Can People With Borderline Personality Disorder Experience Psychosis?

Summary: Yes, people with borderline personality disorder can experience psychosis. In the past, symptoms of psychosis among people with borderline personality disorder may have been downplayed and minimized by clinicians, but new research confirms people with borderline personality disorder experience psychosis more frequently than previously recognized.

Key Points:

• Symptoms of psychosis in borderline personality disorder may resemble symptoms of psychosis in disorders such as schizophrenia.
• People with borderline personality disorder experience psychosis as symptoms such as hallucinations and delusions.
• Hallucinations and delusions in people with borderline personality are similar, but show distinct characteristics, compared to hallucinations and delusions experienced by people with schizophrenia or other psychotic disorders.
• Presence of psychosis in people with borderline personality disorder may indicate increased disease severity and a greater level of disruption, distress, and impairment.

Borderline Personality Disorder (BPD) and Symptoms of Psychosis

In the peer-reviewed publication “Psychotic Symptoms in Borderline Personality Disorder: Developmental Aspects,” a group of researchers examine the prevalence, type, and impact of symptoms of psychosis – a.k.a. psychotic symptoms – in people with BPD as reported in the existing scholarship on the topic. They open their study with a brief history of our understanding of psychosis in BPD, culminating in this observation:

“Even though the borderline concept has historically been intertwined with psychosis, psychotic symptoms in people with borderline personality disorder (BPD) have long been marginalized as somehow not real, transient, or ‘pseudo’ in nature.”

Previous understanding of psychosis and psychotic symptoms in people with BPD revolved around the idea that the phenomena were:

• Transient in nature, and not a stable – i.e. common and persistent – feature of the disorder
• Associated solely with paranoia
• Triggered by stress, and not present without external triggers, such as distress, conflict, or other types of difficulty
• Quasi-psychotic and not bizarre enough to meet criteria for psychosis

However, research shows that these ideas about psychosis in BPD are not necessarily evidence-based, and require a complete reassessment. To understand how people with borderline personality disorder experience psychosis, let’s first define exactly what the disorder is.

Mental health experts define BPD as follows:

“A mental health condition that characterized by a pervasive pattern of instability in relationships, self-image, moods, and behavior and hypersensitivity to possible rejection and abandonment.”

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Borderline Personality Disorder (BPD) Treatment in San Diego

The most common symptoms of BPD include:

• Intense fear of abandonment
• Unstable interpersonal relationships
• Identity instability/frequently changing concept of self
• Impulsive, risky behavior
• Suicidality and self-harm
• Extreme, sudden mood swings
• Unpredictable rage/anger that’s difficult to control
• Paranoia/dissociation

It’s clear that that set of symptoms can create serious problems in daily functioning: intense emotions, extreme vacillation between states of mind, and risk-taking all contribute to difficulties people with BPD face.

The last bullet point – paranoia/dissociation – is important to understand. Previously, consensus among mental health experts held that the dissociative components of BPD were the primary aspect of psychosis in BPD. However, we now know that dissociative thinking is not the only type of psychotic symptom people with BPD experience.

What Symptoms of Psychosis Do People With Borderline Personality Disorder Experience?

Evidence from the study we introduce above shows the following facts about psychosis and psychotic symptoms in people with BPD.

BPD and Psychosis: Presence of Hallucinations and Delusions

Hallucinations:

• Auditory verbal hallucinations (AVH):
  • Present in 40% of people with BPD
  • The most common form of psychotic symptoms among patients with BPD
• Visual hallucinations: 11%
• Gustatory hallucinations: 8%
• Olfactory hallucinations: 17%
• Tactile hallucinations: 15%

Delusions and thought-related symptoms:

• Insertion of external thoughts: 100%
• Blocking of personal thoughts: 90%
• External influence on thoughts: 70%
• Dissociation: 55%
• Delusions: 20%

Auditory verbal hallucinations (AVHs) are the most common form of hallucination in people with BPD, often experienced as “critical, controlling, distressing, malevolent, omnipotent, and emanating from a source with higher social power than the person experiencing them.”

Patients with BPD report that the AVHs are generally more negative than those experienced by people with schizophrenia. However, patients with BPD report not believing in the reality of those voices to the extent that people with schizophrenia do. In other words, while they hear voices loud and clear, they’re less likely to believe those voices are real, compared to a person with schizophrenia.

Delusions in people with BPD are also common, as the data above show. Delusions include believing others have access to personal thoughts, feeling others can remove or place thoughts in their head, or that others can block access to personal thoughts. Patients with BPD are less likely to believe in the authority of the voices they hear, compared to people with schizophrenia. In most cases, delusions and hallucinations in BPD are related, and, unlike in people with schizophrenia, delusions in people with BPD are not associated with disorganized thoughts, distorted thoughts, or negative symptoms.

When People With Borderline Personality Disorder Experience Psychosis, What are the Consequences?

The section above includes what seems to be a paradox: although the auditory verbal hallucinations people with BPD experience are often more negative and sinister than those experienced by people with schizophrenia, people with BPD are less likely to believe they’re real. The authors of the study “Borderline Personality Disorder and Early Psychosis: A Narrative Review” offer this insight:

“When describing AVH, patients with BPD refer a greater distress and negativity in content, yet they seem to be able to manage them better than patients with schizophrenia can.”

This is a feature that distinguishes psychosis in BPD from psychosis in schizophrenia. It supports the idea that many clinicians may need to consider revising their concept of psychosis in BPD, and recognize that the latest evidence indicates psychosis in BPD is both common and has features unique to BPD.

This is important data for the evolution of the treatment of BPD. Evidence shows the presence of psychosis in people with BPD – particularly auditory verbal hallucinations (AVHs) and visual hallucinations – compared to people with BPD without psychosis, is associated with:

• Presence of more BPD symptoms
• Greater frequency of co-occurring mental health disorders
• Increased symptoms of anxiety
• Increased symptoms of depression
• More feelings of loneliness
• Higher incidence of planning suicide
• Higher incidence of attempting suicide
• More frequent admission to hospital
• More frequent readmission to acute inpatient psychiatric care

Here’s how the authors of the study characterize the increased awareness of the presence of psychosis in people with BPD:

“Research over the last two decades has shown that AVH occur frequently in individuals with BPD…in BPD, psychotic symptoms are associated with greater distress, co-occurring psychopathology, suicidal risk, and hospital readmission, suggesting that they should be seen as a marker of illness severity.”

Therefore, based on this expanded understanding, when people with borderline personality disorder experience psychosis, clinicians can readily identify these symptoms and offer appropriately calibrated support to help patients manage symptoms, minimize disruption, and promote the balance and harmony required for long-term healing and growth.