients with inflammatory bowel disease. These empirical data support the clinical observations that some patients with BPD are unable to tolerate ongoing pain and subsequently overutilize pain medications, including opioid analgesics. What might explain an intolerance to persistent pain in patients with BPD? We very strongly suspect that this phenomenon is the manifestation of a broader psychodynamic theme in patients with BPDthe inability to effectively self-regulate.26 According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),27 BPD is characterized by, marked impulsivity beginning by early adulthood and present in a variety of contexts. The presence of impulsivity affirms that individuals with BPD are unable to effectively self-regulate or to modulate themselves. The DSM-IV-TR27

What might explain an intolerance to persistent pain in patients with BPD? We very strongly suspect that this phenomenon is the manifestation of a broader psychodynamic theme in patients with BPDthe inability to effectively self-regulate.
To summarize the preceding data, it appears that the majority of patients with BPD report experiencing minimal pain during acute acts of self-injury. The reasons for this phenomenon remain unknown, but a number of theories are posited in the literature and
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narcotic analgesics by borderline patients, might be a practical indicator of pain intolerance. While few in number, several studies specifically confirm the existence of opioid abuse in a substantial minority of patients with BPD. In this regard, Dulit and colleagues22 found that 15

exemplifies impulsivity, or selfregulation difficulties, in the areas of spending, sex, substance abuse, reckless driving, and binge eating. In support of the DSM-IV-TR27 clarifier, variety of contexts, we believe that self-regulation difficulties might also manifest in the inability of these

individuals to effectively regulate or modulate pain. As a result, the afflicted individual would seemingly over-experience pain, appear pain intolerant, and/or be prone to using excessive amounts of analgesics in an attempt to control pain. Context and the pain paradox. Through the preceding discussion, it appears that individuals with BPD are both insensitive to and over-sensitive to pain. What might explain this seeming paradox? We strongly suspect that the answer resides in the context of the pain experience itself.26 Pain that is self-inflicted, of short duration, and directly under the individuals personal control appears to be excessively well tolerated. This intense but brief experience may be accompanied by a variety of psychological maneuvers, such as dissociation, to enable pain toleration. On the other hand, pain that is endogenous, continuous, and not under the individuals control may be very poorly tolerated. Indeed, it may be that the continuous nature of this type of pain reveals the borderline patients inability to effectively regulate the sensation. In other words, these individuals seem compromised in their innate ability to modulate, control, or manage their experience of pain. Importantly, we believe that this inability to effectively regulate pain is mediated by a number of variables, including comorbid mood and anxiety disorders, which are very prevalent among patients with BPD; childhood histories of trauma with the resulting clinical features of post-traumatic stress disorder (i.e., hypervigilance or hyperarousal), which may result in an intense focus on internal or body sensations; and complex interpersonal dynamics in which eliciting caring responses from others through symptoms is paramount.28

BORDERLINE PERSONALITY AND THE PAIN PARADOX CASE EXAMPLE (FICTITIOUS)

rs. N. was an obese, 46-year-old, Caucasian, married woman with a history of fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, panic disorder, recurrent major depression, dysthymia, generalized anxiety disorder, binge eating disorder, and partner-relationship problem who presented to her family physician four months following an automobile accident. Following the accident, the patient had initially undergone x-rays in the emergency room because of neck pain, but now presented with right-sided upper abdominal pain. During the encounter with her primary care physician, Mrs. N. was continuously 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, family therapist, and psychiatrist. On physical examination, she demonstrated an exaggerated response to light touch. She was sent for chest x-rays to evaluate for a possible rib fracture. Mrs. N. was supposed to return to the clinic immediately following her x-ray. She was unable to be located for three hours either in the lobby or by cellphone. At the end of the day, she approached the reception desk and vociferously complained that she had been abandoned in the lobby all afternoon and had suffered in pain all alone. albeit unintentional, of medical victimhood.

THE INTERPERSONAL DYNAMICS OF PAIN

In our opinion, the interpersonal function of pain is a strong reinforcer for continued symptoms, but is likely to be a secondary event that consolidates over time in the lives of these patients. Once established,

however, the vehicle of pain offers the patient the legitimate opportunity to solicit care and support from others, without the complex task of building relationships and/or experiencing vulnerability. This elicitation of support extends to healthcare professionals as well. Chronic pain symptoms naturally increase the patients contact with healthcare providers, which may explain the observation of higher healthcare utilization among individuals with BPD in primary care settings.2931 Pain also effectively establishes an identity through the role of victim, enabling borderline individuals to reenact their legacy of childhood victimhood (i.e., early developmental adversity or abuse), which many have experienced.26 In this way, selfregulation difficulties (i.e., pain) unintentionally facilitate the development of a distinct social role that of medical victim. If the pain is sufficiently disabling, the patient may seek and secure disability compensation. For some of these individuals, disability compensation may function as societys affirmation,

CLINICAL IMPLICATIONS OF THE PAIN PARADOX

As we have discussed, a meaningful proportion of chronic pain patients suffer from comorbid BPD. These Axis II patients are frequently over-sensitive to or intolerant of endogenous chronic pain, which may be explained by their inherent difficulties with self-regulation. Pain assessment. Unfortunately, the clinician in the medical setting is faced with the complex task of pain assessment in order to determine appropriate treatment options. To assess the severity of pain that patients are experiencing, clinicians in these settings often utilize visual analog scales. These scales are purported to have reasonable validity and reliability.32 There are several types of visual analog scales for pain assessment some have faces that progress from a smile to increasing distress; some use number ratings of 0 (no pain) to 10 (worst pain imaginable); and others
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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 selfreport methods for pain assessment require the patient to estimate along a range of graded responses the severity of their pain. Using this approach, the pain assessment is entirely subjective. While the use of visual analog scales may be a reasonable approach in patients without BPD, there are inherent difficulties with these scales in patients with BPD. Given the borderline patients inherent selfregulation difficulties and exquisite hypersensitivity to their own internal environment from childhood trauma, their perception of endogenous pain is likely to be unnaturally augmented. Because of this, their responses on visual analogue scales are typically artificially inflated. Therefore, it is genuinely challenging to accurately determine pain levels in patients with BPD based upon self-report measures. Unfortunately, at the present time, there are no known alternatives for more accurate pain assessment. The dilemma of prescribing pain medication. In recent years, a clinical mantra has evolved around pain managementthat patients have the right to have their pain treated. Indeed, pain is described as a vital sign in some settings and must be routinely assessed by the medical

how can the clinician feasibly prescribe appropriate doses of pain medication without a precise accounting of pain severity?

A SUGGESTED APPROACH TO PAIN MANAGEMENT IN PATIENTS WITH BPD

We believe that an initial step in the evaluation of the chronic pain patient is the determination of the individuals BPD status. Because many clinicians in medical settings may not be familiar with the diagnosis and dynamics of BPD, it is essential for mental health professionals to provide consultation and/or educational guidance with regard to diagnosis. This guidance must be from a broadly informed perspective, with the realization that patients with BPD may present with different symptoms in different treatment settings.34 Specifically, in psychiatric settings, borderline individuals tend to present with traditional symptoms, including selfharm behaviors and suicide attempts, whereas in medical settings they may present with chronic pain syndromes as well as other somatic syndromes.26 While the surface symptoms appear divergent (i.e., psychological symptoms versus physical symptoms), the psychodynamics and interpersonal dynamics remain unchanged. If the diagnosis of BPD is confirmed, we suggest the following strategy in the general medical setting for chronic pain management: 1)

strategies); 4) the highly conservative use of opioid analgesics; and 5) careful monitoring by the clinician of all narcotic prescriptions. The monitoring of prescriptions may entail intermittent contact with the pharmacy to ensure patient adherence as well as to uncover additional providers of narcotic prescriptions, if they exist. In this recommended approach to pain, note that the clinician in the general medical setting fully assumes the responsibility for carefully regulating the patients use of analgesics, not the patient. In addition, it is not the patients level of pain that determines analgesic prescription, but rather the clinicians best estimate of the patients pain. This approach needs to be reinforced through multiple, regular, brief appointments with the borderline patient. Because the preceding approach might be misperceived as withholding effective treatment from the patient, we believe that it is essential for clinicians in the general medical setting to document in the medical record the patients diagnosis of borderline personality traits or disorder. This diagnosis justifies the preceding conservative approach to chronic pain management and also infers the patients potential risks of addiction, medication misuse/abuse, and overdose (i.e., the patient suffers from BPD). This approach to chronic pain in patients with BPD is essentially grounded on the dictum, Do no harm

Because many clinicians in medical settings may not be familiar with the diagnosis and dynamics of BPD, it is essential for mental health professionals to provide consultation and/or educational guidance with regard to diagnosis.
clinician at each patient encounter regardless of the chief complaint. Yet, how can the clinician in the general medical setting accurately determine pain severity in patients with inherent self-regulation difficulties and psychological stylings (i.e., medical victim dynamics) that profoundly compromise pain assessment? In turn,
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ongoing clarification with the borderline patient that analgesic medications are unlikely to fully treat their pain; 2) the liberal use of nonaddicting analgesics (e.g., nonsteroidal anti-inflammatory drugs); 3) the recommendation of and support for non-pharmacological approaches to pain (e.g., cognitive-behavioral

(i.e., avoid unnecessary narcotic intoxication and addiction in the patient). Note that in this consultation model, the role of the mental health professional is to do the following: 1) assist with BPD diagnosis as well as the treatment teams understanding of the disorder; 2) broach and/or

reinforce the preceding conservative strategy for pain management; 3) evaluate and treat the patient for any underlying mood and/or anxiety syndromes, which tend to intensify the experience of pain symptoms; and 4)

increase the Vicodin as needed; i.e., consider such statements as possibly erroneous until proven otherwise). Overall, it is important to appreciate that the diagnosis of BPD will typically hinder efforts at effective pain

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

CONCLUSION
Patients with BPD seem to have very dichotomous responses to the experience of pain. On the one hand, they appear highly pain tolerant. On the other hand, they appear very pain intolerant. This seeming paradox can be readily explained by the context of the pain. From a pragmatic perspective, we believe that it is critically important to determine the BPD status of the chronic pain patient, because such a diagnosis affects the clinicians subsequent assessment and management of the pain syndrome. In those individuals with BPD, we recommend a very conservative approach to pain management, with careful monitoring of analgesic medications by the prescribing clinician. Mental health professionals can be invaluable in training providers in general medicine settings and pain clinics to initially screen patients for BPD, and to be aware of the frequent association between BPD and chronic pain. If the patient has BPD, the mental health clinician may then recommend and/or reinforce the suggested conservative treatment

[Regarding BPD patients] it is not the patients level of pain that determines analgesic prescription, but rather the clinicians best estimate of the patients pain.
consider referral for cognitivebehavioral intervention for those patients who might be able to benefit. For the psychiatric consultant, BPD can be a difficult disorder to briefly explain to non-mental health professionals with various levels of psychiatric knowledge. However, in our experience, a practical way to efficiently describe this disorder is to highlight the three fundamental elements of the working definition of BPD. All patients with BPD have: 1) a seemingly intact social faade or veneer, which tends to erode under stress; 2) longstanding difficulties with self-regulation (e.g., eating disorders, substance abuse, promiscuity, chronic pain syndromes); and 3) chronic selfdestructive behavior (e.g., cutting self, suicide attempts). In the case of individuals with chronic pain, it may be that the resulting self-defeating lifestyle functions as the means of selfdestructive behavior. When educating the treatment team, it is important to broach the dynamic of splitting. When various professionals interface with the individual with BPD, there is always the risk that the patient will engage in splitting. It is essential to advise clear, succinct, and well-organized documentation of treatment suggestions in the medical record and to communicate these directly to key providers. In addition, it may be helpful to have team members routinely cross-check among themselves any suspicious management statements from the patient (e.g., They said I could management. For example, the inherent self-regulatory difficulties of these patients may culminate in prescription misuse, abuse, and dependence. Their unrelenting needs to engage others may result in multiple status quo appointments, escalating pain complaints, requests for unusual or medically unacceptable approaches or procedures, and requests for questionable disability compensation. Likewise, the psychiatric diagnosis itself tends to stigmatize patients and may result in distancing of the individual by the physician and staff; this may further stimulate the patients attempts for engagement. Because these patients may be continually demanding, there

This diagnosis [BPD] justifies the...conservative approach [described in this article] to chronic pain management and also infers the patients potential risks of addiction, medication misuse/abuse, and overdose (i.e., the patient suffers from BPD).
is always a risk of countertransference on the behalf of the medical team. The treatment team may act out these feelings by indulging the patient with analgesics, withholding all pain-management prescriptions, removing the patient from the practice, and/or tampering with the directives of the pain management specialist. It is important strategy. In this unique role, the mental health professional can hopefully exert a positive impact on healthcare utilization in medical settings, which benefits all of society.

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