Received: 3 December 2018 

|  Revised: 16 April 2019 

|  Accepted: 17 April 2019

DOI: 10.1002/ejp.1411

ORIGINAL ARTICLE

Differential perception of sharp pain in patients with borderline

personality disorder

Natalie Schloss1,2  | Polina Shabes1  | Sarah Kuniss3  | Franziska Willis3,4  |

Rolf‐Detlef Treede   1
| Christian Schmahl   3
| Ulf Baumgärtner 1

1
Department of Neurophysiology,
Center of Biomedicine and Medical
Technology Mannheim, Medical Faculty
Mannheim, Ruprecht Karls‐University
Heidelberg, Mannheim, Germany
2
Department of Neurology, University of
Cologne, Cologne, Germany
3
Department of Psychosomatic Medicine
and Psychotherapy, Central Institute of
Mental Health, Ruprecht Karls‐University
Heidelberg, Mannheim, Germany
4
Department of General, Visceral and
Transplantation Surgery, University
Hospital Heidelberg, Heidelberg, Germany
Correspondence
Ulf Baumgärtner, Department of
Neurophysiology, Center of Biomedicine
and Medical Technology Mannheim
(CBTM), Medical Faculty Mannheim,
Ruprecht Karls‐University Heidelberg,
Mannheim, Germany
Email: ulf.baumgaertner@medma.uni-
heidelberg.de
Abstract
Background: Cutting is the most common method of non‐suicidal self‐injury (NSSI)
to reduce inner tension in patients with Borderline Personality Disorder (BPD). Aim
of this study was to compare pain perception induced by an incision and by applica-
tion of a surrogate model for sharp mechanical pain (a non‐invasive “blade”) in BPD.
Methods: 22 female patients and 20 healthy controls (HC) received a small incision
into the volar forearm, a 7s‐blade application on the same side, and non‐invasive pha-
sic stimuli (pinprick, blade, laser, tactile). Pain intensity as well as affective versus
sensory components were assessed.
Results: Incision was rated similarly by both groups (BPD: 28.6  ±  5.5 vs. HC:
33.9 ± 6.6; mean maximum pain ± SEM; p > 0.8), without significant difference
for “7‐s‐blade” (BPD: 18.1 ± 3.8 vs. HC: 25.3 ± 3.6; mean maximum pain ± SEM;
p  >  0.17) or between “7‐s‐blade” and incision (BPD: p  >  0.12; HC: p  >  0.84).
However, patients’ intensity ratings returned significantly faster to baseline after in-
cision (BPD: 38.9 ± 12.6 s vs. HC: 74.52 ± 11.5 s; p < 0.05), and patients evaluated
“blade” and incision without any affective and with different sensory descriptors,
indicating an altered evaluation of NSSI‐like stimulation with qualitative in addition
to quantitative differences—especially for the sharp pain component.
Conclusions: The reduced perception of suprathreshold nociceptive stimuli is based
on a missing affective component and specific loss of the perception of “sharpness”
as part of the sensory component of pain. The results further demonstrate the useful-
ness of the “blade” for the perception of sharpness in patients.
Significance: Patients with Borderline Personality Disorder (BPD) who engage in
non‐suicidal self‐injury (NSSI) report less pain in response to phasic nociceptive
stimuli. In comparing an invasive pain stimulus to phasic nociceptive stimuli in BPD
patients, the “blade” as non‐invasive surrogate model for sharp mechanical pain in
psychiatric patients is used. In contrast to healthy volunteers, BPD patients do not
report significant affective ratings and specifically display a reduced sensory com-
ponent for sharpness.

© 2019 European Pain Federation ‐ EFIC®     1

Eur J Pain. 2019;00:1–16. wileyonlinelibrary.com/journal/ejp |
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2       SCHLOSS et al.
1  |   IN TRO D U C T ION
Non‐suicidal self‐injury (NSSI)—the deliberate and direct
destruction of body tissue without suicidal intent—is fre-
quently encountered among healthy adolescents and psy-
chiatric patients (e.g., in eating disorder and Borderline
Personality Disorder (BPD); (Swannell, Martin, Page,
Hasking, & St John, 2014 ). Research on this topic has
more than tripled during the early 2000s, attempting to un-
derstand the motivation for as well as underlying pathol-
ogies of NSSI and to develop adequate therapies (Nock,
2010). People with BPD struggle with aberrant impulse
control, emotion‐ and stress‐dysregulation (Leichsenring,
Leibing, Kruse, New, & Leweke, 2011; Lieb Zanarini,
Schmahl, Linehan, & Bohus, 2004), which in 69%–90% of
female BPD‐patients result in NSSI (Zanarini et al., 2008),
predominantly in the form of cutting or burning them-
selves (Kleindienst et al., 2008; Klonsky, 2007) with the
most commonly reported reasons: reducing aversive inner
tension or terminating negative emotions (Kleindienst
et al., 2008; Ludäscher et al., 2009).
About 70%–80% to eighty percentage of BPD patients re-
port little or no pain during acts of self‐injury (Leibenluft,
Gardner, & Cowdry, 1987; Shearer, 1994), and several stud-
ies revealed reduced pain sensitivity in BPD patients who per-
form NSSI compared to healthy controls. BPD patients report
less pain when exposed to non‐invasive thermal (Bekrater‐
Bodmann et al., 2015; Bohus et al., 2000; Russ et al., 1992;
Schmahl et al., 2006, 2004), electrical (Ludäscher et al.,
2007), mechanical and chemical stimuli (Magerl, Burkart,
Fernandez, Schmidt, & Treede, 2012) while their ability to
discriminate intensity and localization of nociceptive stimuli
was normal (Ludäscher et al., 2007; Schmahl et al., 2004).
However, investigations concerning invasive, tissue‐damag-
ing painful stimulation as used during NSSI, are sparse.
Reitz and colleagues (Reitz et al., 2015, 2012) first tested
an incision in BPD‐patients, according to the incision‐model
of Kawamata established for research on mechanisms of
postoperative pain (Kawamata et al., 2002). BPD‐patients
exhibited a significant decrease of aversive tension as well
as a decrease of amygdala activity after an incision—a lim-
bic structure important for emotion and stress regulation
(LeDoux, 2000)—whereas amygdala activity increased over
time in the healthy control group.
However, one methodological problem for further anal-
yses is the limitation to present a single incision stimulus
during fMRI, where repetitive stimulation is required to in-
crease signal strength for a more detailed examination of af-
fected neuronal pain circuitries in BPD. Therefore, Shabes et
al. (2016) established a non‐invasive surrogate model—the
0.1 × 4 mm non‐penetrating “blade” with a force of 4096
mN—offering a repeatable application of an incision‐like
pain stimulus (Shabes et al., 2016).
Willis and colleagues were the first to use the “blade”
to explore the effect of tissue damage in BPD (Willis et al.,
2017) in the context of stress reduction. After experimental
stress induction, BPD patients and controls received either an
incision or the “blade” or a non‐nociceptive control stimulus
(sham). Shortly after the application, both painful stimula-
tions led to a greater stress reduction measured by arousal
ratings than the sham stimulus in BPD, without significant
difference between incision and “blade”, emphasizing the
importance of pain experience rather than tissue injury in
early stress reduction.
It is still unclear, if the pain sensation of a real cut as
well as of the blade stimulus is perceived differently in BPD
under normal conditions without specific stress induction.
We now examined the impact of tissue‐damage (“incision”)
and application of the non‐invasive “blade” without specific
stress induction regarding temporal pain aspects as well as
subjective affective and sensory evaluations in detail in order
to investigate whether there are differences in its processing
within acute BPD patients and between patients and healthy
controls. It was undertaken according to the experimental
paradigm used for healthy participants before (Shabes et al.,
2016) to test the following hypotheses:
1. We expected the blade to be an adequate incision pain
surrogate model in borderline patients with respect to
intensity and quality.
2. Patients with BPD differ from their healthy counterparts
in lower pain ratings for different pain modalities. We
expected to find reduced mechanical and thermal pain
ratings within the same sample of BPD which was pre-
viously reported for separate patient groups for pinpricks
(Magerl et al., 2012) and laser (Schmahl et al., 2004).
3. Patients perceive and describe pain differently from their
healthy counterparts—especially with respect to the sharp
mechanical pain component, due to disturbances of affec-
tive and sensory processing with a) lower affective levels
and b) less perception of the “sharp” component in BPD.
2  |  M ATERIAL S AND M ETHOD S
2.1  | Participants
After approval of the local Ethics Committee (No.
2011‐243N‐MA), the study was conducted in accordance
with the Declaration of Helsinki at the University Medical
Centre Mannheim. Having received both verbal and writ-
ten explanations of all tasks, volunteers gave written in-
formed consent and received monetary compensation for
participation.
The patients investigated in this study took part in a larger
research framework where patients were recruited through
SCHLOSS et al.
a central office of KFO 256. After the diagnostic procedure
conducted by clinically experienced interviewers, all patients
included met the criteria for BPD according to the Diagnostic
and Statistical Manual of Mental Disorders (DSM, APA
2013) determined via the International Personality Disorder
Examination (IPDE) (Loranger, 1999). A subsample of 22
female patients with BPD (mean age 30.45 ± 10.54 SD) par-
ticipated in this study and was compared to 20 female healthy
controls who underwent the same testing protocol as described
in “2.4 Experimental procedure” (Shabes et al., 2016) (com-
parison of healthy women to men; mean age 24.25  ±  4.68
SD). Eleven i.e., 50% of the BPD patients represent a sub-
sample of the patients with acute BPD who also took part in
the study of Wills et al. (2017). All experiments were held at
different dates.
NSSI including tissue‐damage within the preceding
6  months was reported by all BPD‐patients. Any healthy
control subject with a life‐time‐event of NSSI was excluded
from this study. Further exclusion criteria included a lifetime
diagnosis of schizophrenia, bipolar disorder type 1, current
substance abuse, neurologic diseases (i.e., epilepsy, multiple
sclerosis, brain tumors) or pre‐existing mild to severe pain
syndromes. None of the participants took any analgesic med-
ication two weeks prior to this study, also known that use of
potent analgesics might aggravate psychopathology in BPD
  
   3
|
14 sensory (e.g., stinging, burning) and 14 affective items
(e.g., cruel, miserable) (Geissner, 1996; Schilder et al.,
2014). In the SES, pain descriptors were weighed by ratings
on a 0 to 3 ordinal scale (0  =  does not apply, 1  =  applies
somewhat, 2 = applies mostly, 3 = applies fully). According
to previous work, sensory scores can be grouped into “deep”
and superficial pain, which itself can be subclassified into
“heat” (C‐fibre related quality) and “sharp” (A‐δ related
quality) mechanical pain. Hansen et al. performed a factor
analysis to elucidate meaningful sensory qualities by using
the VARIMAX method. Hence, we used these three factors
(thermal, sharp, deep) in order to categorize the relatively
large number of items for simplification (Hansen, Klein,
Magerl, & Treede, 2007).
Considering the aspect of hypoalgesia during dissociative
states in BPD, dissociation was checked via DSS‐4, a valid
short instrument to assess dissociative experience during ex-
periments (Stiglmayr, Schmahl, Bremner, Bohus, & Ebner‐
Priemer, 2009).
T A B L E 1   Demographic data and psychiatric comorbidities. HC
data from Shabes et al. (2016)
Group BPD (n = 22) HC (n = 20)

(Thurauf & Washeim, 2000); as psychotropic drugs selective Age 30.45 ± 10.54 24.25 ± 4.68
serotonin reuptake inhibitors and tricyclic antidepressants Psychiatric comorbidities
were allowed because of the high prevalence of this medi- Mood disorder, current 9 (40.9%)  
cation among BPD patients. For demographic and psycho- Mood disorder, lifetime 19 (86.4%)  
pathological data, see Table 1. Substance abuse, lifetime 9 (40.9%)  
Substance dependence, 8 (36.4%)  
2.2  |  Ratings and questionnaires lifetime
Anxiety disorder, current 8 (36.4%)  
All stimuli were evaluated in terms of pain intensity via a
Anxiety disorder, life time 10 (45.5%)  
numeric rating scale (NRS) and a visual analogue scale
Posttraumatic stress disorder, 7 (31.8%)  
(VAS) which both ranged from 0 (= no pain at all) to 100
current
(= most intense pain imaginable). NRS was given verbally
Posttraumatic stress disorder, 10 (45.5%)  
for every single stimulus, whereas the rating via VAS was
lifetime
executed electronically using a computer mouse for incision
Eating disorder, current 7 (31.8%)  
and 7‐s‐blade application. The time course of VAS rating
was sampled at 10 Hz (Dapsys software provided by Brian Eating disorder, lifetime 10 (45.5%)  
Turnquist). These VAS and NRS were pure “pain scales”, Medication
where “0” indicated either no perception at all or any per- None 11 (50%) 12 (60%)
ception that was not painful (warmth, touch), without anchor Selective serotonin reuptake 5 (23%)  
points in order to have a pure rationale scale. inhibitors
To differentiate between the sensory‐discriminative Tricyclic antidepressants 1 (4.5%)  
and affective‐evaluative components of pain, an extended Beta‐blocker 1 (4.5%)  
version of the German Pain Perception Scale (Schmerz‐ Proton pump inhibitors 2 (9%)  
Empfindungsskala, SES Geissner, 1995) was used, which Oral contraceptives 3 (14%) 6 (30%)
contains 4 additional sensory items (dull, pressing, pull-
Thyroid hormones 1 (4.5%) 2 (10%)
ing, pulsating) than the previous version with 24 descrip-
Phytopharmaca 1 (4.5%)  
tors—derived from the McGill Pain Questionnaire (MPQ,
Melzack, 1975, 1987)—resulting in a list with an number of Asthma medication 1 (4.5%)  
 |
4       SCHLOSS et al.

of 0.4 mm2—chosen to match the area of an incision—and

2.3  | Stimuli
a force of 4096mN (MRC Systems GmbH, Heidelberg,
Germany; Figure 1). Stimuli with bigger tip areas than pin-
2.3.1  |  Reference stimulus: Incision
pricks and sharp, but not skin‐piercing edges are needed
After the different forms of pain‐ratings had been explained to provide more spatial summation in exciting mainly A‐δ
to the participants, they were comfortably seated opposite a and C‐ fibre nociceptors (Slugg, Campbell, & Meyer, 2004,
computer screen used for VAS‐rating to their right and ex- Slugg, Meyer, & Campbell, 2000). When applied for 7 s in
tending their left arm to the side on a table. After disinfec- healthy subjects, this 4096 mN‐blade reached similar peak
tion with 70% alcohol, the incision was conducted by the pain ratings as an incision—as a result of temporal summa-
experimenter with a sterile standard scalpel (model “präzisa tion during longer application; difference was only found
plus“, Dahlhausen, Cologne, Germany), according to the es- in ratings for the late phase, most likely due to the release
tablished procedure to induce incisional pain (Fißmer et al., of cytokines triggering a “burning” sensation in incisional
2011; Kawamata et al., 2002; Pogatzki‐Zahn et al., 2010): the pain (Shabes et al., 2016).
scalpel was gently pushed into the skin of the left volar fore-
arm of every participant leaving a small cut (approximately
4 mm wide and 5–7 mm deep). During and directly after the
2.3.3  |  Phasic test stimuli
incision, participants were instructed not to look at their fore- The response to different modalities of phasic nociceptive
arm which was extended by approximately 90° laterally to stimuli has been shown to be reduced in BPD patients mainly
their left, out of their field of view. They had to focus slightly in separate studies. In order to check reproducibility and to
to the right in front of them on the computer screen, where test different modalities in the same sample, we acquired
a thermometer‐like vertical VAS‐bar indicating the current stimulus‐response functions for quantitative comparison be-
level of pain intensity was shown (zero at the bottom mean- tween stimulus modalities and groups (healthy controls and
ing “no sensation of pain at all” and one hundred at the top BPD patients). For this purpose, stimulus durations were the
“most intense imaginable pain possible”). For the acquisition same (1 s) except for the laser stimulus (for technical reasons
of continuous pain ratings, subjects moved a computer mouse fixed at 1 ms).
on the table away from themselves (increasing pain) or to-
wards themselves (decreasing pain). Moving the mouse away Blade stimuli (1 s)
from the participant increased the filling of the VAS‐bar with To acquire stimulus response functions, we used five differ-
red colour. While the entire time course was sampled in the ent blades with increasing forces of 256, 512, 1024, 2048,
background, it was only possible for the participant to see the and 4096 mN. They were constructed like pinprick stimu-
current rating as red level of the thermometer‐like bar. No lators but all with blunt blades fixed to a plastic mounting
time limit for the rating procedure was indicated a priori to
the participants. Once the rating returned to zero and stayed
stable, indicating the subject did not feel any sensation of
pain anymore, the sampling was stopped, which was the case
at the latest after 4  min (for the participant with the long-
est pain duration). The skin was gently pressed with a swab
and a plaster was applied. Incision was well tolerated by all
subjects.
Since in our previous study (Shabes et al., 2016) we found
differential effects in different time windows following the
incision or blade application, we separated the entire time
course for the later analysis into shorter segments, accord-
ingly. The first took 7 s (the duration of the actual incision
until the scalpel or blade was withdrawn), the others 30 s each
until the end of the pain experience.

2.3.2  |  Human novel surrogate for incision

pain: blade (7 s)
The blade is a custom‐made device comparable to an elon-
gated pinprick stimulator, however with a larger tip area of
4 mm length, 100 µm width resulting in a flat contact area F I G U R E 1   Scalpel and Blade (4096 mN)
SCHLOSS et al.
providing a larger tip area (4 mm length, 100 µm width), and
resulting in a flat contact area of 0.4 mm2.
Pinprick stimuli (1 s)
Pinpricks (MRC Systems GmbH, Heidelberg, Germany)
are already established as part of the Quantitative Sensory
Testing battery proposed by the German Research
Network on Neuropathic Pain; DFNS (Deutsches
Forschungsnetzwerk Neuropathischer Schmerz; (Rolke,
Baron, et al., 2006a; Rolke, Magerl, et al., 2006b)).
Pinprick stimulators have cylindrical flat‐tip wires (diam-
eter 0.25 mm) moving freely inside a steel tube. We used
five forces of 32, 64, 128, 256 and 512 mN of these “blunt
needles”.
Blunt pressure tactile stimuli (1 s)
Serving as control stimuli, five non‐noxious mechanical
stimuli with sphere‐shaped tips were used. They were con-
structed like the blades, with the same forces on different
contact areas: 50.3 mm2 (256 mN), 63.6 mm2 (512 mN),
95.0 mm2 (1024 mN), 132.7 mm2 (2048 mN), and 201.1
mm2 (4096 mN).
Laser heat stimuli (1 ms)
Using laser heat stimuli is the most validated method to ex-
plore the nociceptive system in selectively activating A‐δ and
C‐fibres without exciting tactile receptors of the skin/ sen-
sory cutaneous receptors (Bromm & Treede, 1991; Plaghki &
Mouraux, 2003) and have frequently been used in investigat-
ing pain perception in BPD (Ludäscher et al., 2009; Schmahl
et al., 2004). Therefore, we again stimulated with radiant
heat stimuli generated by a PC‐controlled infrared thulium‐
YAG laser (THEMIS, StarmedTec, Starnberg, Germany;
wavelength 2 µm; pulse duration 1 ms). We used a paradigm
F I G U R E 2   Study design. First, an incision (1 s) was made into the left volar forearm followed by a balanced sequence of phasic (1 s),
mechanical and tactile stimuli to the right volar forearm. After that, a block of laser stimuli (1 msec) was applied, again to the right volar forearm.
At the end, an investigation with the blade (4096 mN, 7 s) was carried out to the left volar forearm. VAS = visual analogue scale (only during and
after incision and 7 s blade application), NRS = numeric rating scale; SES score (“Schmerz‐Empfindungsskala”) for each stimulus; I‐V = stimulus
intensities
  
   5
|
of five different intensities: output energies were 320, 370,
420, 470 and 520 mJ. All participants and the experimenter
wore protective goggles. The experimenter adjusted the laser
beam's position on the right volar forearm after each stimulus
to avoid sensitization or receptor fatigue.
2.4  |  Experimental procedure
After all participants had confirmed they were currently free
of ongoing pain sensation, they received stimuli of different
modalities.
The overall procedure contained the following steps (see
Figure 2):
1. Incision (1  s): As Shabes and colleagues found no dif-
ferences of effects (order effect) when the incision was
executed before or after the remaining stimuli (Shabes
et al., 2016), incision in the present study was executed
at the beginning of the experiment to the left volar
forearm.
2. Pinpricks, blades, and spheres were applied manually,
perpendicular to the skin with variation of location to the
right volar forearm for 1 s. These single modalities were
tested in separate blocks the order of which was balanced
across subjects. Within each of these blocks, five intensi-
ties (of the respective modality) were applied in pseudor-
andomized order (25 stimulations).
3. After that, a block of 25 laser heat stimuli was applied in
the same fashion again to the right volar forearm, for 1 ms.
4. At the end, the application of the sharp mechanical pain
stimulus (blade, 4096 mN) for the duration of 7  s took
place. It was presented to the same arm as the incision (left
volar forearm).
 |
6       SCHLOSS et al.
In BPD patients, it was taken care that the stimula-
tion occurred in areas free of acute or scarred marks re-
lated to NSSI. Every single stimulus was evaluated on a
NRS resulting in a stimulus–response function protocol.
Incision and blade were additionally rated via electronic
continuous VAS‐rating. After every different pain modal-
ity block, both an average and maximum NRS rating were
given post hoc and participants filled in the Pain Sensation
Questionnaire (SES) with respect to sensory and affective
pain components. Patients were also tested for the aspect
of dissociation during the experiment by evaluating their
state of feeling via DSS‐4 post‐hoc (Stiglmayr et al., 2009).
The total duration of the experimental session was approx-
imately 2 hr.
2.5  |  Statistical analysis
Statistical analysis was done using SigmaPlot (Systat
Software Inc.). We checked within the groups for the
same variables as the healthy subjects already had been
investigated for, and additionally for group differences
between patients and healthy controls (HCs): We calcu-
lated repeated‐measures analyses of variance (ANOVAs)
to test the influence of the independent variable “intensity”
within every modality, using logarithmic data of the rat-
ings of each subject's single stimulus response functions.
For pairwise multiple comparisons of different intensities
within the same modality, the Tukey test was calculated.
For every single stimulus modality, we tested for group dif-
ferences (BPD/HC) with the 2‐factorial repeated‐measures
ANOVA (1 factor repetition), with the independent vari-
ables “intensity” and “group”. Further, within each group
a 2‐factorial repeated‐measures ANOVA (2‐factor repeti-
tion) was calculated for the independent variables “inten-
sity” and “modality”.
Unpaired student t tests were used for comparison of dif-
ferent time windows (0–30, 30–60, 60–90 and 90–239 s) be-
tween both groups.
For detection of differences in sensory and affective pain
processing (SES), a 2‐factor ANOVA was calculated for all
ratings (incision, blade (7 s), phasic (1 s) stimuli) including
the main factors BPD versus HC, sensory versus affective SES
components and SES ratings to single items (ratings  =  de-
pendent variable). A single descriptor of the Pain Sensation
Questionnaire SES was considered to have a significant im-
pact on pain perception when its score deviated significantly
from “zero” in paired t tests with Bonferroni correction for
multiple testing.
To test for differences in pain duration, the time of half‐
maximal decay was compared using paired t tests.
p < 0.05 was considered significant. For estimation of ef-
fect sizes, Cohen's d was reported for t test analyses, Cohen's
f2 for analyses of variance (ANOVAs).
3  |  RESULTS
3.1  |  Within BPD patients: “blade” stimulus
versus incision
BPD patients perceived the 7 s non‐invasive blade applica-
tion as painful (22.2 ± 5.3, mean maximum VAS ± SEM)
until ratings turned to baseline, with no significant dif-
ference when compared to maximum incisional pain
(28.6  ±  5.5; p  >  0.12, d  =  0.25; Figure 3). However,
there were temporal differences, as it took significantly
longer to reach the mean maximum rating for blade pain
(5.5 s) compared with the time it took after incision (3.3 s;
p  <  0.05, d  =  0.24). Pain ratings for blade dropped sig-
nificantly faster to baseline (29.2 ± 0.4 s) than for incision
(38.9 ± 12 s; p < 0.05, d = 0.24; Figure 3).
Regarding pain evaluation, there was no significant
main effect on SES scores for modality (incision, 7s blade;
p = 0.06, f2 = 0.03) but a significant main effect of the af-
fective‐sensory components (p < 0.001, f2 = 0.36; 2‐facto-
rial ANOVA; no significant interaction p = 0.205; Tab. 2).
Post hoc tests revealed that this effect was due to the differ-
ence for the sensory pain component between incision and
blade (7 s; p < 0.05, f2 = 4.82) and not caused by differ-
ences for the affective pain component between modalities
(p > 0.6). BPD patients scored the affective component less
than the sensory component for both stimuli (p < 0.05, post
hoc tests; see Figure 4a).
Describing incision‐ and blade(7s)‐induced pain using
SES, blade evoked a similar perception pattern as incision,
but with overall significantly higher ratings for incision:
scores for the three sensory factors (thermal, sharp and
deep) according to the factor analyses from (Hansen et al.,
2007) were significantly higher for incision than for blade
(7 s) within BPD patients (sharp: p < 0.01, d = 0.74, ther-
mal: p < 0.05, d = 0.58, deep: p < 0.05, d = 0.54), but with
F I G U R E 3   Mean time course of 7‐s‐blade pain (black line)
versus incisional pain (grey line) in BPD patients (n = 22).
SCHLOSS et al.
F I G U R E 4   (a) Description of the affective and sensory pain
components by means of the Pain Sensation Questionnaire (Schmerz‐
Empfindungsskala, SES) for incision and blade (7s) in BPD (n = 22)
with significantly lower affective than sensory scores for both stimuli
(p < 0.05). *** p < 0.001. (b) SES pain ratings for the three sensory
submodalitites according to the factorial analyses from (Hansen et
al., 2007): “deep” pain and “superficial” pain consisting of the two
components “sharp” mechanical pain (A‐delta‐fiber related quality)
and “heat” pain (C‐fiber related quality); from sensory pain descriptors
form the Pain Sensation Questionnaire (Schmerz‐Empfindungsskala,
SES) scores for incision and blade (7 s) in BPD (n = 22). Blade evoked
a similar perception pattern as incision (sharp > thermal > deep), but
with overall significantly higher values for incision. * =p < 0.05,
**=p < 0.01
a similar descending order for both stimuli, with “sharp” as
the highest scored modality, followed by thermal and deep
(sharp > thermal > deep, Figure 4b).
The single SES description (raw) items again showed sim-
ilar profiles for incision and blade (7 s) without any affective
descriptor as statistically significant (Bonferroni‐correction).
For the sensory pain component, 4 sensory descriptors were
found to be statistically different from zero for incision (“cut-
ting”, “burning”, “stinging”, “pulling”) versus 2 for blade
(“stinging”, “pressing”), with differences between stimulus
modalities for “cutting”, “burning” and “throbbing” which
  
|
   7
were scored significantly higher for incision (p  <  0.05,
d  =  0.9) and one descriptor “pressing”, which was scored
significantly lower for incision than for blade (p  <  0.005,
d = 1.11; see supplementary Figure S1 for detailed overview).
3.2  |  Group comparison
3.2.1  | Blade
Mean pain ratings across the entire time course of the
4096mN‐blade application until ratings returned to baseline
were lower in BPD (22.2  ±  5.3 SEM) than in the healthy
control group (32.5 ± 4.8 SEM; p < 0.05, d = 0.46; Figure
5a,b). Accordingly, evaluating the individual maximum pain
ratings, BPD patients reported significantly lower pain, with
23.1 ± 4.6 compared to 33. 9 ± 4.7 (HC; p < 0.05, d = 0.52).
Concentrating only on the first 7 s, where the actual blade‐ap-
plication took place, there was no significant difference be-
tween groups (mean maximum pain ratings: BPD 18.1 ± 3.8
and HC 25.3 ± 3.6; p = 0.17, d = 0.43; Figure 5b).
Although peak ratings of healthy subjects were higher, the
mean time course of both groups was similar without signif-
icant differences, both reached maximum pain after 5.3 (HC)
and 5.5 (BPD) seconds (mean) and reached baseline again
after 20–30 s.
3.2.2  | Incision
There was no significant difference for incision between
groups (p  >  0.6, d  =  0.2), although nominally ratings
were slightly lower in BPD patients than in healthy sub-
jects, with a mean maximum rating in the BPD group
average across time of 28.6  ±  5.5 (mean  ±  SEM; on av-
erage 3.3  s after beginning of the incision; Figure 5c)
compared to 33.9  ±  6.6 in the HC group, after 3.6  s on
average after incision‐start. As in both groups the interin-
dividual pain duration was highly variable, time courses
were roughly similar. While 3 healthy subjects rated up
to over 80/100 mm on the VAS scale and 2 of them even
over 90, there was also only one BPD patient who reported
a maximum pain sensation of 85. Further, only 2 healthy
participants gave ratings under 10, whereas there were 6 of
these in the BPD group. In addition, there was also no sig-
nificant difference in the individual peak ratings of incision
induced‐pain: 31.2 ± 5.5 (BPD) compared with 40.0 ± 6.7
(HC; p > 0.3, d = 0.32). We also found no significant dif-
ferences in the early phases—0 to 30  s as well as 30 to
60  s—but after a minute, in the time window 60 to 90  s,
healthy women gave significantly higher ratings than BPD
patients (p < 0.05, d = 0.69; Figure 5d). With a mean decay
to half‐maximal pain of 33.0 ± 7.9 s, and finally to base-
line after 74.5 ± 11.5 s in HC, BPD patients dropped sig-
nificantly faster to baseline again after less than a minute
 |
8       SCHLOSS et al.

F I G U R E 5   (a) Mean time course of blade pain (7 s) in BPD patients (grey line; n = 22) versus healthy controls (black line; n = 20). (b) Mean
ratings for BPD patients and healthy controls and in the time windows 0 to 7 s ± SD. No significant difference between BPD and HC for both blade
pain and incision pain (p > 0.1 for blade; p > 0.7 for incision; unpaired student t test) and between incision and blade pain within each group (BPD:
p > 0.4; HC: p > 0.8; unpaired student t test). (c) Mean time course of incisional pain in BPD patients (grey line; n = 22) versus healthy controls
(black line; n = 20). (d) Mean ratings for BPD patients and healthy controls in the time windows 0 to 30, 30 to 60, 60 to 90, and 90 to 239 s ± SD.
Between 60 and 90 s, BPD patients gave significantly lower pain ratings (p < 0.05; unpaired student t test). HC data from Shabes et al. (2016)

F I G U R E 6   Comparison of stimulus‐
response functions for mechanical (left) and
laser heat (right) stimuli (all 1 s) between
BPD patients (n = 22) and healthy controls
(n = 20). In both groups, modality and
intensity affect pain rating significantly
(p ≤ 0.001). There was a significant main
effect of group for all modalities (p ≤ 0.001)
except for tactile spheres (p > 0.6). HC data
from Shabes et al. (2016)

with 38.9 ± 12 s (p < 0.05, d = 0.68) and showed a trend
towards statistical significance of 16.0 ± 3.5 s for reaching
half‐maximum pain (p < 0.06, d = 0.64).
Similar as for BPD patients, mean pain ratings during
the first 7  s in HC did not differ significantly between in-
cision and blade application (incision: 24.2 ± 4.4 vs. blade:
25.3 ± 3.6, p > 0.8, d = 0.06; Figure 5b).
3.2.3  |  Stimulus response functions for
phasic stimuli
BPD patients tended to give overall lower pain ratings than
their healthy counterparts (Figure 6): A significant group
difference was found for modality as well as for intensity as
main effect (p < 0.001, f2 = 0.24; with a significant interac-
tion group X modality p < 0.001, F = 5.48; but no significant
interaction group × intensity p = 0.47, F = 0.88). Borderline
patients gave significantly lower pain ratings than healthy
controls for pinprick (p < 0.05, f2 = 2.1), 1s blade (p < 0.001,
f2 = 9.26) and laser (p  <  0.01, f2 = 1.66) stimuli. In both
groups, spheres as control stimuli were similarly not evaluated
as painful (p > 0.6). There was no significant difference for
the lowest two intensities of each modality between groups,
rated rather “tactile” than painful, whereas healthy controls
showed significantly higher pain ratings for the higher third
(only laser, p < 0.05, f2 = 0.03), the fourth and fifth (laser and
SCHLOSS et al.
blade, both p < 0.01, f2 = 0.05) intensity. In both groups, stim-
ulus modality had a highly significant impact on pain intensity
(2‐way ANOVA modality: p < 0.001, f2 = 0.62; intensity: 1‐
factorial ANOVA, p < 0.001, f2 = 0.13; Figure 6). There was
no significant difference within each group between ratings
for blade (1 s) and laser (HC p > 0.6; BPD p > 0.3). Using
the blade as a surrogate for incisional pain, it elicited 2 to 3
times higher pain ratings than provoked through the other me-
chanical modalities in both groups. In summary, BPD patients
reported less pain for pinprick, blade and laser stimuli.
3.3  | SES‐scores
Stimulus modality influenced SES scores, consisting of sen-
sory and affective subscales, significantly (p  <  0.001, f2 =
0.24) and there were statistically significant differences be-
tween groups (p < 0.05, f2 = 0.01) and between affective and
sensory scores (p  <  0.001, f2 = 0.13; 3‐factorial ANOVA;
main effects affective‐sensory, modality, group; Table 2).
There was no statistically significant interaction between
group and modality (p  >  0.1) or between group and affec-
tive‐sensory (p > 0.8), but between modality and affective‐
sensory (p < 0.001, f2 = 0.04).
Concentrating only on incision and phasic blade‐applica-
tion (1 s), there were significant differences between groups
(2‐factorial ANOVA; main effects group, affective‐sensory;
p < 0.001, f2 = 0.05; Table 2). There was no significant dif-
ference between groups for incision SES scores (affective:
p  >  0.1, d  =  0.44; sensory: p  >  0.2, d  =  0.37), however 1s
blade induced pain was scored lower in BPD than HC for both
modalities (affective: p < 0.05, d = 0.72; sensory: p < 0.05,
d = 0.66, Figure 7a).
Significant differences were found for several descriptors
as single items of the sub‐modalities affective/sensory for the
blade stimulus and incision: 7 descriptors (2 affective and 5
sensory) characterized incisional pain in healthy subjects,
whereas in BPD no affective and only 4 sensory descriptors
(“cutting”, “burning”, “stinging” and “pulling”) were found.
The affective descriptor “agonizing” and the sensory descrip-
tors “cutting” and “stinging” were rated significantly lower in
BPD (p(agonizing) < 0.005, d = 0.48; p(cutting, stinging) < 0.05 d(cut-
ting) = 0.39, d(stinging) = 0.36). Similar different evaluations
were also found for blade, where the same sensory descrip-
tors “cutting” and “stinging” and additionally “piercing” and
the affective depiction “dreadful” were rated significantly
lower in BPD (p  <  0.05, d(stinging) = 0.31, d(piercing) = 0.32,
d(dreadful) = 0.39; for “cutting” p < 0.001, d = 0.58).
Single items were again grouped as three factors (ther-
mal, sharp, deep), according to (Hansen et al., 2007). In
both groups, sensory SES scoring patterns for incision and
blade (1s) were similar (sharp > thermal > deep), whereas
both incision and blade (1s) were perceived significantly
less sharp in the BPD group compared to their healthy
  
|
   9
counterparts (p < 0.01, d(incision) = 1.02, d(blade) = 1; Figure
7b).
For both groups, scores for the sensory pain compo-
nent were significantly higher than for the affective pain
component, independent of the stimulus modality (in BPD:
p < 0.001 for incision, blade and laser; p < 0.05 for pin-
prick and sphere; in HC: p < 0.001 for incision, blade, pin-
prick and laser; p < 0.05 for sphere; see Figure 8 depicting
the comparison of affective and sensory pain evaluation
between the group of BPD patients and HC for incision,
blade, pinprick, laser and sphere (1 s).
For the control stimulus (spheres), pinprick and laser, the
SES‐scoring pattern of the descriptors was similar between
groups. For pinpricks, in both groups the descriptor “sting-
ing” depicted pain sensation. For laser heat, 4 same sensory
descriptors were found in both groups (“burning”, “scald-
ing”, “stinging” and “hot”) with one additional sensory item
(“pulling”) in healthy controls and one additional affective
item (“agonizing”) in BPD, without significant difference.
As expected, there were no descriptors found characterizing
pain for our tactile control stimuli (spheres; see supplemen-
tary Figure S2 in the Supplement for detailed overview of the
comparison of affective and sensory pain descriptors form
the SES Pain Sensation Questionnaire scores between BPD
and HC).
3.4  | Dissociation
Patients did not dissociate during pain stimulation according to
DSS 4 questionnaire (score = 0.77 ± 0.35 [< 1.57 as score for
transition to dissociation] (Stiglmayr et al., 2009)).
4  |  DISCUSSION
This study is investigating incisional pain under standard-
ized experimental conditions in patients with acute BPD in
comparison with the new sharp mechanical pain stimulus
“blade” and well‐established, experimental nociceptive and
tactile control stimuli with respect to time courses of pain
perception as well as affective and sensory evaluation. For
the whole duration of incisional and blade pain, ratings were
lower in BPD than healthy controls, however there was no
significant difference in the early (7 s) phase during stimulus
application. The same was true for the comparison between
“blade” and incision for both BPD and HC. Hence, in BPD
tonic (7  s) blade stimulation induces comparable effects at
the initial time course of an incision. Stimulus‐response func-
tion for both nociceptive mechanical and heat stimuli indi-
cated reduced pain perception in comparison with HCs.
Overall, patients with BPD evaluated pain sensation as
less unpleasant, and interestingly, the sensory component
“sharp” in specific was rated less in BPD patients.
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10       SCHLOSS et al.

T A B L E 2   SES‐scores: Main‐effects/
Least square
Interaction‐effects of 2‐/3‐factorial ANOVAs (3
In BPD Incision, blade 7 s means ± SEM df F P
way interactions not shown)
Modality   1 3.7 0.059
Incision 4.4 ± 0.5      
blade 7sec 3.0 ± 0.5      
Evaluation scores   1 36.5 <0.001
Sensory 5.9 ± 0.5      
Affective 1.5 ± 0.5      
Modality X sensory‐affective   1 1.6 0.205
In BPD Incision, blade 1 s
Modality   1 9.4 0.003
incision 4.4 ± 0.5      
blade 1sec 2.3 ± 0.5      
Evaluation scores   1 34.9 <0.001
Sensory 5.4 ± 0.5      
Affective 1.3 ± 0.5      
Modality X sensory‐affective   1 3.4 0.07
Both groups, incision, blade 1 s
Group   1 11.9 <0.001
BPD 3.3 ± 0.4      
HC 5.4 ± 0.4      
Evaluation scores   1 52.8 <0.001
Sensory 6.4 ± 0.4      
Affective 2.2 ± 0.4      
Group X sensory‐affective   1 0.1 0.738
Both groups, all stimuli
Group   1 7.8 0.006
BPD 2.8 ± 0.3      
HC 3.9 ± 0.3      
Modality   4 29.9 <0.001
incision 5.1 ± 0.4      
blade 1 s 3.6 ± 0.4      
pinprick 1 s 1.7 ± 0.4      
laser 1 s 5.9 ± 0.4      
sphere 1 s 0.2 ± 0.4      
Evaluation scores   1 73.0 <0.001
Sensory 4.9 ± 0.3      
Affective 1.7 ± 0.3      
Group × modality   4 1.6 0.187
Group × sensory‐affective   1 0.7 0.824
Modality × sensory‐affective   4 6.6 <0.001
Note: Upper (first) panel: results of 2 way ANOVA for the comparison incision versus blade within
BPD patients with main factors modality (incision, 7 s blade) and SES (sensory, affective), and
interaction. Second panel: Same as upper (first) panel, however with modality and SES for the 1 s
blade stimulus (used in the stimulus‐response functions), Third panel: results of 2 way ANOVA
for the SES/ group comparison (modalities incision and 1 s blade pooled) with main factors group
(BPD, HC) and SES (sensory, affective) and interaction. Forth (lowest) panel: Results of 3‐way
ANOVA for groups, modalities, and SES with main factors group (BPD, HC), modality (5 modali-
ties) and SES (sensory, affective), and 3 1 × 1 interactions.
SCHLOSS et al.   
|
   11

in BPD is less likely in “normal” skin areas. Considering

4.1  |  Incisional pain
Incision as a tissue‐injuring stimulus was perceived as simi-
larly painful by BPD patients and their healthy counterparts
regarding time course and pain ratings. However, there was
a difference in the late time window, with ratings of BPD
patients returning faster to baseline already after a minute.
A faster decay of pain ratings in BPD was also observed
following intradermal injection of capsaicin (Magerl et
al., 2012). One may speculate, that this difference derives
from different appraisal of the later ill‐defined, dull per-
ception of the late phase, which was rated as less aversive
in patients (Magerl et al., 2012) and yielded surprisingly
low affective SES scores in our sample. However addi-
tional evidence for this hypothesis, for instance by findings
that BPD patients report less soreness following injury is
missing. Differences in peripheral processes like reduced
release of cytokines and specific mediators (bradykinine,
prostaglandins) after injury in BPD patients as attenuation
due to frequent injuries appears less likely as reason for
lower pain ratings given the time courses of experimental
pain (seconds to minutes vs. cytokine release (hours to days
(Geis, Geuss, Sommer, Schmidt, & Kleinschnitz, 2017;
Sommer & Kress, 2004)). Likewise, a reduced responsive-
ness of C‐fibres which primarily code the late phase of in-
cisional pain in contrast to Aδ‐fibres which are responsible
for the early pain (Brennan, Zahn, & Pogatzki‐Zahn, 2005)
the scars that many BPD patients show on their extremities
(arms), it seems plausible that these regions are somewhat
anaesthetic to external (nociceptive) stimuli. However, we
explicitly avoided stimulating these areas.
BPD patients might adapt to a stimulus that is well known
to them, as it is used to reduce states of inner tension, through
learning processes and may even associate the pain experience
with a positive effect, since it reduces aversive stress. Normally,
brief painful stimuli lead to withdrawal reflexes to prevent in-
jury, resulting in avoidance strategies (Leknes & Tracey, 2008);
this form of “protective process” might be lost in BPD due to
positive reinforcement anticipating relief or pleasant feelings.
BPD patients scored the sensory descriptors “cutting” and
“stinging”, forming the factor “sharp”, significantly lower
for both incision and blade stimulus than healthy controls.
Previous studies agree in a normal sensory‐discriminative
pain system in BPD (Ludäscher et al., 2007; Schmahl et al.,
2004), so the difference here may be due to the specific no-
ciceptive stimulus and the fact, that BPD patients who fre-
quently engage in NSSI in form of cutting themselves may be
more familiar with a feeling of tissue‐damage (Morewedge,
Kassam, Hsee, & Caruso, 2009).
Although previous investigations of pain perception used
different modalities of painful stimuli, they suggest that ab-
normalities of the affective system presumably contribute
to the frequently reported hypoalgesia (Bohus et al., 2000;

F I G U R E 7   (a) Comparison of affective and sensory SES pain ratings for incision (left) and blade (1 s, right) between BPD patients
(n = 22) and healthy controls (n = 20). No significant difference for incision between groups, but for blade (1 s) for both affective and sensory
scores. * =p < 0.05. (b) Comparison of sensory SES pain ratings for the three factors (thermal, sharp and deep) (Hansen et al., 2007) for incision
(left) and blade (1 s, right) between BPD patients (n = 22) and healthy controls (n = 20). Both groups showed similar evaluation patterns
(sharp > thermal > deep). Descriptors depicting the “sharp” component were rated significantly less in the BPD group for both incision and blade
(1 s) than in the HC group. **=p < 0.01. HC data from Shabes et al. (2016)
 |
12       SCHLOSS et al.
F I G U R E 8   Description of the sensory (top) and affective
(bottom) pain components by means of the Pain Sensation
Questionnaire (Schmerz‐Empfindungsskala, SES) in BPD and HC.
Both sensory and affective scores for the 1s blade application were
significantly lower in BPD than in HC (p < 0.05). HC data from
Shabes et al. (2016)
Kemperman et al., 1997; Schmahl et al., 2006). While healthy
controls described incision pain with affective adjectives
(“agonizing” and “heavy”), BPD patients did not perceive
the pain as unpleasant and even asked for positive labels like
“pleasant” which were not part of the SES.
Suprathreshold ratings for both nociceptive mechanical and
laser heat stimuli were significantly lower in BPD compared to
controls, which was previously described in studies looking at
separate modalities (Bekrater‐Bodmann et al., 2015; Bohus et
al., 2000; Ludäscher et al., 2007; Magerl et al., 2012; Pavony &
Lenzenweger, 2014; Schmahl et al., 2006, 2004).
Combining the results of the SES‐scores with the ones of
the stimulus response functions, weaker mechanical pain stim-
uli were perceived differently in quantity but similar in quality.
In contrast, perception of more intense, sharp mechanical pain
stimuli differed in both quantitative and qualitative aspects
with less intensity and altered description in BPD. Taken to-
gether, our findings suggest that BPD patients seem to have an
altered pain perception based on different evaluation.
4.2  |  New surrogate: Blade
Comparing time courses of pain perception during incision
and blade application, the 7 s blade application provoked an
incision‐like sensation in pain intensity. Considering that the
blade, in contrast to the incision, is a non‐invasive stimulus,
there may be no C‐fibre induced late pain with components of
neuroinflammation, which could result in longer‐lasting pain
like in tissue‐injury. As reported previously for HCs (Shabes
et al., 2016), the same difference was found for BPD patients
with significantly longer pain duration following incision than
blade application. Whether reduced cytokine release might
play a role in BPD is unclear, especially at this early time
point (seconds to minutes after injury). However, days after
inflammation or injury rise of cytokine levels and pain be-
haviour in rodents have been demonstrated (Geis et al., 2017;
Kleinschnitz, Brinkhoff, Zelenka, Sommer, & Stoll, 2004).
While pinpricks have been tested in BPD patients before
(Magerl et al., 2012), our results showed that the new surro-
gate for sharp mechanical pain yielded more intense painful
sensations than pinpricks due to spatial and temporal summa-
tion. Therefore, we suggest using the blade for further inves-
tigations not only in healthy subjects, but also in (psychiatric)
patients to achieve a given pain intensity, where other me-
chanical stimuli like e.g., stronger pinpricks may result in
skin damage. Even in much less responsive BPD patients, the
blade stimulus was able to induce a moderate pain sensation.
With our results we support Willis et al.’s findings of
who already tested the “blade” in patients with current
BPD in a stress context. However, they compared pain rat-
ings of different samples, where in one sample incision was
induced and in the other the “blade” was applicated, and it
is possible, that interindividual variability of pain percep-
tion might have interfered and influenced ratings (Iannetti,
Zambreanu, Cruccu, & Tracey, 2005; McIver, Kornelsen,
& Stroman, 2018; Schulz, Tiemann, Schuster, Gross, &
Ploner, 2011). To avoid this, we used a within‐design with
application incision and “blade” in the same participants.
Since in the study by Willis et al. (2017) incision and blade
stimuli were applied after stress induction, the mechanism
of “stress‐induced analgesia” could have affected pain
ratings (Bodnar, Kelly, Brutus, & Glusman, 1980; Kelly,
1982), which were indeed clearly lower (about 54%) than
in our current study. Similarly, ratings in another study
during stress in BPD by Naoum et al. (2016) yielded lower
ratings (approx. 69%). (Ludäscher et al., 2007) Taken both
results into account, we can conclude that BPD patients as
SCHLOSS et al.
well as their healthy counterparts—stressed or not stressed
before—perceived the “blade” as less, but similarly painful
as an incision.
Since 11 patients participated in both studies, it is im-
portant to mention that none of them received the incision in
both experiments as it was randomized, in which study the
incision was carried out. As the data for the control group
were taken from 20 healthy women reported in Shabes et al.,
we likewise did not find a significant difference in HCs be-
tween “blade” and incision contrary to Willis et al.’s result.
In a recent fMRI imaging study in BPD patients, Reitz et
al. investigated self‐injurious behaviour with a single incision
inside the scanner (Reitz et al., 2015) and called for method-
ologic reasons for a surrogate that may be used repetitively.
The psychophysical results of the present study showing sim-
ilarities in perception and qualitative and quantitative evalua-
tion for the initial impact/incison make the blade a candidate
for repetitive application with clear induction of pain even in
patients with severe impairment, which cannot be achieved
using pinprick stimuli.
As previously mainly heat pain had been tested in BPD
with respect to brain activation (Kluetsch et al., 2012;
Niedtfeld et al., 2010; Schmahl et al., 2006), the blade en-
ables the examination of the processing of sharp mechanical
pain, which can be useful, too, for the examination of brain
processes in patients with pain syndromes, e.g., fibromyalgia
or acute/postoperative pain.
4.3  |  Altered pain perception in BPD
In summary, we found a difference in the late time window
during incision, lower pain ratings for different nociceptive
stimuli—the higher the stimulus intensity the more signifi-
cant the difference—and differences in affective and sensory
evaluation. As BPD patients often report hypo‐ or even an-
algesic sensations during nociceptive inputs (Leibenluft et
al., 1987; McCown, Galina, Johnson, DeSimone, & Posa,
1993; Shearer, 1994), several theories about underlying
pathomechanisms are already subjects of recent discus-
sions. Beside theories about abnormalities in opioid activ-
ity, e.g., the endogenous opioid system theory of BPD (New
& Stanley, 2010; Prossin, Love, Koeppe, Zubieta, & Silk,
2010), a dysfunction in sympathetic and parasympathetic au-
tonomic nervous system activity in BPD is debated as well
(Austin, Riniolo, & Porges, 2007; Porges, 2007; Weinberg,
Klonsky, & Hajcak, 2009). The importance of the opioid sys-
tem in BPD also gets underlined considering that the use of
potent analgesics (morphine) might aggravate psychopathol-
ogy in BPD with NSSI (Thurauf & Washeim, 2000). With
the proposal of the blade as sharp mechanical pain stimu-
lus this might help shed light on the issue mentioned using a
stimulus similar as an incision for investigations in patients
frequently self‐injuring themselves.
  
|
   13
4.4  | Limitations
When interpreting our results, some limitations should be kept in
mind. Our group size of 20 seems relatively small, but accord-
ing to studies which calculated power for group fMRI studies
(Desmond & Glover, 2002; Hayasaka, Peiffer, Hugenschmidt,
& Laurienti, 2007; Mumford & Nichols, 2008), the sample size
of this study is adequate. The stress context which is clinically
relevant for NSSI in BPD (Stiglmayer et al., 2005) was not mod-
eled in this study, as discussed above. To achieve objective and
reproducible results, pain stimulation was executed by the study
investigator. As the difference between this situation and a self‐
inflicted injury as well as the possibility to have a glance at the
act of incision (unlikely but possible in our setup) might impact
actual pain processing through attention or anticipation (Bowler
et al., 2017), further studies should concentrate on the differentia-
tion between self‐versus other‐inflicted injuries or the impact of
seeing blood during tissue‐injury (Naoum et al., 2016).
5  |  CONCLUSION
As for healthy subjects, also in patients with reduced pain per-
ception the blade can be used to model sharp pain, mimicking
the early “impact” phase of incisional pain, but less the late
phase. With respect to BPD patients, we found reduced percep-
tion of mechanical and heat pain based on altered processing of
both the affective and sensory pain components for mechanical
stimuli, most likely due to the background of repeated NSSI in
BPD patients, comprising memory and emotional influence.
No significant affective component was present in BPD to-
gether with reduced and qualitatively changed intensity com-
ponents for the stimuli used in the context of NSSI—including
especially the reduction of the “sharp” component.
ACKNOWLEDGEMENTS
This work was supported by Deuts​che Forsc​hungs​gemei​nschaft
(DFG), KFO256 IP6.
CONFLICT OF INTEREST
None declared.
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SUPPORTING INFORMATION
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How to cite this article: Schloss N, Shabes P, Kuniss
S, et al. Differential perception of sharp pain in
patients with borderline personality disorder. Eur J
Pain. 2019;00:1–16. https​://doi.org/10.1002/ejp.1411