In the complex landscape of postpartum health, chest pain frequently prompts urgent medical evaluation to exclude life-threatening cardiac conditions. However, an emerging body of evidence underscores that non-cardiac chest pain in postpartum women can often mask underlying psychiatric disorders that elude traditional cardiological assessments. A recent diagnostic case report published in BMC Psychiatry sheds new light on this clinical challenge, illustrating how recurrent episodes of chest pain in a postpartum patient ultimately unveiled a previously undiagnosed borderline personality disorder (BPD).
This compelling case revolves around a 29-year-old woman who made five separate visits to the Emergency Department over a span of two months, each time presenting with acute episodes of chest pain accompanied by palpitations and intense fear of dying. Standard cardiac investigations including electrocardiograms and biomarker analyses consistently returned normal, dismissing organic cardiac pathology. Such repeated presentations highlight a diagnostic conundrum encountered frequently in acute care: somatic symptoms mimicking panic or cardiac events without an identifiable physiological basis.
The case report’s authors emphasize the importance of extending clinical inquiry beyond cardiology when faced with recurrent medically unexplained somatic complaints in the postpartum period. Postpartum women constitute a unique patient cohort undergoing pronounced physiological and psychological fluctuations, rendering them vulnerable to psychiatric disorders, including trauma-related personality disturbances. Notably, borderline personality disorder, characterized by intense emotional dysregulation and unstable interpersonal relationships, may manifest predominantly through somatic symptoms in acute settings, masking its core psychopathology.
Borderline personality disorder is traditionally challenging to diagnose in emergent contexts due to symptom overlap with panic disorder and mood disturbances. In this patient’s case, repeated episodes of chest discomfort occurred in temporal proximity to emotionally distressing interactions with her estranged spouse, indicating a psychosocial trigger. Unlike classical panic disorder, the clinical profile included pervasive fear of abandonment, marked affective instability, and rapid shifts in identity perception, which collectively support a BPD diagnosis according to the DSM-5 criteria.
A critical component of this diagnostic breakthrough was the incorporation of collateral information alongside structured psychiatric evaluation. Such an approach enabled clinicians to delineate five core DSM-5 criteria: abandonment fears, affective instability, identity disturbance, impulsivity, and unstable relationships. Interestingly, the patient also had a history of isolated self-injurious behavior, a sixth criterion often associated with BPD; however, it was excluded from the threshold in this particular assessment due to its episodic nature.
This case exemplifies the necessity of trauma-informed, multidisciplinary perspectives in postpartum care when physical symptoms persist without organic explanations. Psychiatric conditions like BPD may manifest through somatic complaints, complicating diagnosis and delaying appropriate intervention. Hence, integrating psychiatric screening into emergency and obstetric care protocols may enhance detection of personality disorders that profoundly affect maternal mental health.
Treatment strategies tailored for this patient included pharmacotherapy with sertraline, targeting emotional dysregulation, alongside propranolol to manage somatic symptoms such as palpitations. Beyond medication, referral for Dialectical Behaviour Therapy (DBT), a validated psychosocial intervention specifically designed for BPD, was initiated. Early follow-up findings indicated improved emotional self-regulation and cessation of emergency presentations, suggesting a promising therapeutic trajectory despite unknown long-term outcomes.
The significance of this report lies in its demonstration of how complex psychiatric disorders like borderline personality disorder can masquerade as somatic emergencies in vulnerable postpartum patients. This recognition challenges healthcare providers to move beyond reductive diagnostic frameworks that prioritize physical etiologies and to integrate comprehensive mental health evaluations into postpartum protocols rigorously.
Moreover, this case underscores the public health imperative to enhance awareness of personality disorders among frontline clinicians, particularly in emergency settings where time constraints often preclude detailed psychiatric assessments. Educational initiatives aimed at identifying hallmark BPD features—abandonment fears, unstable relationships, affective dysregulation—may catalyze earlier referrals and improve maternal mental health outcomes.
In a broader context, the case report also implicates the psychosocial milieu of postpartum women, where interpersonal stressors such as estrangement can exacerbate latent psychiatric vulnerabilities. It advocates for routine screening of relational stress and trauma histories during postpartum check-ups to preempt potential psychological crises manifesting as somatic complaints.
From a neurobiological perspective, the somatic manifestations of BPD—including chest pain and palpitations—likely reflect dysregulated autonomic nervous system activity triggered by emotional arousal. This intersection between affective neuroscience and psychosomatic medicine opens fertile ground for further research to delineate the pathophysiological pathways linking personality pathology with somatic symptomatology.
Clinicians and researchers alike are called upon to consider this integrative paradigm, recognizing that postpartum chest pain devoid of cardiac etiology may serve as a clinical window into untreated psychiatric disorders such as BPD. Early psychiatric diagnosis coupled with evidence-based interventions including DBT and pharmacotherapy can substantially mitigate symptom burden and improve quality of life for affected women.
As postpartum women negotiate profound biological, psychological, and social changes, this case report serves as a pivotal reminder to adopt comprehensive, multidisciplinary care models. A failure to identify the psychiatric underpinnings of recurrent somatic symptoms risks perpetuating cycles of emergency visits, patient distress, and healthcare utilization without addressing root causes.
In conclusion, the diagnostic revelation of borderline personality disorder in a postpartum patient with recurrent chest pain emphasizes the complex interplay between somatic and psychiatric health. This case advocates for heightened clinical vigilance, trauma-informed assessments, and integrated care pathways to optimize maternal mental health outcomes and reduce the burden of medically unexplained physical symptoms in postpartum populations.
Subject of Research:
Investigation of recurrent postpartum chest pain as a somatic manifestation of undiagnosed borderline personality disorder and its diagnostic challenges within acute medical settings.
Article Title:
Recurrent postpartum chest pain unmasking undiagnosed borderline personality disorder: a diagnostic case report
Article References:
Shrivastav, A., Tiwaskar, S., Kumar Sahu, P. et al. Recurrent postpartum chest pain unmasking undiagnosed borderline personality disorder: a diagnostic case report. BMC Psychiatry 25, 838 (2025). https://doi.org/10.1186/s12888-025-07307-z
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