Are We Overlooking Psychosis in Borderline Personality?

When most hear the word "psychosis," they think of primary psychotic disorders like schizophrenia and schizoaffective disorder. Yet, research has shown there are many paths to the experience. I came across a study recently that found that as many as 94% of people diagnosed with borderline personality disorder may experience persecutory delusions (Merrett et al., 2022) and 26% to 54% report hearing voices (Savero et al., 2022). Among the most common of those reported were visions, voices, and paranoia.

Psychosis in Borderline Personality: Similarities and Differences From Schizophrenia

Treatment for borderline personality often focuses on the emotional and interpersonal aspects of the condition. Phenomena usually associated with psychosis are not routinely assessed in individuals with borderline personality, and, when brought to the forefront, may be dismissed by clinicians. The term "pseudohallucination" has been sometimes applied clinically to those with a diagnosis of personality disorder who report hallucinations, implying a less serious, or even feigned, aspect to it.

Still, research has shown that in addition to being common, the voices heard by individuals with borderline personality disorder share much of the clinical significance as those in other conditions. An fMRI study found patterns of neural activity in people with borderline personality disorder that were similar to those with schizophrenia (Strawson et al., 2022). In addition, the voices are almost always reported as negative (Savero et al., 2022), causing a high level of distress.

The array of experiences among voice hearers is wide. Some have questioned the validity of the term "pseudo hallucination" altogether (Van der Zwaard). The term might reflect a cynical view on behalf of the assessor, which is not often helpful in treatment. We don't call panic attacks "pseudo-heart attacks."

It's critical to note that these experiences are real to these individuals. While a person with borderline personality may have more insight into the internal nature of their experiences and may report less bizarre ideology than individuals with a diagnosis of schizophrenia, the distress caused can still be great.

Still, there do appear to be some differences between psychotic symptoms in borderline personality and those observed in schizophrenia. Within schizophrenia, hearing voices is by far the most common experience of hallucination, with hallucinations involving multiple senses being less common. Within this study (Merrett et al., 2022), many sampled individuals with borderline personality disorder reported multi-sensory hallucinations including ones involving the sense of smell., which is not common in schizophrenia. This is of interest as the sense of smell has been strongly linked to memory. It could be wondered if this particular presentation is in any way linked to traumatic memories. Lastly, while hearing two or more voices talking to each other (dialog voices) is common in schizophrenia, this has been less commonly observed in borderline personality disorder (Savero et al., 2022).

Negative symptoms such as social withdrawal and emotional blunting, common in schizophrenia, are typically not observed in psychosis associated with borderline personality (Niemantsverdriet et al., 2017). On the contrary, emotional reactivity is a hallmark of borderline personality.

What is described is a different array of psychotic spectrum symptoms between the two conditions. This is not to cast doubt on the validity of these symptoms. Mood disorders with psychotic features also have unique patterns. Symptoms are usually mood-congruent; for example, a person in the throes of mania is more likely to have a delusion of having millions of dollars whereas someone experiencing depression might have more prominent delusions of guilt. In both cases of mood disorders with psychotic features and borderline personality, the person may preserve more awareness during psychosis, recognizing that their experiences are "odd." In addition, in these conditions, the psychosis also typically ends with a mood episode while psychosis in schizophrenia tends to be more pervasive.

PTSD With Secondary Psychotic Features

Experience of trauma is common both in individuals diagnosed with schizophrenia and borderline personality. Still, it is especially associated with borderline personality with 93% of those diagnosed in one study reporting childhood trauma (Fung et al., 2023). Observations have been made that voices heard by individuals with borderline personality often are associated with traumatic events and may have a dissociative quality (Beatson et al., 2019). A focus on psychosis alone in borderline personality would also risk missing necessary needs in terms of addressing trauma-related aspects.

Although not included within the Diagnosis and Statistical Manual Fifth Edition (DSM V), secondary psychotic features have been explored as a feature for some individuals diagnosed with post-traumatic stress disorder, a common comorbidity in borderline personality (Compean and Hamner, 2017). Trauma is a significant risk factor for psychosis. Still, the mechanism (or mechanisms) of this are unknown.

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The diathesis-stress model of psychotic disorders hypothesizes that when under a certain level of stress, a cascade of neurobiological events may take place, which ignite the spark of the condition in individuals with a genetic predisposition (Pruessner et al., 2017). There is not enough evidence to guess if or how relevant this may be for individuals with borderline personality disorder. Nonetheless, it does point to the complexity of the condition.

Compassionate Approaches

Borderline personality on its own is associated with a heightened risk of suicide, as are persecutory delusions and other psychotic symptoms. These challenges deserve inquiry. Given the ubiquity of these experiences, perhaps all with a diagnosis of borderline personality should also be screened for psychosis. Many feel a sense of shame when hearing voices, for example, and may not volunteer this information in session. Receiving normalization and validation of these experiences could be empowering and open the door to discussion.

A systemic review found that voices heard by individuals with borderline personality disorder responded well to the same psychiatric interventions used for psychotic disorders like Schizophrenia (Slotema et al., 2018). Still, psychotherapy is a vital component of approaching these experiences. This is particularly so given the trauma-related and often stress-induced nature of psychosis in borderline personality. Some interventions such as compassion-focused therapy and dialectical behavioral therapy have been utilized for both psychosis and borderline personality. Yet, these are complex presentations and research is still needed to establish best practices.

Regardless, when psychosis and borderline personality disorder travel together, both the traditional borderline personality traits and psychosis deserve intervention within a compassionate and trauma-informed space. Recovery is possible. Validation of the individual's experience along with partnership in the healing process is imperative.

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