The Hidden Health Risks of Borderline Personality Disorder

In May 2026, House Resolution 1327 was introduced in the US House of Representatives to support designating a “Borderline Personality Disorder Awareness Month.” The proposal highlighted the need for greater awareness of the more than 1.6% of Americans with borderline personality disorder (BPD). Notably, it acknowledged the misperceptions and stigma that people with BPD often face in both mental health and other healthcare settings.Richard Zhang, MD, MAPatients with BPD are sometimes labeled as “difficult”; their concerns may be dismissed by healthcare professionals and indicated treatments delayed. This reflects a broader risk that patients with mental health conditions have their physical symptoms overlooked or even misattributed to psychological distress. Awareness of medical conditions that commonly co-occur with BPD is crucial to providing comprehensive, equitable, and effective care. People with BPD experience an average life expectancy reduction of over 14 years, due not only to high-risk behaviors but also to medical illnesses. Recognizing these medical associations can help physicians avoid diagnostic overshadowing — the tendency to attribute physical symptoms to a psychiatric diagnosis — and ensure that patients with BPD receive appropriate evaluation and treatment for coexisting medical conditions.Cardiovascular ConditionsBPD has been associated with significantly elevated risks for cardiovascular disease and mortality. In a 23-year follow-up study, participants with cluster B personality disorders, which include BPD, had 6.13-fold higher odds of cardiovascular mortality. Multiple mechanisms may contribute to the incidence and severity of conditions such as hypertension, atherosclerosis, and ischemic heart disease.Recurring emotional dysregulation in BPD, often provoked by relational challenges, intensifies the body’s physiologic stress response. Perceived rejection can be felt as especially painful and even destabilizing. Acute surges of anger and descents into dysphoria activate the sympathetic nervous system and hypothalamic-pituitary-adrenal (HPA) axis. The resulting catecholamine release increases heart rate, blood pressure, and arterial constriction, placing additional strain on the cardiovascular system. Chronic cortisol release likewise contributes to hypertension and inflammatory disruption of vascular endothelium. While certain emotions serve important evolutionary purposes, their intensity and long-term, frequent recurrence in undertreated BPD can become maladaptive and detrimental to the heart.Moreover, some people with BPD cope with underaddressed distress or loneliness through substance use. Such behavior may also relate at times to impulsivity and risk-taking. For example, they are 4.1 times as likely as the general US population to have nicotine dependence. The adverse cardiovascular impacts of sustained use of alcohol, tobacco, and many recreational drugs are well established. Patients with these co-occurring conditions may benefit from addressing both substance use and the underlying affective and interpersonal difficulties that contribute to it.Metabolic RisksMetabolic syndrome appears to occur at over twice the rate in people with BPD than in the general population. This is associated with dysregulation of lipid and especially glucose metabolism. In turn, one’s risks increase for such conditions as type 2 diabetes and coronary artery disease that adversely impact long-term quality of life and mortality risk.The progression toward metabolic problems mechanistically overlaps with that of cardiovascular disease in those with BPD. Chronically recurring emotional activation of cortisol release and inflammatory processes is understood to contribute to visceral fat deposition and insulin resistance. Persistent elevations in inflammatory cytokines such as TNF-alpha and interleukin-6 may also contribute to these metabolic changes.Besides BPD itself, physicians should consider the metabolic impacts of off-label psychotropic medication use. Pharmacotherapy may appropriately target co-occurring psychiatric conditions. That said, while BPD can be treated with psychotherapeutic modalities, there are no FDA-approved medications for this personality condition. Off-label medications are nonetheless frequently prescribed long-term for symptoms of irritability, anxiety, and low mood in BPD. Long-term use of antipsychotics such as quetiapine and olanzapine, for example, can increase appetite, contribute to weight gain, and even disrupt glucose control independently of weight gain.Pain SyndromesOveractivated in undertreated BPD, the stress response system influences not only cardiovascular but also other somatic systems. Pain is processed and modulated at multiple levels of the nervous system, including the spinal cord's dorsal horns and regions of the brain such as the insula, anterior cingulate cortex, prefrontal cortex, and amygdala. The processing of emotional pain overlaps with that of peripheral somatic pain at some cortical points. This has implications for people with BPD who have persistently deep emotional pain.Long-term activation and hypersensitivity of the central nervous system (CNS) may predispose patients to chronic pain conditions. Here, the negative experience of pain becomes pervasive and amplified beyond what certain stimuli originally would have elicited. As many as 65% of patients with BPD experience pain disorders in their lifetime; conversely, as many as 30% of patients with chronic pain are estimated to meet diagnostic criteria for BPD. This overrepresentation of co-occurring BPD has been observed for conditions such as chronic spinal pain, arthritis, and severe headaches. Recent research suggests an especially close association between BPD and fibromyalgia which, even without peripheral tissue injury, arises primarily from CNS sensitization of pain signaling.Co-occurring ConsiderationsPsychiatrists, and physicians in every specialty, should consider concurrent medical risks in patients with BPD and other mental health conditions. These patients deserve the same comprehensive clinical evaluation as any other patient. As with any label, the diagnosis of BPD does not explain all of a patient’s behaviors and concerns. Beyond statistical associations, BPD symptoms may contribute partly to the pathophysiology of many co-occurring medical illnesses. Connecting patients with BPD to effective psychotherapy could thus improve the cardiovascular, metabolic, and other somatic domains of their health. Dialectical behavior therapy (DBT), for example, has been found to normalize elevated heart rates in patients with BPD. Each patient’s specific needs should be considered when selecting treatment. Emotional dysregulation can improve from the skills-building of DBT and perspective-taking insights of mentalization-based treatment; conflict-prone household dynamics often benefit from family therapy.House Resolution 1327 was remarkable for bringing national attention to misperceptions of BPD. As healthcare professionals, many of us will care for patients with BPD at some point. It is incumbent on us to care for these patients holistically and accurately so that stigma surrounding BPD continues to diminish and equitable outcomes become a reality.Richard Zhang, MD, MA, is an assistant professor of psychiatry at the Boston Medical Center in Massachusetts. His academic interests center on intersections among health, humanities, culture, and law.