BPD and somatoform disorder, somatic complains, hypocondriasis, medically unexplained symptoms, Munchausen...

Connection between borderline personality and somatoform disorders, physical complains. A lot of BPD people seems to have "unexplained" physical problems. There is a lot of studies about this, but once again the goal is not to stigmatize or say to a patient "wake up !" but to see such troubles as warning signs. You will find on the last part of this document our vision which we hope comprehensive and listening to the suffering

The DSM IV describes 5 subtypes of somatoform disorders:
• Body Dysmorphic Disorder: Preoccupation with an imagined defect in appearance
• Conversion Disorder (hysterical neurosis. Was traditionally labelled "hysteria" ): Loss of or alteration in physical functioning.
• Hypochondriasis(hypochondriacal neurosis)
• Pain Disorder: Persistent complaint of pain in the absence of organic disease and with evidence of a psychological cause
• Somatization Disorder (This disorder was previously designated Briquet's syndrome)
And Undifferentiated Somatoform Disorder

* Zimmerman M, Mattia JI. - Dept. of Psychiatry and Human Behavior, Brown University School of Medicine,

* Frankenburg FR, Zanarini MC. - Boston University School of Medicine, Harvard Medical School, Boston, USA.
2OO6 Curr Opin Psychiatry.- Personality disorders and medical comorbidity.
RECENT FINDINGS: In general those with personality disorders do not feel as fit as others do. Also, those with personality disorders in addition to other psychiatric disorders are likely to have more health problems than those without personality disorders. People with active borderline personality disorder have been shown to have more medical problems than those with remitted borderline personality disorder.
SUMMARY: Clinicians caring for people with personality disorders need to be aware of possible medical comorbidity..

* Zimmerman M, Mattia JI. - Dept. of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, USA.
1999 Compr Psychiatry - Axis I diagnostic comorbidity and borderline personality disorder.
In comparison to nonborderline PD patients, borderline PD patients more frequently received a diagnosis of ... and any somatoform disorder

* Okasha A, Omar AM, Lotaief F, Ghanem M - Neuropsychiatric Department, Ain Shams University, Cairo, Egypt.
1996 Compr Psychiatry - Comorbidity of diagnoses in a sample of Egyptian patients with neurotic disorders.
...Some comorbidity was shown between borderline PD and somatoform disorder

* Noyes R Jr, Langbehn DR, Happel RL, Stout LR, ... - Dept. of Psychiatry, Iowa Colleges of Medicine Iowa City
2OO1 - Psychosomatics - Personality dysfunction among somatizing patients.
A greater percentage of somatizers met criteria for one or more DSM-IV personality disorders, especially obsessive-compulsive disorder

* Chabrol H, Chouicha K, Montovany A, Callahan S. - Centre d'Etude et de Recherche en Psychopathologie, Universite de Toulouse-Le Mirail - France
2OO1 Encephale - Symptoms of DSM IV borderline personality disorder in a nonclinical population of adolescents
Comorbidity with anxiety disorders appeared also to be high: anxiety symptoms were found in 91.4% of the borderline subjects who reported symptoms of generalised anxiety disorder, panic disorder, and somatoform disorders

* Katon WJ, Von Korff M, Lin E. - Dept. of Psychiatry and Behavioral Sciences, University of Washington, Seattle.
1992 Am J Med 1992 - Panic disorder: relationship to high medical utilization.
Relationship between panic disorder, somatization, functional disability, and high medical utilization. People with panic disorder in the community compared to both community psychiatric and nonpsychiatric controls tend to perceive themselves as having poor physical health. Most patients with panic disorder present to their primary-care physician with somatic complaints, especially cardiac (tachycardia, chest pain), gastrointestinal (epigastric pain or irritable bowel syndrome), or neurologic complaints (headaches, dizziness, or presyncope)

* Horenstein M.
1986 Presse Med - Spasmophilia or panic attack?
For many years, the symptoms grouped under the label "spasmophilia" have been differently evaluated in France by psychiatrists, who ascribe them to hysteria or anxiety, and by endocrinologists and general practitioners for whom they are all due to neuromuscular hyperexcitability, the cause of which must be sought in the biochemistry of calcium. Since anxiety can be biochemically induced, the hypotheses put forward by "spasmophilologists", such as disorders of calcium metabolism or hyperventilation, can now be tested in the laboratory.

* Cristina S, Sandrini G, Ruiz L, Verri AP, ... - Casimiro Mondino Neurological Institute, Pavia, Italy
1996 Funct Neurol - A record card for the study of Neuronal Hyperexcitability Syndrome.
Neuronal Hyperexcitability Syndrome (NHS) is a nosographic picture which is difficult to diagnose, due to the lack of specific standard diagnostic criteria. With slightly varying symptoms the syndrome has also been defined as Spasmophilia and Hyperventilation Syndrome. It is difficult to distinguish between NHS and panic attack disorder as there is considerable overlapping of symptomatology

* Cowley DS, Roy-Byrne PP. - Dept. of Psychiatry and Behavioral Sciences, University of Washington, Seattle.
1987 Am J Med - Hyperventilationandpanic disorder.
Hyperventilation syndrome and panic disorder are both common, serious, and easily treatable disorders
About 50 percent of patients in each group show evidence of both disorders

* Saper JR, Lake AE 3rd. - Michigan Head Pain and Neurological Institute, Ann Arbor, Michigan, USA
2OO2 Headache - Borderline personality disorder and the chronic headache patient: review and management recommendations.
Severe headaches and migraine appear to be more prevalent in patients with BPD than the general population.
Headaches and other symptoms in patients with BPD can be successfully managed over the course of a long-term relationship with clearly defined limits

* Slepoy VD, Pezzotto SM, Kraier L, Burde L, ... - Facultad de Ciencias Medicas, Universidad de Rosario, Argentina
1999 Dig Dis Sci 1999 - Irritable bowel syndrome: clinical and psychopathological correlations.
Irritable bowel syndrome is a common disorder in gastroenterology consultations.
... and Rorschach Psychodiagnostic Tests. The last one showed that 78% suffered from distortion in reality perception. Within psychological gnosiology, these patients would be diagnosed as borderline personalities

* Snyder S, Pitts WM.
1986 Acta Psychiatr Scand - Characterizing somatization, hypochondriasis, and hysteria in the borderline personality disorder.
Somatization, hypochondriasis, and hysteria have often been considered as associated features of the borderline personality disorder

* Abramowitz SI, Carroll J, Schaffer CB.
1984 J Clin Psychol - Borderline personality disorder and the MMPI.
The borderline patients manifested significantly greater hypochondriasis, depression and hysteria

* Ohshima T. - Chibaken Sodegaura Welfare Center, Chiba, Japan.
2OO1 Psychiatry Clin Neurosci. - Borderline personality traits in hysterical neurosis.
The objective of the present study is to demonstrate the traits of the psychopathology of Borderline Personality Disorder (BPD) compared with hysterical neurosis.
Both of BPD and hysterical neurosis groups were not so fairly well discriminated. However, these results suggested that impulse-action pattern and disorder of interpersonal relationships were traits of borderline personality disorder. We could admit manipulation, intolerance of aloneness as its symptoms

* Sutherland AJ, Rodin GM. - Dept. of Psychiatry, Toronto General Hospital, University of Toronto, Ontario.
1990 Psychosomatics 1990 Fall - Factitious disorders in a general hospital setting
Associated psychiatric disturbances included substance use, psychogenic pain disorder, malingering, dysthymic disorder, and borderline personality disorder.

* Ehlers W, Plassmann R. - Center for Psychotherapy Research, Stuttgart, Germany.
1994 Psychother Psychosom - Diagnosis of narcissistic self-esteem regulation in patients with factitious illness (Munchausen syndrome).
... showed that 9 patients (50%) had a borderline personality disorder

* Bools C, Neale B, Meadow R. - Dept. of Pediatrics and Child Health, St. James's University Hospital, Leeds, UK.
1994 Child Abuse Negl - Munchausen syndrome by proxy: a study of psychopathology.
Munchausen Syndrome by Proxy (the fabrication of illness by a mother in her child) is often a serious form of child abuse that has been recognized increasingly over recent years
Lifetime psychiatric histories are reported for 47 of the mothers
The most notable psychopathology was the presence of a personality disorder in 17 (36%) of the mothers, which were predominantly Histrionic and Borderline types

* Bouden A, Krebs MO, Loo H, Olie JP. - Service Hospitalo-Universitaire de Sante mentale et therapeutique, Paris.
1996 Presse Med - Munchausen syndrome by proxy: a challenge for medicine]
In Munchhausen syndrome by proxy, a subject, usually a mother, pretends her child has a serious medical disorder. After simulating ficticious symptoms, or even producing clinical signs such as convulsions, fever, bleeding, vomiting, diarrhea or skin eruptions, the mother repeatedly takes her child to different hospitals for care. During hospitalization, the mother shows great concern for the child and is highly cooperative with the health care team. ... The underlying psychopathological structure is difficult to apprehend. Narcissic fragility and borderline personality are the must frequent, but passive-dependent hysteric personality or sadomasochist behavior can be found and depression is often associated... Psychiatric treatment and sometimes legal action are required to avoid this particular kind of child abuse.

* Truman TL, Ayoub CC. - Tallahassee Memorial Hospital, Florida, USA.
2OO2 Child Maltreat - Considering suffocatory abuse and Munchausen by proxy in the evaluation of children experiencing apparent life-threatening events and sudden infant death syndrome.
This study describes 138 young children admitted to the hospital over a 23 year period for recurrent apparent life threatening events (ALTEs), unexplained deaths, or with Sudden Infant Death Syndrome (SIDS). Findings demonstrate a co-occurrence of risk factors that raise suspicions of suffocatory abuse or Munchausen by Proxy. Of the 35 children who died, SIDS was the presumed clinical diagnosis at the time of death in 71 % of the cases. Comprehensive chart review and autopsy findings revealed a non-SIDS diagnosis in 54% and confirmed or suspicious child abuse in 37% of these deaths.
(aapel: We also think that some SBS, Shaken Baby Syndrome are caused by parent / caregivers with psychiatric problems, especially personnality disorders)

* Fisher L, Chalder T. - Guy's, King's and St. Thomas' School of Medicine, London, UK
2OO3 - J Psychosom Res - Childhood experiences of illness and parenting in adults with Chronic Fatigue Syndrome.
OBJECTIVE: There are many similarities between chronic fatigue syndrome (CFS), the somatoform disorders and problems otherwise known as "medically unexplained symptoms." There is some evidence to suggest that a combination of inadequate parenting and early illness experience may predispose the individual to develop medically unexplained symptoms in adult life
CONCLUSION: It is possible that maternal overprotection in particular is related to the formation of belief systems about avoiding activity that operate to adversely influence behaviour in patients with CFS

* Aghabeigi B, Feinmann C, Harris M. - Joint Dept. of Maxillofacial Surgery and Oral Medicine, Eastman Dental Hospital, London.
1992 Br J Oral Maxillofac Surg - Prevalence of post-traumatic stress disorder in patients with chronic idiopathic orofacial pain.
Five (15%) had a history of post traumatic stress disorder (PTSD) which coincided with the pain onset. The majority of these PTSD sufferers also had a personality disorder. The implications of these findings in the diagnosis and management of post-traumatic chronic TMJ pain syndromes is discussed.

* Keel P. - Psychiatrische Universitatspoliklinik Zweigstelle, Basel, Switzerland.
1998 Z Rheumatol - Psychological and psychiatric aspects of fibromyalgia syndrome (FMS).
Fibromyalgia patients hardly suffer from major psychiatric illnesses. Repeated traumatic experiences during childhood and as adults can be discovered in many cases

* Kroenke K. - Dept of Medicine and Regenstrief Institute for Health Care, Indiana University School of Medicine, Indianapolis
2OO3 Int J Methods Psychiatr - Patients presenting with somatic complaints
"Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders... Antidepressants and cognitive-behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache..."

* Linzer M, Felder A, Hackel A, Perry AJ... - Dept of Medicine, Duke University Medical Center, Durham, North Carolina
1990 Psychosomatics - Psychiatric syncope: a new look at an old disease.
72 patients with unexplained syncope and presyncope
Symptoms appeared to be explained by a psychiatric diagnosis in 24% patients
Treatment aimed at the psychiatric diagnosis resulted in a remission from syncopal or presyncopal symptoms in 90% of patients who complied with therapy.

"Borderlines have a large incidence of Fibromyalgia.
Headaches are very common with BPD as are migraines, abdominal pain or malaise irritable bowel, TMJ, PMS.
Common features include a tendency to demonstrate factitious illnesses, which may lead to overuse of medical resources" (mhsanctuary)

"Fibromyalgia in my experience is strongly associated with the BPD and the generalized anxiety disorder - particularly the cognitive component
I'd take Panic disorder very, very seriously. The combination of panic and BPD has a 25% suicide rate" (Leland M. Heller, MD, “Borderline Personality Disorder and Fibromyalgia”, www.biologicalunhappiness.com)

"Factitious disorder has been associated with borderline personality traits and substance abuse disorders" (Eve G Spratt MD, "Somatoform Disorder: Somatization",  emedecine 2OO4)

"CFS can occur simultaneously with personality and mental health disorders, such as Bipolar, MPD, Borderline Personality, and Anxiety Disorder" (Iona Miller and Graywolf Swinney, "Chronic Fatigue Syndromes and the Consciousness Restructuring ", asklepia.org)

"Ce qu'on appelle la spasmophilia n'est en fait qu'une forme débutante de panic attack, à l'intensité limitée." (Christophe André, psychiatre vice-president de l’AFTCC)

Here is our feeling.

Do BPD people have somatoform, unexplained physical problems ?
yes, it is a common behavior. The symptom or deficit is not intentionally produced or feigned

Do they ALL (bpd) have such problems ?
That's a good question. It is rare to a bpd people to have "nothing", no physical complain, but it is possible. Once again, such manifestations are here like a warning sign and must be carefully managed to know "why"

Which kind of "illnesses" or somatoform disorders are found in some BPD people ?

• CFS - Chronic Fatigue syndrome : Characterized by profound fatigue that is not improved for example by bed rest
• FMS - Fibromyalgia syndrome(fibromyositis): Characterized by chronic, widespread, musculoskeletal pain and multiple tender points. People with fibromyalgia also frequently suffer from profound fatigue, sleep disturbances, cognitive difficulties, anxiety and depression. There is also "Myofascial pain syndrome"
• Headaches (chronic) : Recurrent migraine or tension-type headaches
• HVS - Hyperventilation Syndrome : Condition in which minute ventilation exceeds metabolic demands, resulting in hemodynamic and chemical changes that produce characteristic symptoms (eg during panic attack)
• Hypochondriasis: When a patient remains preoccupied with the fear that they have a serious medical illness despite the fact that medical evaluation has ruled out such an illness
• Irritable Bowel Syndrome : Constipation, diarrhea, frequent abdominal pain, abdominal gas and nausea
• NHS - Neuronal Hyperexcitability Syndrome (spasmophilia) : Spasmophilia: This ailment is characterized by cramps, a tingling sensation, restlessness, and back spasms (also linked with panic attack and hyperventilation)
• Panic attack : Intense anxiety of sudden onset and brief duration characterizes a Panic Attack (DSM IV)
• PMS - Premenstrual syndrome  : Please read PMS page
• Sleep disorder  : Please read Insomnia / nightmares page
• Somatization (Briquet's syndrome) : Pattern of medically unexplained complaints of multiple physical symptoms
• TMJ, TMJD, TMD - Temporomandibular Joint Dysfunction or Disorder Syndrome : Describes a variety of conditions that affect jaw muscles, temporomandibular joints, and nerves associated with chronic facial pain
• ...

Is it possible that some borderline patients may have a comorbid "false" disorder ?
Yes, we speak about "Factitious disorder"

What is a "factitious" disorder ?
Patient's with this mental disorder are so eager to assume the role of a sick person that they intentionally feign or produce symptoms. For exemple patients with Munchausen syndrome spend much of their life traveling from place to place and moving from hospital to hospital to be admitted as patients

Why some (future) borderline people feign factitious disorder ?
For example when a mother has some problems and doesn't care about her child. If the child notice that, when he / she is sick, the mother is a loving one, then he / she will do his / her "best" to be sick.

And what about Munchausen syndrome by proxy ?
The subject, usually a mother, pretends her child has a serious medical disorder. After simulating ficticious symptoms, or even producing clinical signs such as convulsions, fever, bleeding, vomiting, diarrhea or skin eruptions, the mother repeatedly takes her child to different hospitals for care. During hospitalization, the mother shows great concern for the child and is highly cooperative with the health care team
The mother has, during this stage, the possibility to be "a good mother"
It is obvious that the mother has serious mental problem (one of them could be borderline personnality disorder)

Which treatments for somatoform disorders and such illnesses ?
It of course necessary to adapt the borderline treatment to take in account some kind of pains (especially with medication). But to really solve the problem, the solution is not in the treatment of the "physical" illness, but in  the treatment of the borderline disorder which lead to somatoform and other unexplained diseases...