However, pain is not only physical because a sensory experience can also be due to mental health conditions such as depression, anxiety, or anger.

Therefore, a difference exists between pain and the cause of the pain. The link between the two is mediated by our nervous system through a process known as nociception.

It was estimated that 20.4% of adult individuals had chronic pain and that 7.4% of adult individuals had chronic pain which limited their activities, such as working, in the past 3 months [2].

1- What is emotional pain?

Emotional pain can be defined by the heartache we feel when losing someone or something that was important to us.

2- Is pain an emotion or feeling?

A Feeling is the outcome or expression of our interpretation of an emotion that was caused by pain (physical or psychological).

3- What is the worst mental pain?

They are several mental conditions that are characterized by unbearable psychological and emotional pain that is characterized by suicidal thoughts (suicidal ideation).

These include Emotionally unstable personality disorder (borderline personality disorder) and seasonal affective disorder.

4- What are Nociceptors?

Nociceptors are sensory neurons that respond to damage or potential damage through alerting communications to the brain and spine [3].

Nociceptors can be mechanical, thermal, mechano-thermal, polymodal, or silent.

Mechanical nociceptors respond to mechanical damage or pressure, while thermal nociceptors respond to cold or hot temperatures.

Mechano-thermal nociceptors respond to both mechanical and thermal stimuli, while silent nociceptors respond to inflammatory mediators.

5- What Are the Types of Pain?

• Acute Pain

Acute pain is caused by spasms of skeletal muscles and the activation of the sympathetic nervous system that is due to an injury or a trauma. The duration of the pain is short and disappears with the healing of the injury.

• Chronic Pain

Chronic pain is also caused by an injury or a disease, but the pain would continue even after the healing period.

• Nociceptive Pain

Nociceptive pain is caused by an injury, trauma, chemicals, or surgery that results in the activation and release of inflammatory mediators by nociceptor neurons (sensory neurons) which activate inflammation in the injured area [4].

• Neuropathic Pain

Neuropathic pain is due to direct damages or compression of the sensory nerves associated with sciatica, neuropathies such as phantom limb pain, Wallerian degeneration, segmental demyelination, or diabetic neuropathies.

5- Are There Other Classifications of Pain?

• Allodynia

Allodynia is a pain that is caused by a stimulus that is not the one that initiated the pain, such as feeling pain after a gentle shake of hands or light touch on the back.

• Analgesia

Analgesia is characterized by the inability to feel the pain caused by a stimulus (cause) that should normally have caused pain.

• Hyperpathia

Hyperpathia is a neuropathic pain characterized by an abnormal, repetitive, and elevated pain reaction to the stimulus (cause).

• Causalgia

Causalgia is neuropathic pain that combines a sensation of burning pain, hyperpathia, and allodynia.

• Dysesthesia

Dysesthesia is an unpleasant and abnormal sensation such as cold sensation, tingling, burning, numbness, tickling, or pain that is caused by nerve trauma or irritation.

• Hyperalgesia

Hyperalgesia is characterized by an abnormally increased sensitivity to pain due to the release of inflammatory hormone-like substances, known as prostaglandins, that increase the sensitivity of the nociceptors.

Hyperalgesia can be caused by fibromyalgia, diabetes, infection, trauma, postherpetic neuralgia, and complex regional pain syndrome.

• Hyperesthesia

Hyperesthesia is characterized by an increased sensitivity to stimuli associated with senses such as hearing, tasting, touch, smelling,

Hyperesthesia is caused by excessive stimulation of the nervous system such as overconsumption of caffeine.

• Hypoalgesia

Unlike analgesia characterized by the inability to feel pain, hypoalgesia is associated with a reduced response to a painful stimulus.

6- What Are the Symptoms of Pain?

The symptoms of pain are categorized corresponding to the pain intensity, duration, and pain-related disability [5]. These categories allow the classification of pain into mild, moderate, or severe using assessment methods:

• Visual Analogue Scale

This method consists in drawing a line between two points. The first point is the “no pain” and the second point is the “as bad as it could be”.

The individual in pain is requested to mark the level of pain within the two endpoints.

• Graphic Rating Scale (GRS)

This method represents a drawing of a line with levels from 1 to ten representing the intensity of pain. No pain is represented by the number 0 and “as bad as it could be” is represented by the number 10.

The individual in pain is requested to indicate the number from 0 to 10 which represents the level of pain experienced by the individual.

• Verbal Rating Scale

This method evaluates the pain experienced by the patient using adjectives to describe the level of pain.

• Pain Drawing

In this method, the patient is requested to indicate the location of the pain on a drawn human body.

• McGill Pain Questionnaire (MPQ)

This questionnaire assesses the pain-rating index, the number of words describing the pain, and the level of pain on a scale of 1-5.

8- What Is the Treatment of Pain?

Pain is mainly managed.

• Non-pharmacological Management

Non-pharmacological management involves:

– Exercise such as swimming, walking, yoga, Pilates, and exercise bike.

– Physical therapy through physiotherapists and occupational therapists who will help with stretching and pain-relieving exercises.

– Psychological management through social support, psychologists, and psychotherapists.

• Pharmacological Management

For mild and moderate pain, non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are used.

Although there is a high risk of dependency, opioid analgesics (e.g., morphine) are used for the treatment of severe pain.

Conclusion

Although the risk factors in the progression from acute to chronic pain are well known, identifying patients who are predisposed to this progression through assessing the status of the acute pain, the physiological and reactivity of the patients to pain, should help better manage this switch from acute to chronic pain.

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The prevalence of BPD is estimated to be 1.6% in the general population and 20% in the inpatient psychiatric population [1]. It is estimated that 10% of BPD patients commit suicide, which is 50% higher than that of the total population [2].

What causes borderline personality disorder?

The causes of BPD are complex and involve genetic factors and adverse childhood experiences that alter emotions and cause impulsivity leading to behavioral alterations and psychosocial struggles and deficits.

Studies using neuroimaging technologies identified differences in certain parts of the brain of BPD patients, including the amygdala, hippocampus, and medial temporal lobes. Neurobiological studies suggested the potential implication of serotonin in the pathogenesis of BPD [1].

1- Genetic Factors

Evidence of the involvement of genetics in BPD was provided by the study of identical and non-identical twins. A study showed that the rate of BPD in Identical twins is 70%, while it was only 7% for non-identical twins [3]. These results were confirmed by other twin studies that reported a genetic heritability of 50% [4].

2- Adverse Childhood Experiences

Many patients with BPD reported experiences of traumatic neglect and abuse during their childhood, including childhood sexual abuse that represented 40-70% of the reported cases of BPD and difficulties reaching stable attachments or losing attachments figures (e.g., parents) [5][6].

Borderline Personality Disorder Symptoms

The symptoms of BPD are complex and involve affective, cognitive, behavioral, and interpersonal symptoms [7]:

1- Affective Symptoms

These symptoms include intense and frequent episodes of uncontrolled and constant anger with repeated fights, chronic feelings of emptiness, and affective instability associated with anxiety and irritability.

1- Cognitive Symptoms

These symptoms are characterized by temporary stress-related feelings of being persecuted or harassed, or the presence of severe dissociative symptoms such as the feeling as if one is outside, one’s body, and loss of memory.

2- Behavioral Symptoms

These symptoms are associated with impulsivity and frequent suicidal behavior, gestures, or threats, or self-mutilating behavior.

3- Interpersonal Symptoms

These symptoms are associated with hysterical efforts to prevent real or imaginary abandonment but also the existence of unstable and intense interpersonal relationships that are characterized by a switch between extreme acts of devaluation and overestimation of an admired aspect of another person.

Diagnosis of Borderline Personality Disorder

Before performing a comprehensive psychiatric assessment, a careful history and physical examination are performed. Diagnostic screening tools for BPD are also used such as the Zanarini Rating Scale for borderline personality disorder [1]. It has also been shown that patients with BPD have high rates of comorbid disorders:

• Mood disorders 80% to 96%
• Anxiety disorders 88%
• Substance abuse disorders 64%
• Eating disorders 53%
• Attention deficit hyperactivity disorder (ADHD) 10%-30%
• Bipolar disorder 15%
• Somatoform disorders 10%

Borderline personality disorder treatment

1- Psychosocial Interventions

These interventions involve mentalizing-based therapy (MBT) to help the emotional aspect of the patients, dialectical behavior therapy (DBT) that combines mindfulness practices with tangible interpersonal and emotion regulation skills, and transference-focused psychotherapy (TFP) to help make the patients aware of problems associated with interpersonal interactions.

2- Pharmacotherapy

So far, there are no medications that are approved to specifically treat BPD; however, medications such as SSRIs, mood stabilizers, and antipsychotics are used for the control of anxiety, depression, sleep disturbance, or psychotic symptoms [7].

Prognosis of Borderline Personality Disorder

Compared to other mental disorders such as bipolar disorder, BPD seems to have a better prognosis. A study has reported a remission of 75% of hospitalized patients who were included at the start of the study followed up was for 6 years.

The study also reported that only 6% of those who achieved remission had a later recurrence and only 4% of the patients committed suicide within the 6-year study period [8]. Another study that included 290 patients with BPD, reported a remission of 35% after 2 years, 91% after 10 years, and 99% after 16 years.

Conclusion

Although borderline personality disorder is a severe mental disorder characterized by high rates of suicide, psychosocial interventions combined with pharmacotherapy to relieve symptoms such as anxiety, depression, and psychosis, have led to high rates of remission. However, while waiting for better and more cost-effective treatments, early intervention and prevention strategies during childhood or adolescence can certainly help the development of this disorder.

References

[1] Chapman J, Jamil RT, Fleisher C. Borderline Personality Disorder. [Updated 2021 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

[2] Swartz, M., Blazer, D., George, L. and Winfield, I., 1990. Estimating the prevalence of borderline personality disorder in the community. Journal of personality disorders, 4(3), pp.257-272.

[3] Torgersen, S., Lygren, S., Øien, P.A., Skre, I., Onstad, S., Edvardsen, J., Tambs, K. and Kringlen, E., 2000. A twin study of personality disorders. Comprehensive psychiatry, 41(6), pp.416-425.

[4] Amad, A., Ramoz, N., Thomas, P., Jardri, R. and Gorwood, P., 2014. Genetics of borderline personality disorder: systematic review and proposal of an integrative model. Neuroscience & Biobehavioral Reviews, 40, pp.6-19.

[5] Zanarini, M.C., Yong, L., Frankenburg, F.R., Hennen, J., Reich, D.B., Marino, M.F. and Vujanovic, A.A., 2002. Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. The Journal of nervous and mental disease, 190(6), pp.381-387.

[6] West, M., Keller, A., Links, P.S. and Patrick, J., 1993. Borderline disorder and attachment pathology. The Canadian Journal of Psychiatry/La Revue canadienne de psychiatrie.

[7] Lieb, K., Zanarini, M.C., Schmahl, C., Linehan, M.M. and Bohus, M., 2004. Borderline personality disorder. The Lancet, 364(9432), pp.453-461.

[8] Zanarini, M.C., Frankenburg, F.R., Hennen, J. and Silk, K.R., 2003. The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160(2), pp.274-283.

[9] Gunderson, J.G., Stout, R.L., McGlashan, T.H., Shea, M.T., Morey, L.C., Grilo, C.M., Zanarini, M.C., Yen, S., Markowitz, J.C., Sanislow, C. and Ansell, E., 2011. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of general psychiatry, 68(8), pp.827-837.

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