“I feel like so much more of myself”: The experience of modifying appearance in borderline personality disorder

Abstract

Body modifications such as tattoos and piercings have known identity-affirming functions. Despite this, as a subject of psychological research they are mainly studied in relation to self-injurious behavior. Given the frequency of both self-damaging behavior and unstable identity in borderline personality disorder (BPD), and informed by a sample of 17 pilot interviews, we hypothesized that for people with BPD, body modifications provide relief from internal and aversive identity-related concerns. The present study takes a qualitative approach to examine body modification and related emotional and intrapersonal experiences in BPD. Participants with BPD (N = 47) participated in a semi-structured interview targeting appearance modification experiences. Rapid qualitative analysis methods were used to sort interview content into five domains of interest: physical sensations, affect regulation, sense of self, emptiness and identity disturbance, and impulsivity. Participants described a wide range of body modifications and associated experiences. Results substantiated the potential for appearance modifications to positively impact sense of self in BPD — mitigating identity disturbance and emptiness — and revealed complex emotional consequences when these modifications do not “work.” Results also challenge inferred causal relationships between non-suicidal self-injury (NSSI) history and appearance modification: while participants reported sensory similarities between the behaviors, appearance modifications carried specific positive connotations and consequences NSSI did not. This study reveals a complex and nuanced picture of appearance modification in BPD, with particular implications for identity affirmation and mood induction. Results identify common themes across highly variable and personal narratives, opening a window into BPD lived experience.

Introduction

We modify our physical appearances daily: from selecting an outfit when we wake up, to applying makeup before going out at night. Permanent and semi-permanent body modifications — such as tattooing and piercing — come with higher associated stakes, including temporary physical discomfort and current and historical social stigma (Pitts, 2003). Writing on appearance modifications suggests a range of underlying motivations for these more permanent changes, such as aesthetics, individuality, and self-expression (Kalanj-Mizzi et al., 2019; Wohlrab et al., 2007), as well as community affiliation, which may be particularly relevant for societally-marginalized groups (Pitts, 2003). In the general public and in non-clinical samples, many body modifications serve a communicative purpose: across various levels of extremity and social acceptability, they relay identity-related information to the world.

In borderline personality disorder (BPD) — a psychological disorder manifesting in symptoms such as impulsivity, self-harm and suicidality, and instability in relationships and self-image (Gunderson et al., 2018) — the decision to modify one’s body in a painful and identity-affirming manner is difficult to disentangle from symptomatology. Identity disturbance is a core symptom of BPD (APA, 2022). While many people experience identity as stable over time and across contexts (Jørgensen & Bøye, 2022), people with BPD may lack this sense of continuity, which can manifest in dramatically-shifting career paths, hyperabsorption in romantic relationships, and difficulty maintaining stability in crucial domains of life functioning (Wilkinson-Ryan et al., 2000; Fuchs 2007). Chronic sensations of emptiness, another core symptom of BPD, have been linked to impulsive action (Miller et al., 2021). Some research posits that attempts to alleviate emptiness may motivate self-destructive behavior, including non-suicidal self-injury (NSSI; Miller et al., 2020; Brickman et al., 2014). Emptiness is nebulous symptom which often requires metaphor to describe; people with BPD report feeling swallowed, carved from wood, or like actors in their own lives(Miller et al., 2020). Miller et al. (2020) recently suggested that chronic emptiness could be mitigated by identity-affirming actions, such as strengthening a sense of personal autobiography or unique sense of self.

Considering the centrality of disturbed identity functioning and self-injurious behavior to BPD, appearance modifications are often pathologized in this population. Many studies have probed for relationships between tattooing, piercing, and self-directed violent or otherwise dangerous behaviors (Bui et al., 2010; Carroll et al., 2002; Preti et al., 2006; Stirn, 2003). However, appearance modifications hold potential positive and negative functions in BPD: while the sensory experience of tattooing and piercing invites comparisons to self injury, the identity-affirming aspect could be specifically helpful for a population experiencing chronic struggles with unstable identity.

In BPD specifically, features such as identity disturbance, emptiness, and history of NSSI are correlated with number of body modifications (Blay et al., 2023; Vizgaitis & Lenzenweger, 2019). à Campo et al. found an association between both BPD and schizophrenia and desire for dramatic appearance modifications, one potentially explained by disturbed identity (2007). These findings evidence the idea that body modifications are linked to identity-related psychological experiences such as those common in BPD. However, the literature is limited in scope. Of these studies, only one uses a clinical sample (Blay et al., 2023). These studies also wholly rely on survey-based self-reports of emotional experiences, with limited ranges of predetermined response options, rather than sourcing data and narrative about experiences directly from participants. Self-experience in BPD and the often highly-individual nature of appearance modifications are difficult to generalize. Qualitative methods hold promise to circumvent negative assumptions and researcher bias, and more fully characterize appearance modification in BPD.

Present Study

This study aims to address the gaps in specificity, individuality, and lived-experience perspective in existing literature on BPD and body modification. Using a qualitative approach, we sought to understand how people with BPD describe the experience of modifying their bodies, in their own words, and what relationship these modifications might have to aversive internal experiences (such as emptiness and identity disturbance) in BPD.

Methods

Ethics

All participants gave written informed consent under oversight from the Yale University Investigational Review Board. Participants for the pilot sample were recruited from the study “Ketamine in Borderline Personality Disorder” (HIC#2000025217). Participants in the main study sample were recruited from two studies involving clinical assessments, cognitive psychology tasks, and fMRI scanning (one local and one national sample, both under HIC#2000026215). Study procedures were conducted in accordance with the Declaration of Helsinki. This study was not pre-registered.

Pilot Data

We analyzed a set of pre-existing pilot interviews with people with BPD about their appearance modifications, collected as part of a previous study (n=17 total interviews). After thorough review and familiarization with the interview data, we observed several patterns suggesting a link between appearance modifications and relief from negative internal states in BPD (Figure 1).

Figure 1.

Initially hypothesized model of appearance modification experience in BPD based on pilot data

Multiple participants reported: 1) a sense of urgency preceding modifications; 2) emptiness and boredom before modifications; and 3) a tendency to view modifications as a means of relieving these states (Table S1). Based on these observations, we constructed a new semi-structured interview to systematically explore these patterns (see interview guide in Table S2).

Interview Design

The final interview targets five core domains: “impulsivity and spontaneity”, “affect regulation”, “emptiness and identity disturbance”, “sense of self”, and “physical sensations”. These domains were informed by the initially-observed patterns, BPD target symptoms, and the literature (Blay et al., 2023; Vizgaitis et al., 2019) then broadened to support qualitative analysis (Figure 2).

Figure 2.

Final domain construction process

The interview was reviewed by two academic content experts, two lived-experience consultants, and Fineberg lab staff for accessibility and sensitivity before implementation.

Participant Recruitment Strategy and Demographics

Participants were recruited via social media and Yale Center for Clinical Investigation newsletters. Phone screens briefly assessed BPD symptoms (Structured Clinical Interview for DSM-IV Axis II Personality Disorders Borderline Personality Disorder screener questions (SCID-BPD; First et al., 2016)). Likely-eligible participants were invited to a Zoom visit for BPD diagnostic interview with trained clinical research staff (Diagnostic Interview for Personality Disorders BPD section (DIPD; Zanarini et al., 1996)), appearance interview, and surveys.

Participants (N = 47) were aged 18–65, and met criteria for current or past BPD. They were predominantly female, white, and college-educated (Table 1).

Table 1:

Participant Demographics and Clinical Characteristics

Gender
Female	34 (72.3%)
Male	6 (12.8%)
Non-Binary	4 (8.5%)
Other	3 (6.4%)
Age (years)
Mean (SD)	27.6 (6.47)
Race
American Indian / Alaska Native	1 (2.1%)
Asian	8 (17.0%)
Black or African American	6 (12.8%)
White/Caucasian	27 (57.4%)
More Than One Race	5 (10.6%)
Education (years)
Mean (SD)	16.0 (2.98)
Number of Piercings
Mean (SD)	3.21 (4.44)
Number of Tattoos
Mean (SD)	3.51 (5.09)
Total Modifications
Mean (SD)	5.32 (8.01)
BSL23 Score
Mean (SD)	1.50 (0.885)
Missing	13 (27.7%)
BPD Symptom Count (DIPD)
Mean (SD)	6.21 (1.89)

Table Notes: Education years in the US context are such that 12 corresponds to finishing high school, 16 corresponds to finishing an undergraduate university degree. BSL23 = Borderline Symptom List 23-item version, standard interpretation is 0.28–1.07 (mild), 1.07–1.87 (moderate), 1.87–2.67 (high) (Kleindeist 2020). BPD Symptom Count is out of the nine symptom model in the Diagnostic and Statistical Manual (DSM5) where having at least 5 symptoms is the diagnostic cut-off for BPD. DIPD = Diagnostic Interview for Personality Disorders, BPD section.

Procedure

Interview duration averaged 19.3 minutes (SD = 6.4). Interviews were recorded and transcribed via Zoom cloud. Transcripts were checked for accuracy and de-identified prior to coding.

Data Analysis

We used rapid qualitative analysis (RQA; Hamilton, 2013; Watkins et al., 2017) to code interviews for each of the 5 domains. Where thematic qualitative analysis (e.g. Braun and Clarke, 2006) is open-ended and unstructured, RQA begins with specific questions, embraces a semi-structured interview format, and works with brief interviews and limited time. Additionally, literature suggests that RQA is as rigorous and effective as traditional thematic analysis methods (Taylor et al., 2018).

Research assistants familiar with BPD (TA, LF, SZ) were trained in RQA by reviewing articles and watching an online lecture (Hamilton, 2013), with guidance from KJ. They were oriented to the domains and interviews prior to coding; all coders contributed to the transcription cleaning process to familiarize themselves with the data. Coding began after a training phase — in which coders each independently reviewed one selected test interview and discussed results as a group and with KJ. Each interview was reviewed by two coders; each extracted domain-relevant quotes. Disagreements about domain relevance or fit of a quote led either to exclusion of the quote or deliberation toward consensus. KJ reviewed each finalized domain independently to synthesize information and identify relevant themes, trends, and sub-themes and to make final decisions. We made the decision not to code gender-affirming modifications (i.e., top surgery or physiological changes occurring after starting gender-affirming hormone therapy) as appearance modifications. These modifications are typically tied to a specific kind of identity affirmation distinct from BPD.

Reflexivity/Positionality

The coding and authorship team locate their interest in personality disorders in a variety of disciplines. KJ is a white, female post-baccalaureate researcher with one tattoo and 12 piercings. Her undergraduate background in Psychological Science and English informs her interest in language used to describe personal experience, especially those related to psychological disorders and personality. TA is an Asian, female masters’ student with one tattoo and three piercings, interested in personality and trauma disorders through a psychoanalytic lens. LF is a white, latina, female undergraduate researcher with three tattoos and seven piercings, interested in how personality disorders impact social cognition. SZ is an Asian-American, female undergraduate researcher with five piercings, interested in the neural mechanisms behind psychological disorders and learning from the lived experiences of those affected by emotional distress.

Data Availability

For participant confidentiality, full transcripts of interviews will not be made publicly available. However, the full dataset of quotes used to inform analysis will be made available upon reasonable request. The full interview guide is available in supplemental materials.

Results:

Domains

We present each of the five domains here along with key illustrative quotes.

Domain 1: Degree of spontaneity and impulsivity involved in appearance modification

Discussion of spontaneity and impulsivity was highly variable across the sample. Twenty participants (43%) reported that their appearance modifications were not impulsive, and 26 (55%) reported at least one impulsive appearance modification. Participants who reported impulsivity often reported associated senses of urgency behind the decision to change their appearance, or a need for change:

“[it doesn’t feel] necessarily that I have to [make a modification], but an overwhelming and overpowering desire to”

(Y2473, female, 37 years old).

“It’s pretty frequent. More so with tattoos and piercings, where I feel like I have to get another one”

(Y2040, non-binary, 21 years old).

However, some participants reported actively acknowledging and counteracting impulsivity in their appearance-modification processes:

“But I knew because I was impulsive, and I can do things impulsively, that I needed some time to think about this… one of those skills that I learned was to manage my impulsivity. And that was a way that I could do that for myself”

(Y2094, female, 26 years old).

Self-control, prioritizing meaning, and opposite-acting against impulsivity served as internal barriers to impulsive modification. Other factors, such as cost and accessibility and reliability of available artists, served as external barriers. Ultimately, no clear trend emerged regarding the degree of impulsivity with which participants made appearance modifications; some endorsed impulsive body modifications, others did not.

Domain 2: Physical sensations involved in appearance modifications

Results were similarly mixed in descriptions of physical sensations associated with appearance modifications. Eighteen participants (38%) endorsed low-to-no discomfort during appearance modifications, and 12 (25%) reported feeling pain during their modifications. Some participants reported subverted expectations during the modification experience, occasionally associated with a sensation of pride regarding their ability to tolerate pain:

“‘Are you sure that’s where you want to get your first tattoo? It’s really a sensitive area…’ And I said yes, and she kept… I remember being very proud of the fact that, like, I could withstand the pain while getting that tattoo.”

(Y2040, non-binary, 21 years old).

Direct questions about physical sensations also prompted many participants to reflect on similarities, and differences, to NSSI:

“It… not gonna lie, it made me a little happy, because it felt a little like self-harm… I’ve noticed that whenever I used to get a lot more tattoos I used to self-harm a lot more”

(Y2550, female, 25 years old).

“I’d say, like, I don’t actively participate in self-harm, like cutting, or any of that. I’ve never done that. But sometimes I do like to feel when the piercing first goes in, and how it enters my skin. So I do like the physical aspect to it. Also, with the tattoo… I almost find it, I guess, meditative. Just really taking a moment to be really present and conscious of a decision that I’m making”

(Y1628, female, 20 years old).

“I remember thinking of the similarities of that feeling with self-harming, and how it wasn’t… it wasn’t like me doing it, like I couldn’t control, like how fast or how long the pen was making a mark for, or like, that sort of thing, whereas… like I wasn’t in control of the instrument”

(Y2040, non-binary, 21 years old).

“It’s more satisfying to like, sit in a chair and like, be in the pain you would be in if you were to like, you know, hurt yourself, but it turns out to be something beautiful instead. And I think that’s cool.”

(Y2059, female, 22 years old).

However, despite the sensory similarities, multiple participants also reported tattooing, specifically, as having a preventative function against self-injury:

“It was supposed to be higher up on my wrist, right here, and it was in recognition of … in remembrance to try and stop self harming, and especially self harming in that area”

(Y2040, non-binary, 21 years old).

“But I used to self harm, and I used to self harm on that thigh, specifically, so it kind of was art to cover up some of the scars that I had, and also a way to be like, well, now I can’t do it here, because if I do, I’m going to mess up this beautiful artwork”

(Y728, non-binary, 27 years old).

Blunted pain response and high pain tolerance occurred for some participants in the study, but not all. For those with self-injury histories, NSSI served as an easily-accessible comparator and reference point for the sensation. However, tattooing and piercing were experienced by some as actually antithetical to NSSI — carrying a different meaning and more positive aesthetic sensibility.

Domain 3: Appearance modifications as a means of affect regulation

35 participants (74%) endorsed using, or experiencing, their appearance modifications as a means of affect regulation. Some participants drew direct comparisons between the regulating capacity of appearance modifications and that of non-suicidal self-injury:

“When I have made a super drastic change or something that’s just really dramatic it’s usually been because I was angry and instead of self-harming… I would cut my hair because it was a type of release for me”

(Y1697, female, 21 years old).

Other participants, in this vein, expressed awareness of a tendency to use appearance modification as a “coping mechanism”: handling negative emotional states via body modification, rather than facing those feelings head-on.

“I feel like once I realize that if I have, like, emotional pain, I have to deal with that and I cannot just, like, sublimate it to other forms … This is when I stopped using my appearance as my way of expression and started doing it in other forms”

(Y2088, female, 28 years old).

Some participants reported awareness of negative affective states — such as anger and depression, as well as general dissatisfaction with their lives and appearances — before modifying their bodies:

“[My tattoos are] definitely tied to situations in my life in which I was going through something emotionally”

(Y1675, female, 39 years old).

“There’s a lot of anger, resentment, insecurity in these choices that I made with my body, my appearance, I think”

(Y1466, male, 25 years old).

“I felt kind of just like, sad and out of control”

(Y2080, non-binary, 21 years old).

And for many of these participants, these modification-preceding negative emotions were understood to have a causal relationship with their appearance changes:

“…there is absolutely a predictive quality … You can definitely predict my likelihood of getting a tattoo with my mood,”

Y2765 (female, 40 years old).

However, even in the absence of elevated preceding negative affect, participants reported that appearance modifications served to boost their mood:

“I felt really, like, empowered afterwards … I felt like I’d kind of taken control”

(Y728, non-binary, 27 years old).

“I was psyched up. I was super happy, excited. Yeah. I couldn’t wait to get home to show him”

(Y1475, female, 44 years old).

For some, mood induction was attributable less to the appearance modification itself, and more to the experience of successfully undertaking a major life decision. This elevated mood could expand to cover not just the act of getting the modification, but the whole process of planning:

“I guess, like, I was happier afterwards? Because it was a goal, like, I want one?”

(Y1009, female, 23 years old).

“I was excited to get it before I got it, like it was a nice thing to finally look forward to and do for myself.”

(Y2044, genderqueer, 28 years old).

However, many others described positive emotional states induced specifically by the modification process:

“It felt very liberating and productive, to be making something beautiful out of pain”

(Y2040, non-binary, 21 years old).

Appearance modifications, on the whole for our sample, provided emotion regulation. For some participants, this took the form of alleviating negative affect; for others, this took the form of specific positive mood induction.

Domain 4: Impact of appearance modifications on sense of self

Thirty-seven participants (79%) reported or endorsed that their appearance modifications strengthened their sense of self. Some participants understood their appearance modifications as means of self-expression: making tangible, and thus stronger, their personal and mental states:

“I think I wanted the outside to match more of what I envision the inside to be”

(Y2473, female, 37 years old).

“At the moment they were very important, because, like, they really helped me balance my internal feeling with my external experience. I felt like, ‘Yes, this is something that I had to do in order to achieve this like… moment of having no anxiety, having no internal conflicts,”

(Y2088, female, 28 years old).

“[My mom] was like, “I don’t know why you’re doing this. Just let me pay to get them all [your tattoos] removed” … my pushback was, “I want everyone to know. I want to be able to feel what I’m feeling”

(Y1675, female, 39 years old).

Other participants reported that their appearance modifications had the reverse effect, serving to shape their internal senses of self from the outside:

“I always feel, like, nervous and maybe regretful, and then I look at the finished product, and I’m just like, “Actually, this is great. This is really good. I feel so much like more of myself”

(Y1584, agender, 29 years old).

Many participants expressed interest in the idea of “control.” Appearance modifications were means of willfully impacting and asserting agency over their public image:

“They’re pretty important. I like having control over other people’s perception of me”

(Y2059, female, 21 years old).

Many other participants reported that their appearance modifications served as important reminders of personal events, character traits, mental states and mottos:

“I feel like getting my tattoo was… for me, when I’m in a bad place mentally, it’s like being able to read [the text of the tattoos] and remind myself that everything is going to be fine. [It] has been really beneficial to me, especially before this diagnosis, and before figuring out who I am, mentally”

(Y2075 female, 23 years old);

“So I think probably one of the thoughts that I had when I was getting them was that,“Hey, I like service,” or, “Yeah, I wanna remember, like love, light and peace!” So I probably have that thought and was like,“Okay, yes, I want this to be a consistent thought, so I’ll just get it tattooed”

(Y2210, female, 26 years old).

Others modified their appearance to reflect stable character traits and interests:

“I have a giant Lord of the Rings tattoo, because I’m a really big Lord of the Rings fan. So I was just like, ‘This is a thing that is very solid about me,’ like, I do really love this like series, and all this, so I’m going to put that on me, because it’s like, grounding”

(Y1584, agender, 29 years old).

Ultimately, appearance modifications impacted participants’ senses of self through two main pathways: expression, and creation. Participants’ tattoos, haircuts, and piercings reminded them of their identities, values, personal histories, and interests.

Domain 5: Emptiness and identity disturbance preceding appearance modifications

Thirty-two participants (68%) endorsed emptiness or identity disturbance before a body modification. Participants tended to frame the relationship between these states and their appearance modifications to be, to some degree, causal:

“I know that I feel sad, and I know that I feel that… emptiness, the total existential meaninglessness. So the tattoos that I tend to choose are laden with meaning”

(Y2765, female, 40 years old).

Language used to describe this pre-modification precipitating state clustered around feeling “sick [of feeling this way]”, “bored”, or “numb”, with regard to both participants’ lives, and their appearances:

“I tend to have moments where, like, I feel, like, really depressed and numb, and just having a sense of newness, kind of helps. It helps me get out of that, like, state of mind”

(Y297, non-binary, 26 years old).

Many participants reported that appearance modifications were responses to, or solutions to, these states:

“It was refreshing to have something different? It was like taking control back of something”

(Y1773, male, 42 years old).

However, many participants also expressed that they did not receive the lasting benefits from their appearance modifications that they had desired:

“I also kind of just felt blank. Like, I thought afterwards I’d feel like a bit happier, but then, I was just like, ‘Oh.’”

(Y1277, female, 20 years old).

While most participants positively experienced the impact of their appearance modifications on their senses of self, and many viewed them as possible solutions to negative internal states (such as emptiness and identity disturbance) these solutions were not always successful.

Discussion

This qualitative exploration leverages a large set of interviews to extend the existing body of literature on appearance modification in BPD. In particular, we aimed to provide a more comprehensive and nuanced description of the relationships between identity, emptiness, self-damaging behavior, and appearance modification in people with BPD, including how these behaviors and emotional states differ experientially and inform one another.

Often-positive relationships between body modification and identity

Most salient in these interviews was the impact appearance modifications had on participants’ sense of self. Whether some felt their appearance modifications shaped or reminded them of their identities, and others felt attached to them as means of self expression, the overwhelming consensus was that appearance modifications enhanced sense of self. This finding is of particular relevance given the frequency of disturbed identity in BPD (Gad et al 2019; Wilkinson-Ryan, 2000), including difficulty recalling and constructing coherent life narratives (Adler et al., 2012; Fuchs 2007). Building and strengthening a sense of personal history has been proposed as a way to mitigate both emptiness and identity disturbance (Miller et al., 2020). These interviews demonstrate that tattoos and piercings may physically represent internal engagement with this process, depicting significant life events, personal strength, resilience through trauma, and recovery. Tattoos reminded participants not to self-injure, of their choice to keep living after suicide attempts, and of interests and values critical to their self-image (e.g., the birth of a son, Lord of the Rings, a service trip). For many participants, appearance modifications reflect positivity and joy.

Additionally, strategies such as intentionally engaging in life activities and work are useful for BPD (Gunderson, 2014; Lariviere, 2022; Miller et al., 2021), although stigma and stress can temper the benefits (Nault, 2025). Our participants’ reflections prompt us to consider appearance modifications through this lens. Tattooing, specifically when done with thought and intention, can encourage people with BPD to reflect on their position in the world, relationships, and personal histories. Even the act of preparing for a tattoo — booking an artist, budgeting, and considering placement and content — is a goal-directed and reward-oriented process consistent with behavioral activation (Martell et al., 2013). Multiple participants experienced body modification as an opportunity to act against their impulsivity: knowing this was a behavior with high risk for impulsive engagement encouraged them to slow down and think intentionally about their decisions. Engaging in a behavior some might pathologize or deem risky in a thoughtful, values-driven way could be a place where people with BPD can feel accomplished and proud.

Clinicians and those who work with people with BPD can be reminded that appearance is a locus where those struggling with impaired identity functioning and self narrative may find agency and self-expression: means of grounding themselves in an image that feels permanent and meaningful.

Mixed experiences of using appearance modifications to respond to negative affect

In tandem with the numerous positive experiences shared, multiple participants volunteered that emptiness and dysphoric mood persisted after they made appearance modifications — even when they had done so with the express purpose of easing these states. This demonstrates that the potentially-affirming benefits of appearance modifications may lead to emotionally-laden consequences when they do not work: serving to elucidate, concretize, and make explicit more stable senses of emptiness and identity disturbance, rather than alleviate them. This is consistent with current literature regarding symptom chronicity. Emptiness is one of the slowest BPD symptoms to change over time (Zanarini et al. 2007; Zanarini et al. 2016), and while people with BPD can identify coping strategies for mitigating emptiness, most of them are short-term (Miller et al., 2021). While some people with BPD might find appearance modification helpful, it is by no means a cure to identity disturbance and emptiness, nor a treatment. It is important for people with BPD, and their loved ones, to understand the potential for elevated disappointment when a modification hoped to provide stable affirmation fails.

A variety of existing work on BPD proposes identity disturbance as a core feature of the disorder (e.g., Kernberg, 1975). Psychotherapy has been shown to reduce experiences of diffuse identity in BPD patients (Roepke et al., 2011; Stepp et al., 2008; Doering et al., 2010; Diamond et al., 2023), with some treatment approaches (e.g., mentalization-based therapy, transference-focused psychotherapy) specifically emphasizing the long-term characterological shifts required to reduce identity disturbance.

Rather than considering appearance modifications as repeated failures to achieve concretized identity, clinicians working with BPD may benefit from using body modifications as an entry point into larger conversations about distress related to identity disturbance, factors which positively and negatively contribute to sense of self, and the type of longitudinal and internal work required to resolve internal conflict.

Relationships between body modifications and selfharm

Limited previous research on appearance modification in BPD suggests that tattooing and piercing in BPD may serve a quasi self-harming function (Blay, 2023). The narratives of people with lived experience of BPD and self-harm collected in this study shed light on this association.

Many participants in this study did use self-injury as a sensory reference point when describing their appearance modifications, with one participant explicitly noting a relationship between their own desire to get tattoos, and increased self-harm. However, participants also articulated crucial differences. While they reported tattooing and piercing provided a form of affect regulation, this was often in the form of specific, positive mood induction. Participants found their tattoos to be more productive, artistic, expressive, and positive than self-injury; in some cases, tattoos even served to deter participants from engaging in NSSI again. While emotion regulation is a widely-indicated primary function of NSSI (Nock & Prinstein, 2004; Turner et al., 2012), this is best supported in the case of relief from negative emotions. When sensations such as anger, fear, sadness and guilt reach the point of intolerability, self-injury can disrupt or stop them (Chapman et al., 2006). When it comes to the induction of specifically positive affect, findings are sparse and mixed: the most often-endorsed positive affective states induced by NSSI are positively valenced, yet low-arousal, such as relief and relaxation (Pereini et al., 2021). These states are difficult to detach from the negative correlates which likely precede them; relaxation and relief are emotions more associated with a lack of negative sensation than their own independent positive affective state. It is along this axis that participants’ description of their body modifications differs from existing popular and well-evidenced models of self-injury.

While many participants reported feeling worse before getting a tattoo or a piercing, or that modifications clustered around difficult times in their lives, the negative emotional states reported were far from the overwhelming “cascade” of emotion that often precedes NSSI. What surfaced repeatedly in interviews was the specific desired positive outcome. NSSI is often conceptualized as experiential avoidance (Chapman et al., 2006), yet for many participants in this study, body modifications are a form of engagement that reflect the choice to pursue specific mood-boosting activity rather than to avoid intolerable emotional experiences. Further work may consider engaging a sample of participants with BPD, and histories of both appearance modification and self harm, to more thoroughly interrogate the distinctions and sensory similarities between these experiences.

Expanding the model describing the functions and impacts of appearance modifications in BPD

The wide variety of stories collected here reflect both shared themes and heterogeneity in experiences of appearance modification. While some reflections fit our initial proposed model — engaging in impulsive appearance change to resolve mounting urgency and boredom — our results highlight greater importance and frequency of other themes, especially positivity, hope, and belonging associated with body modification.

Understanding the risks, benefits, and complex emotional states associated with appearance modification in BPD can help not only people with BPD, but also their providers and loved ones to recognize how symptoms might interact with appearance modifications. This awareness can support thoughtful engagement with modifications, provide language for shared experience without pathologizing, and set expectations regarding symptom-specific consequences (i.e., pervasive emptiness, sensory familiarity).

Limitations and Future Research

This work has several limitations that merit discussion. While most participants’ group status was assessed via full-length clinical interview, three participants’ groups were determined only through phone screen assessment. Although the SCID-II has been found to reliably predict BPD status (Chanen et al., 2008; Fowler et al., 2018), ideally each participant would be assessed on the same measures. Additionally, our sample skews white, young (mid-twenties), and female. These demographics may influence attitude towards body modification, and prevent confident generalization to a general population. Future work should more explicitly engage interactions between racial and cultural identity and appearance modification in BPD. Additionally, because all data were collected within a BPD sample, we are unable to draw conclusions about non-BPD groups. Further work is needed to confirm similarities and differences in experiences of body modification in people who do not have BPD.

Several decisions made to focus this project risk oversimplifying the appearance-modification experiences we sought to characterize. These include separating gender transition from other appearance modifications, and grouping emptiness and identity disturbance, symptoms with evidence of distinction (Miller et al., 2018; Herron, 2022).

Finally, RQA is limited by its reliance on pre-established domains of interest in interview content. In our paper, we see ideas recur across coding domains (i.e., interpersonal and communicative functions of appearance modification, tattoos facilitating autobiographical memory) which may, under a different analytic lens, prove robust enough to develop into their own themes. Current work is underway in our group to extend this project using an entirely inductive thematic approach (Allan et al., in prep): approaching these interviews without any pre-existing coding categories to see which themes occur. Despite limitations, this study paints a more complete picture of self-experience and appearance modification in BPD, one which refuses easy assumptions and stereotyping. It also provides a promising foundation of language and experience for expansion upon in future work, both qualitative and otherwise. Further research may consider investigating the interpersonal function of body modifications for people with BPD: how might changes made to outward presentation impact social relationships? How do people with BPD feel about the interpersonally-communicative role of their appearance modifications, or the community affiliation they might provide? Additionally, future studies may consider incorporating validated emptiness and identity measures to further investigate what might cause some participants to positively experience their appearance modifications (or see them as “successful”), and others to not. It may also be fruitful to compare body modifications to other experiences of affectively-valent lifestyle choices.

Conclusion

Understanding body modifications and the stories they tell — harrowing or silly, traumatic or joyful, emotive or intentionally bland — is a key aspect of understanding a person. Talking with people with BPD about their body modifications opens a window of understanding into BPD lived experience.

Outdated and un-curious biases propose simplistic, causal relationships between mental illness and body modifications, suggesting that tattoos equal self-injury or symptom-driven eccentric behavior. In this project, we describe a fuller picture of the bidirectional and affectively complex relationships between BPD and body modifications. People with BPD experiencing chronic emptiness and identity disturbance might find some relief in practices such as tattooing and piercing — relief distinct from that achieved by NSSI. However, this relief is often transient in nature, rather than serving as a lasting solution to internal discomfort caused by emptiness and identity disturbance. In understanding and articulating individual experiences of appearance modification, clinicians and people with lived experience of BPD may be able to locate language for lasting identity disturbance, towards identifying strategies to extend the feeling of affirmation and strengthened sense of self that body modifications can temporarily provide.

The multi-dimensionality of body modifications as described by the participants in this project and summarized here can inform clinical approach to planned and existing body modifications, supporting clinicians to join with their patients in a curious stance to open further conversation about links between emotional and bodily self, public and more intimate presentation of identity, suffering, and belonging.