Current Psychiatry Reports

https://doi.org/10.1007/s11920-024-01498-0

REVIEW

Acute, Chronic, and Everyday Physical Pain in Borderline

Personality Disorder
Melissa Nance1 · Khrystyna Stetsiv1 · Ian A. McNamara1 · Ryan W. Carpenter1 · Johanna Hepp2

Accepted: 13 March 2024

© The Author(s) 2024

Abstract
Purpose of Review Physical pain is an underrecognized area of dysregulation among those with borderline personality dis-
order (BPD). Disturbances are observed within the experience of acute, chronic, and everyday physical pain experiences for
people with BPD. We aimed to synthesize research findings on multiple areas of dysregulation in BPD in order to highlight
potential mechanisms underlying the association between BPD and physical pain dysregulation.
Recent Findings Potential biological mechanisms include altered neural responses to painful stimuli within cognitive-
affective regions of the brain, as well as potentially low basal levels of endogenous opioids. Emotion dysregulation broadly
mediates dysregulation of physical pain. Certain psychological experiences may attenuate acute physical pain, such as
dissociation, whereas others, such as negative affect, may exacerbate it. Social challenges between patients with BPD and
healthcare providers may hinder appropriate treatment of chronic pain.
Summary Dysregulated physical pain is common in BPD and important in shaping health outcomes including elevated BPD
symptoms, chronic pain conditions, and risk for problematic substance use.

Keywords Personality disorders · Borderline personality disorder · Physical pain · Chronic pain

Introduction and everyday pain and, in contrast, reduced sensitivity to

Borderline personality disorder (BPD) is characterized by
an enduring pattern of disturbances in affect, impulsivity,
self-image, and interpersonal relationships [1]. Another, less
recognized, area in which people with BPD commonly expe-
rience disturbances is physical health, especially the experi-
ence of physical pain [2–8]. As the body signals to the brain
that something is awry, physical pain is both a ubiquitous
experience and important for maintaining adaptive function-
ing. Dysregulation in the experience of pain, either in the
direction of too little pain or too much, can have significant
consequences. BPD has been associated with greater chronic
Ryan W. Carpenter and Johanna Hepp contributed equally.
* Johanna Hepp
johanna.hepp@zi-mannheim.de
1
Department of Psychological Sciences, University
of Missouri, St. Louis, St. Louis, USA
2
Department of Psychosomatic Medicine and Psychotherapy,
Medical Faculty Mannheim, Central Institute of Mental
Health, Heidelberg University, J5, 68159 Mannheim,
Germany
acute pain. This apparent contradiction has been termed the
“pain paradox” of BPD [9–11].
In the current paper, we first define chronic, everyday,
and acute pain and review the evidence for their relationship
to BPD. Following this, we examine evidence for processes
potentially related to pain dysregulation in BPD. In this review,
we adopt a biopsychosocial framework (Fig. 1), which has
been applied to both the experience of physical pain [12, 13]
and BPD [14, 15] and may be particularly useful in highlight-
ing mechanisms involved in their association. The biopsycho-
social model of chronic pain conceptualizes the experience of
pain as being shaped by biological (e.g., neural), psychologi-
cal (e.g., affect), and social (e.g., relationships) mechanisms
which interact with one another to influence pain experiences
[12, 13]. Likewise, Linehan’s biosocial theory of BPD identi-
fies interactions between biological, psychological, and social
components [14]. We review evidence for the association of
pain and BPD within each of these three interrelated domains.
Before proceeding, it is important to note that this review
was initially conceptualized as a review of recent work on
physical pain in personality disorders broadly. We conducted
a comprehensive literature search of original studies listed

Vol.:(0123456789)

Fig. 1  Biopsychosocial framework for understanding the relationship
of physical pain and borderline personality disorder
in PubMed with the search terms “pain” OR “chronic pain”
AND “personality disorder,” “paranoid,” “schizoid,” “schi-
zotypal,” “antisocial,” “borderline,” “histrionic,” “narcis-
sistic,” “avoidant,” “dependent,” “obsessive–compulsive,”
“alternative model of personality disorders,” “HiTOP,” and
“NSSI.” Studies on NSSI were further inspected to identify
studies with samples that represented a personality disorder
population. We considered studies that assessed categorical
personality disorders and studies that assessed dimensional
personality disorder traits within the past 5 years (January
1st, 2018–February 9th, 2023). The initial search yielded
582 results, from which 198 duplicate results were removed
and 339 studies were removed for not assessing physical
pain and personality disorders/traits. In total, N = 45 studies
were identified that matched our criteria. Of the 45 articles
identified, only 5 studies examined antisocial personality
disorder/psychopathic traits, 1 study examined trait narcis-
sism, and 2 studies examined dimensional personality traits.
Articles focused on antisocial personality tended to examine
empathy for other’s pain rather than one’s own experience
of painful stimuli. We therefore focus this narrative review
on pain in BPD. We return to this point, and the need for
additional attention to the experience of pain in personality
disorders broadly, in the conclusion.
Chronic, Everyday, and Acute Pain
Chronic pain involves experiencing pain over time (typi-
cally ≥ 3 months) and is recognized as pain that exceeds
normal healing time and lacks nociceptive benefits, such
Current Psychiatry Reports
as functional warnings about injuries [16]. Chronic pain is
prevalent in BPD samples and, in turn, BPD features are
common in chronic pain samples. For instance, Heath et al.
[17] found that 65% of patients entering outpatient treatment
for BPD (N = 65) met DSM-IV criteria for pain disorder,
a disorder characterized by pain that causes clinically sig-
nificant distress or impairment where psychological factors
are judged to have an important role in the onset, severity,
exacerbation, or maintenance of the pain [18]. Likewise, a
prior review suggests that approximately 30% of people with
a chronic pain disorder meet criteria for BPD or report sig-
nificant BPD traits [9] - a significant health disparity given
the rate of BPD among the general population of the United
States (US) is around 2% [19, 20]. Physical pain, particularly
chronic pain, can lead to a reduction in participation in daily
activities, which we will refer to as pain-related disability.
Aside from chronic pain, virtually everyone experiences
everyday pains that are context-specific, relatively short-
lived, and can be generally self-managed (e.g., with over-
the-counter pain medication). As many as 80–89% of those
with BPD report experiencing some level of physical pain
within the past day [17, 21]. Within a non-clinical sample
(N = 206), BPD features were cross-sectionally associated
with greater past-year nonchronic pain [11]. Furthermore,
in an ambulatory assessment study, Carpenter et al. [22••]
observed that BPD outpatients (n = 26) reported greater eve-
ryday pain intensity and variability than community partici-
pants (n = 26). These findings suggest that people with BPD
are prone to experiencing pain in their daily lives, includ-
ing pain that does not rise to the definition of chronic pain.
These everyday pains are worthy of attention. Similar to
mood dysregulation, daily experience of pain dysregulation
can potentially lead to significant impacts on functioning
[23]. It may also contribute to why people with BPD appear
to be over-represented in samples of people seeking pain
treatment [9] and may lead them to self-manage their pain
in maladaptive ways (e.g., substance use [24]).
Perception of acute pain in BPD has received consider-
able attention because people with BPD frequently engage
in non-suicidal self-injury (NSSI; i.e., tissue damage without
the intent to die), an inherently painful behavior. Experi-
mental work has found that people with BPD and a history
of NSSI report reduced acute pain in response to painful
stimuli. For example, Fales and colleagues [25••] recently
reviewed laboratory pain induction studies that examined
acute pain perception of individuals with BPD. Overall,
those with BPD showed a higher pain threshold (the amount
of time elapsed until pain onset after a stimulus is applied)
and lower pain intensity (how painful a stimulus is per-
ceived) relative to comparison participants. In contrast to
this experimental work, however, a recent large (N = 1630)
retrospective study of people with a history of NSSI (almost
all of whom reported significant BPD features) found that
Current Psychiatry Reports
most people who self-harm report mild-to-moderate pain
during NSSI, and BPD features were not associated with
amount of pain reported [26]. Thus, there appears to be a
discrepancy between what people report in the laboratory
in response to standardized stimuli and what they experi-
ence in their daily lives. It may be that people with BPD do
have generally greater acute pain tolerance, but also that pain
plays an important role in experiencing benefits from NSSI
(e.g., reduction of negative affect). These benefits may lead
them to self-harm in a manner that increases their experi-
ence of pain [26, 27]. A significant challenge, however, of
understanding the relationship of BPD and acute pain expe-
rience is distinguishing possible effects of BPD from those
of having a history of NSSI, given the considerable overlap
of BPD and NSSI history.
Biological Processes
Pain arises when nociceptive nerves are stimulated in the
body; the resulting signal is transmitted up the spinal cord
to the brain, and the signal is then interpreted in the brain.
At times, the central nervous system can incorrectly inter-
pret stimuli as painful due to an increased responsiveness of
nociceptors to sub-threshold input, a phenomenon known as
central sensitization. Central sensitization may be a relevant
process for understanding the tendency for people with BPD
to report more chronic and everyday pain. In a sample of
chronic pain patients (N = 181), those with BPD were more
likely to meet criteria for fibromyalgia, which is the pro-
totypical central sensitization disorder [28•]. Furthermore,
those with a chronic pain disorder and greater BPD features
experienced greater poly-somatic complaints associated with
central sensitization than those with chronic pain disorder
but without elevated BPD features [28•]. These findings
indicate that chronic pain experiences for people with BPD
could be, in part, related to the perception or appraisal of
sensory inputs as painful that other individuals would not
perceive as such.
Atypical perception of innocuous stimuli in BPD has
been demonstrated through recent laboratory work. For
instance, people with BPD (n = 25) exposed to pleasant
touch stimuli (e.g., a brush stroke on the hand) rated it as
less pleasant than control participants (n = 25) [29•], which
could be related to negative evaluation tendencies seen in
BPD. Individuals with BPD have also shown differences in
threshold and perceived intensity for innocuous stimuli that
align with prior research on painful stimuli. Recent work
found that those with BPD report lower intensity of pleas-
ant touch [29•] as well as higher thresholds to detect warm
thermal stimulation (n = 22 patients with BPD compared
to n = 33 control participants) [30•]. These results suggest
those with BPD may have hyposensitivity not only to painful
laboratory stimuli, but also to innocuous stimuli. This, how-
ever, is the opposite of what would be expected if BPD was
associated with central sensitization. It is worth noting that
these findings deviate from previous research that did not
find differences in the ability to detect non-painful stimuli
for those with BPD [31, 32], indicating a need for continued
research on the perception of non-painful stimuli in BPD
and factors, such as body mass [32], that may contribute to
hyposensitivity. It is also possible that the effect of BPD on
perception of innocuous stimuli is only large enough to be
detected when individuals with current BPD are compared
to individuals with no prior psychopathology, given that the
two studies that did not find differences for individuals with
BPD (n = 27 and n = 29) included individuals who had a his-
tory of major depressive disorder with no current psychopa-
thology (n = 20), and healthy controls (n = 44), or individuals
with remitted BPD (n = 19) and healthy controls (n = 22).
Multiple brain areas are involved in pain processing,
including affective, cognitive, and somatosensory areas,
reflecting the complex integration of sensory and emotional
experiences that culminate in the perception of pain. When
unpleasant, but non-painful, electric stimulation was used
in a recent fMRI study, no group differences were observed
between control participants (n = 15) and women with BPD
(n = 15) in the right primary somatosensory cortex, right
secondary somatosensory cortex, posterior insula, right pos-
terior midcingulate cortex, and right supplementary motor
area [33]. A separate fMRI study found that individuals with
a history of NSSI (N = 81, ~ 1/3 of whom reported having
BPD) showed greater neural activation in the primary and
secondary somatosensory cortex during thermal stimulation
than control participants, which may be explained by the
fact that their fMRI protocol used individually calibrated
heat pain and the NSSI group required higher temperatures
to detect pain [34]. These studies suggest that individuals
with BPD respond to pain and innocuous stimuli within
somatosensory areas in ways similar to those without BPD;
however, cognitive and affective neural processing of painful
stimuli may explain differences in the experience of pain.
For instance, a recent review of 13 fMRI studies investigat-
ing BPD and self-injurious and suicidal behaviors suggests
that people with BPD and a history of self-harm and/or sui-
cide attempts show altered brain activity in regions involved
in cognitive processes and affect regulation. Specifically,
their review found evidence for altered neural patterns for
individuals with BPD in the lateral orbitofrontal cortex, dor-
sal anterior cingulate cortex, and medial and dorsolateral
prefrontal cortex, as well as in the nucleus accumbens and
amygdala in response to pain stimulation [35].
Reduced sensitivity to acute pain could increase risk for
engaging in NSSI by removing a natural physiological bar-
rier to self-harm [36]. At the same time, the experience of
physical pain may actually be important for experiencing

desired effects of NSSI, such as emotional relief. This may
occur either via pain itself (pain onset) or the reduction of
pain following self-harm (pain offset) [26, 37]. Olié et al.
[38] recently found heightened activation in the nucleus
accumbens in people with BPD (n = 20) compared to con-
trols (n = 23) following thermal stimulation, potentially indi-
cating a rewarding effect of pain experience. These fMRI
findings suggest that people with BPD might experience a
pleasant sensation in response to heat that others perceive
as painful, underscoring the affective processing involved in
pain perception. A recent study which recruited individuals
with BPD with and without history of NSSI, alongside con-
trol participants (n = 20 in each group), found that those with
BPD and history of NSSI showed heightened responses in
the left lateral orbitofrontal cortex in response to unexpected
rewards, which may indicate a propensity to learning that
NSSI can provide a rewarding effect [39].
Recent work has also investigated the role of the endog-
enous opioid system in how people with BPD experience
pain. Endogenous opioids are produced in the brain and cir-
culate widely throughout the nervous system. Opioids are
important for maintaining the body’s homeostasis generally
and play a specific role in regulating the perception of pain
by reducing acute pain [40]. That the release of endogenous
opioids reduces acute pain levels in humans generally is
well-established. More recently, certain symptoms of BPD,
such as dysphoria and risk-taking behaviors, have been sug-
gested as indicators of low baseline levels of endogenous
opioids [41]. Supporting this idea, opioid antagonist treat-
ments have recently been shown to reduce BPD symptoms
in a retrospective chart analysis of individuals with BPD
(N = 161) who received inpatient treatment [42]. Opioid
antagonists may acutely block the rewarding effects of prob-
lematic coping behaviors that would otherwise activate the
endogenous opioid system (e.g., NSSI, substance use), while
chronic administration may restore balance in the neuro-
transmission of endogenous opioids. However, evidence for
the use of opioid antagonists to treat BPD is preliminary and
more research is needed on the mechanisms behind improve-
ment in symptoms.
Stanley and colleagues [43] first proposed that people
who engage in NSSI might have an endogenous opioid defi-
ciency. This was based on findings that those with a cluster
B personality disorder and history of self-injurious behav-
ior (n = 14) had lower levels of cerebrospinal β-endorphin
and met-enkephalin compared to a diagnostically matched
group of individuals with no history of self-harm (n = 15)
[43]. Specifically, they posited that genetic vulnerability and
early life adversity could lead to chronically low levels of
endogenous opioids, which individuals attempt to counter
by engaging in self-injurious behaviors to stimulate release
of endogenous opioids. A recent study found that adoles-
cents with a history of NSSI (n = 94) showed lower plasma
Current Psychiatry Reports
β-endorphin levels, increased pain thresholds, and lower
pain intensity compared to control participants (n = 35) [44].
Furthermore, in a recent ambulatory assessment study in
individuals with DSM-5 NSSI disorder (N = 51, 63% meet-
ing criteria for BPD), Störkel et al. [45] observed that NSSI
acutely increased salivary β-endorphin levels and found evi-
dence of a positive association between severity of the self-
inflicted injury and β-endorphin levels. While these studies
focus on NSSI, the majority of participants met for BPD
and it is possible biological mechanisms and hypothesized
causes (stress and trauma exposure) are applicable to people
with BPD irrespective of NSSI history, although more work
is needed to understand whether this is the case.
Low levels of circulating endogenous opioids might also
leave people with BPD at risk of experiencing chronic pain
and more intense everyday pain. Considerable evidence has
accumulated for endogenous opioid dysfunction in chronic
pain, particularly low endogenous opioid CSF/plasma lev-
els in chronic pain patients [46, 47]. Among chronic pain
patients (N = 28), endogenous opioid system dysfunction
has been associated with elevated acute and chronic pain
sensitivity, as well as pain-related disability [48]. Limited
evidence suggests that individuals with BPD may have low
baseline levels of endogenous opioids. Prossin et al. [49]
used positron emission tomography to examine availability
of β-endorphin receptors in women with BPD (n = 18) and
matched comparison participants (n = 14). The authors found
that BPD was associated with greater baseline β-endorphin
receptor availability in the orbitofrontal cortex, caudate,
nucleus accumbens, and amygdala, and further observed
differences in receptor binding potential in response to sad-
ness in the pregenual anterior cingulate, left orbitofrontal
cortex, left ventral pallidum, left amygdala, and left infe-
rior temporal cortex. Findings from this study have been
interpreted as evidence of dysregulation in the endogenous
opioid system for individuals with BPD, including low basal
levels of endogenous opioids and compensatory responses in
opioid receptors within reward processing regions. In addi-
tion to chronic pain outcomes, risk for problematic opioid
use seen in BPD populations may be linked to endogenous
opioid system dysfunction [50•].
Psychological Processes
Emotion dysregulation is a core component of BPD, concep-
tualized as including heightened and labile negative affect,
emotion sensitivity, and maladaptive coping strategies [51].
Negative affect has been associated with pain experiences
among those with BPD. For example, Carpenter et al. [22••]
found, in their ecological momentary assessment study,
that everyday physical aches and pains were associated
with negative affect for both BPD (n = 26) and community
Current Psychiatry Reports
(n = 26) individuals, but that pain predicted future negative
affect more strongly in the BPD group. Reynolds et al. [52]
used path models in a cross-sectional chronic pain sample
(N = 147) to examine whether trait affective lability, anxi-
ety, and depression accounted for associations between BPD
features and multiple indices of pain over the past year (pain
severity, pain-related affective interference, and pain-related
activity interference). Pain severity measured pain on an
11-point scale at its worst, least, and average over the past
year, as well as current level of pain. Pain-related activity
interference assessed pain’s interference with general activity,
walking ability, and normal work whereas affective interfer-
ence assessed interference with mood, interpersonal relation-
ships, and life enjoyment. Although their study design did
not allow for examining causal mediation, they found that
affective lability and trait anxiety showed significant indirect
effects accounting for the association between BPD features
and all three indices of pain and pain interference. Addition-
ally, serial path models indicated that anxiety around pain
experience accounted for additional variance in the model
[52]. Similarly, Johnson et al. [28•] assessed negative affect
and BPD symptoms cross-sectionally within a chronic pain
sample (N = 181) and found that associations between BPD
features and chronic pain symptoms were accounted for by
level of anxiety and depression. Negative affect has also been
shown to mediate the relationship between interpersonal
stressors and health problems across multiple domains (i.e.,
headaches, stomachaches, and muscle pains) in daily life for
individuals with BPD (n = 81) and depression (n = 50) [53].
Together, these findings indicate that emotion dysregulation
may contribute to the high prevalence of chronic and every-
day pain observed among individuals with BPD. At the same
time, the direction of this association remains unclear, as it is
also possible that regularly experiencing pain worsens emo-
tion dysregulation over time.
Maladaptive coping strategies contribute to emotion dys-
regulation within BPD and may also contribute to pain dys-
regulation by increasing negative emotions and emotional
lability over time. The use of NSSI to regulate negative
affect is common in BPD and while it may have short-term
benefits, it may ultimately increase dysregulation. Use of
emotion suppression, another potentially maladaptive cop-
ing strategy, in response to social stressors and under high
distress has recently been associated with greater daily pain
interference for individuals with BPD features (N = 89), even
after accounting for daily pain intensity [54].
In addition to finding generally higher pain threshold
and lower pain intensity among those with BPD, Fales and
colleagues’ review [25••] indicated that BPD participants
had higher pain tolerance (the length of time one is able to
endure a painful stimulus) specifically under conditions of
emotional distress. This process, known as stress-induced
analgesia, has also been observed in other clinical and
non-clinical groups, as well as in animals, and is believed to
be a generally adaptive, evolved pain suppression response
[55]. However, outside of the laboratory, evidence for stress-
induced analgesia during NSSI is lacking. For instance, in a
recent large (N = 1630) cross-sectional study of people with
a history of NSSI who were high in BPD features, greater
emotional distress before NSSI predicted greater NSSI pain
[26]. It remains unclear whether and why stress-induced
analgesia may be enhanced in individuals with BPD and
what this means for people with BPD [27].
Dissociation, a psychological state characterized by per-
ceived disconnection, is another psychological process that
may impact the experience of acute pain in BPD. Transient
dissociation is common among people with BPD, particularly
in response to stress. Furthermore, prior review of 70 studies
indicates that BPD symptom severity is associated with both
experiencing dissociation and decreased pain perception [56].
A recent study by Chung et al. [57•] found that individuals
who currently met criteria for BPD (n = 25) showed greater
pain hyposensitivity during experimental pain induction than
those with remitted BPD (n = 20) and a non-clinical control
group (n = 24). This study also examined pain perception and
dissociation following a personalized stress task, finding that
stress and dissociation independently contributed to pain hypo-
sensitivity for both the current and the remitted BPD groups
[57•]. Dissociation has also been associated with lower self-
reported NSSI pain [26]. Broadly, there is evidence for adverse
effects of dissociation on affective-cognitive functioning, body
perception, and treatment response in BPD [58]. Dissociation
has also been suggested as a transdiagnostic symptom involved
in the pathway between adverse childhood experiences, psychi-
atric disorders (e.g., BPD and post-traumatic stress disorder),
and pain chronicity or pain-related disability [59].
Dissociation commonly includes a distorted perception of
the self, one’s body, or one’s sense of agency. A factor that
may be related to experiencing dissociation is a person’s abil-
ity to sense their own body, or their interoceptive sensitivity.
Individuals with high interoceptive sensitivity are better able
to differentiate between various signals from their body’s
organs (e.g., heart rate). Among those with BPD, interocep-
tive sensitivity has been associated with pain intensity ratings
in laboratory pain tasks. Specifically, low body awareness
has been associated with analgesia [60], which may facilitate
NSSI behaviors and explain prior findings of high pain thresh-
old and low pain intensity among those with BPD. However,
people with higher levels of interoceptive sensitivity and BPD
(n = 46) rated lower temperatures as evoking moderate pain
and reported higher pain intensity ratings than control par-
ticipants (n = 47) [60]. The fact that the effect of interoceptive
sensitivity was observed for those with BPD but not control
participants may be explained if individuals with BPD specifi-
cally respond to internal stimuli with anxiety and catastrophic
thinking, such as in response to recurrent pain.

Social Processes
Social processes that affect acute and chronic pain in BPD
play out in different contexts, which include not only the
context of personal relationships but also the healthcare
context. Within personal relationships, the BPD feature of
negative relationships (i.e., unstable interpersonal relation-
ships) has been associated with increased rates of pain-
related disability, general disability, and unemployment in
a chronic pain sample (N = 147) [61••]. Individuals with
maladaptive interpersonal patterns may experience a lack of
social support, as well as more conflictual relationships with
healthcare providers, and discontinuity in healthcare provid-
ers as a result of conflict, each of which could contribute to
greater chronic pain and disability. People with BPD utilize
healthcare services at rates greater than the general popu-
lation [62], and yet, many who seek treatment for chronic
pain experience barriers to accessing treatment, which again
underlines the need for scientific attention. Chronic pain is
a subjective experience and medical providers must rely on
patient reports of their pain experiences. However, patients
with BPD may be perceived as untrustworthy by healthcare
providers, even when their diagnosis is not known. When
raters in three samples (N = 98, N = 94, N = 44) viewed video
samples of BPD and healthy control participants as targets,
they rated BPD targets as less likeable, less trustworthy, and
less cooperative [63, 64]. Providers may perceive patients
with BPD as less trustworthy because they report high lev-
els of pain severity and express frustration with the (lack
of) treatment provided for their pain conditions [65•] or as
a result of negative stigma [66]. The interpersonal deficits
seen in BPD, and those in chronic pain samples with BPD
features, may contribute to the perpetuation of chronic pain
experiences in spite of attempts to receive treatment for
chronic pain or contributory medical conditions.
Appropriate treatment for chronic pain is an especially
important issue for those with BPD given challenges specific
to this population. Despite concerns about risks, prescription
opioids remain a primary treatment option of chronic pain,
particularly in the US [67]. Frankenburg et al. [68] found
that participants with BPD (n = 264) were more likely to
report prescription opioid use than comparison participants
with another personality disorder (n = 63), which may be
due to higher rates of co-occurrence of BPD with chronic
pain conditions. Additional evidence suggests that peo-
ple with BPD may be at risk for problematic prescription
opioid use. For instance, in a sample of outpatients who
currently or have previously been prescribed pain medica-
tion (N = 185), BPD symptoms were associated with meas-
ures of prescription pain medication misuse [69]. In col-
lege student samples, BPD features have been associated
with negative reinforcement motives (coping and pain) for
Current Psychiatry Reports
prescription opioid use (N = 594) [70] and measures of mis-
use, including opioid consequences and dependence features
(N = 606) [71]. Finally, in samples in treatment for chronic
pain (N = 147) and samples in treatment for substance use
disorder (N = 208), BPD features have been associated with
prescription opioid misuse, with particularly strong associa-
tions between measures of misuse and the identity distur-
bance and self-harm/impulsivity facets of BPD [72•, 73]. It
is important to note that these findings do not indicate that
people with BPD cannot benefit from appropriate opioid
therapy. However, patients with BPD and chronic pain may
benefit from additional monitoring and resources (e.g., sup-
port, psychoeducation, psychosocial therapy) when complet-
ing a course of prescription opioids.
Conclusions
We reviewed evidence on chronic, acute, and everyday pain
in BPD from the past 5 years, and conclude that BPD symp-
tom severity is positively associated with pain dysregulation
and pain-related disability [28•, 52, 61••]. The experiences
of pain in BPD may be mediated by interconnected biopsy-
chosocial processes, manifesting in emotion dysregulation
and dysregulated experiences of physical pain. Recent fMRI
studies suggest that neural activation in cognitive/affective
areas in people with BPD differs from healthy control par-
ticipants [35], but those with BPD generally showed no dif-
ferences from control participants in somatosensory areas
[33, 34]. While preliminary and based on small sample sizes,
these fMRI studies may indicate that altered pain percep-
tion is specifically related to affective processing of sensory
information. This idea is reinforced by recent findings that
negative affect and affective instability contribute to chronic
pain experiences in individuals high in BPD features [28•,
52]. There is also evidence to suggest that pain and emo-
tion dysregulation may be manifestations of chronically
low endogenous opioids, which regulate the experience of
pain [41–43, 49, 50•]. Social challenges between providers
and patients with BPD features [63, 64, 65•, 66] could lead
to non-pharmacological treatments for chronic pain being
underutilized in BPD populations. Providers may also be
less willing to prescribe opioids to people with BPD, poten-
tially leading people with BPD to go without adequate pain
treatment or to seek out non-prescribed opioids or other sub-
stances to self-medicate their pain.
In summary, our review indicates that dysregulated physi-
cal pain is common in BPD and important in shaping health
outcomes, including risk for opioid misuse, BPD symptoms,
and chronic pain. Evidence suggests that emotion dysregula-
tion components (emotion sensitivity, negative affect, affec-
tive lability, and maladaptive coping behaviors) mediate the
relationship between BPD and dysregulated physical pain.
Current Psychiatry Reports
Underlying emotion dysregulation, differences in the cogni-
tive and affective neural processing of information, as well
as physiological deficits in the endogenous opioids system,
likely also contribute to physical pain dysregulation. Mis-
trust and interpersonal challenges between patients and pro-
viders may exacerbate chronic pain symptoms and disability
levels by hindering appropriate treatment of chronic pain.
We recommend regularly assessing BPD traits in
chronic pain populations and vice versa, and encourage
comprehensive care for physical and mental health. Addi-
tionally, chronic pain should be assessed as a psychother-
apy outcome for BPD populations, along with measures
of BPD symptoms, emotion dysregulation, and negative
affect. Evaluating multiple indices of physical and mental
health regularly in this population can provide evidence
for directionality and indicate if improvements in emotion
regulation improve pain experiences.
Beyond BPD, pain processes in other categorical per-
sonality disorders and the new dimensional personality
disorder diagnosis in ICD-11 warrant further attention
[74]. The present article focused on BPD because this
was the disorder commonly examined in recent literature
and it is also the personality disorder with the highest
reported incidence of chronic pain [21] and largest body
of evidence on dysregulated acute pain [25 •• ]. How-
ever, there is evidence for high rates of trauma history
and emotion dysregulation in other personality disorders
[75], which may similarly alter the endogenous opioid
system [76] and neural responses to pain, contributing
to altered pain perception. Furthermore, BPD has been
suggested to reflect general personality pathology [77].
Biological, psychological, and social processes observed
within BPD samples could occur on a transdiagnostic
and dimensional spectrum, but research on dimensional
models of personality disorder and pain was exceedingly
rare within the past five years.
Author Contribution J.H., R.C., and M.N. conceptualized the article.
M.N. performed the literature search and wrote the initial draft of the
manuscript. J.H., R.C., K.S., and I.M. all contributed to editing sec-
tions. All authors provided critical feedback and helped shape the man-
uscript. J.H. and R.C. contributed equally and share last author status.
Funding RWC is supported by the National Institute on Alcohol Abuse
and Alcoholism (NIAAA, K23 AA029729). Johanna Hepp: JH is sup-
ported by the German Research Foundation (HE 9093/1-1).
Declarations
Competing Interests The authors declare that they have no competing
interests.
Open Access This article is licensed under a Creative Commons Attri-
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