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Living well with chronic pain

Chronic Physical and Emotional Pain Disorders

Fibromyalgia can be seen as the "borderline personality" of the medical world.

On the face of it, the diagnoses of fibromyalgia and borderline personality disorder have little to do with each other. Fibromyalgia is a musculoskeletal syndrome which manifests with widespread muscle and joint pain, significant fatigue, and frequently in sleep and cognitive disturbances; while borderline personality disorder is characterized by a pervasive pattern of instability in self-image, interpersonal relationships, and emotions.

As a psychotherapist who lives with chronic pain and works primarily with people diagnosed with borderline personality disorder, it is not surprising that I would see overlaps. After all, finding similarities with clients is valuable for building empathy, deepening insights, and contributing to the therapeutic alliance. However, the commonality I have found is striking—not so much about symptoms themselves, but in the wider context of their social meaning and treatment. Both conditions are poorly understood problems whose prognoses depend largely on validation and pain management skill-building. Consider:

1. Bias. People with chronic pain (especially with fibromyalgia) are often maligned as “difficult,” as are people with borderline personality disorder. Many healthcare professionals prefer not to treat people with either condition. Part of this reluctance comes from professionals own struggles to work effectively with people either condition. This lack of understanding can cause clients’ symptoms to worsen.

2. Blame. Fibromyalgia has been criticized as a poorly defined, wastebasket category, or—even worse—a specious diagnosis of people who cannot contend with normal or “imagined” aches and pains. Similarly, people with borderline personality disorder are often blamed for their difficulties. When people think of borderline personality, the focus is often on behavior, seen as a character defect, rather than on the experience or circumstances that led to the condition. In both cases, individuals are criticized for their inability to “get better” or “get over it” rather than treated as suffering from a legitimate, painful condition. Much has been written about the “controversy” of fibromyalgia, and whether reported experiences are “real.”  In response, patients may even doubt the legitimacy of their own experience or blame themselves for their own suffering.  

3. Hypersensitivity. The underlying experience of people with borderline personality disorder is extreme emotional sensitivity: Events are more likely to be experienced as emotional, and the resultant arousal is significantly more intense and slower to recede than for other people. People with fibromyalgia suffer from hypersensitivity to physical pain, in whom seemingly benign stimuli such as noise, light, cold, or stress of any kind can exacerbate pain.

4. Overwhelming distress. Because everyone experiences pain, the significance of these conditions can be underestimated. Sufferers can be seen as weak, unable to handle distress. However, the persistent and pervasive distress experienced by people with these diagnoses is distinct from typical or expected ups and downs. Living with borderline personality disorder has been described as existing in an emotionally flooded state or as an “emotional burn victim.” The pain of fibromyalgia and related conditions can overwhelm even the most grounded of people—accounting for the high prevalence of depression among chronic pain sufferers. Symptom overlap can also occur. Emotional pain can manifest somatically; and unrelenting physical pain can magnify emotionality, alter one’s sense of self, affect relationships, and increase vulnerabilities to distress. High levels of distress can make each day or moment an exercise in crisis management. People are often desperate for comfort and relief.

5. Causation. It is not yet well understood why people develop either of these disorders. However, the prevailing theories emphasize a genetic predisposition that becomes activated by environmental factors, leading to dysregulation in the central nervous system. Fibromyalgia may emerge from a latent vulnerability that causes trauma-based pain to become systemic rather than dissipate as expected. Borderline personality disorder may develop from heightened emotional vulnerability plus invalidating early childhood experiences (often abuse and neglect) that reinforce the inhibition and exaggeration of expressions of emotion and pain.

Functional MRIs reveal that people with borderline personality disorder cannot access the part of the brain associated with controlling emotional intensity, and “over-function” in areas associated with fear and other strong emotions. Research suggests that fibromyalgia and related pain disorders are “central sensitivity syndromes” with neurophysiological abnormalities that include over-activation of the pain processing system.

Simply put, people with both disorders suffer from kinks in their emotion and pain-processing systems, respectively. Both disorders likely develop through a complex interaction of biological and environmental factors, and remain in place because of altered processing systems.

6. Prognosis. DSM-IV (the "diagnostic bible" for the mental health system) classifies borderline personality as an Axis II disorder (along with mental retardation and other personality disorders), meaning that it is life-long and pervasive. Most other common mental health conditions, such as depression, anxiety, and schizophrenia, are classified on Axis I, which implies that they are treatable and can remit. (We shall see if the long-awaited DSM-V amends this categorization.) Diagnoses of fibromyalgia similarly emphasize its permanence, as indicated in the phrase “chronic pain.” Effective treatments for either of these disorders emphasize adaptive strategies to improve function and reduce suffering, rather than eliminate pain.  

Similarities do not stop here. What helps also overlaps. Many people with emotional and physical pain turn their lives around when they become able to accept their experience as it is, while simultaneously working to change what they can control. This seemingly simple notion is both complex and learnable. In the next article, I will share observations from my work with dialectical behavioral therapy (an approach that synthesizes acceptance and change strategies) that can help individuals who suffer from distress and sensitivities of any kind.

Deborah Barrett, Ph.D., MSW, LCSW is a clinical associate professor in the School of Social Work at the University of North Carolina at Chapel Hill.

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