Is There Psychosis in Borderline Personality Disorder?

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Summary: Yes, in some cases, there may be psychosis in borderline personality disorder. Recent research shows psychosis in borderline personality disorder occurs more often than previous research suggests.

Key Points:

Psychosis in borderline personality disorder most often appears as hallucinations and/or delusions.
Psychosis in borderline personality disorder is often similar to psychosis in other mental health disorders.
While the symptoms of psychosis in borderline personality resemble those in other mental health disorders, they have distinct and identifiable characteristics.
Psychosis in borderline personality disorder is associated with increased severity and functional impairment.

Psychosis in Borderline Personality Disorder (BPD)

In a new study on the presence of psychotic symptoms in borderline personality disorder, mental health experts conducted a comprehensive review of the available research on psychosis in borderline personality disorder to identify exactly which type of symptoms are most common in the disorder, how they affect the course of the disorder, and the level of consequences they may cause for people diagnosed with borderline personality disorder.

This study is important for our overall understanding of BPD and helps us improve how we support patients with BPD. Until recently, despite the common and consistent appearance of psychosis and psychotic symptoms in BPD, the research team observes:

“Psychotic symptoms in people with borderline personality disorder (BPD) have long been marginalized as somehow not real.”

Let’s be clear: the psychotic symptoms and the psychosis in borderline personality disorder are, indeed, very real symptoms with a very real impact on people with BPD. Misconceptions around psychosis in BPD revolved around the following ideas:

They only appear sometimes and don’t last long
They only appear in association with severe paranoia
They’re only stress related, and not consistent symptoms of the disorder.
The symptoms don’t appear as detached from reality as those in other disorders with psychosis.

New research – like the study we link to above – shows us it’s time for a thorough revision of psychosis in borderline personality disorder. It’s time to revisit how we understand the presence of symptoms of psychosis in borderline personality disorder and what they mean for the diagnosis, treatment, and long-term prognosis for people with BPD.

Before we learn more about this new knowledge about BPD, let’s review what we know about the disorder.

What is Borderline Personality Disorder (BPD)?

The American Psychiatric Association (APA) offers this comprehensive definition of BPD:

“Borderline personality disorder is one of 10 personality disorders identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). People with borderline personality disorder have a pattern of unstable relationships, intense fears of being abandoned, impulsive behavior, and extreme emotions, such as intense bouts of anger or anxiety.”

Now let’s look at the diagnostic criteria for BPD as defined in the DSM-5:

“Borderline personality disorder is diagnosed when a pattern of extreme changes in self-image, impulsive actions, and troubled relationships emerges.”

When a person shows five of the following symptoms, they meet criteria for diagnosis of BPD:

Consistent pattern of unstable and intense relationships, where the individual moves between extremes: a one moment they may love a person deeply, and the next, they may hate them.
Extreme, persistent, and frantic efforts to prevent and/or avoid abandonment by the person or people important to them.
Frequently changing image self: one moment self-esteem may be very high, and the next moment, very low, i.e. a love/hate relationship with self.
Consistent risky behavior and impulsivity including but not limited to dangerous/risky sex, substance misuse, irresponsible/heedless spending, binge eating, unsafe/reckless driving, and binge eating.
Suicidality: suicidal ideation, planning suicide, attempting suicide.
Non-suicidal self-injury (NSSI), i.e. self-harm with no suicidal intent.
Intense, short bouts of sadness/anxiety.
Persistent feeling of hopelessness, emptiness, and purposelessness.
Intense, sudden anger that’s disproportionate to the situation
Anger management issues: temper tantrums, getting in physical fights
Stress-related paranoia, extreme suspicion/distrust of the motives of others
Persistent feeling of being detached from world, a sense that the world, self, and others is/are not real

When we review that list of symptoms, it’s immediately clear how they can disrupt day-to-day life. From fear of abandonment, rapidly shifting and contrasting emotions, and frequent variations in self-concept, to extreme impulsivity, paranoia, and feelings of dissociation, these symptoms can create fear and confusion in other people, increase levels of conflict, and make typical daily functioning very difficult.

For information on how we help patients manage the symptoms of the disorder, we encourage you to read our BPD treatment page:

Borderline Personality Disorder Treatment in San Diego

Traditional understanding of BPD held that stress related paranoia leading to dissociation was the main way psychosis appeared in BPD, and that the psychotic, dissociative features of paranoia were transitory and not true psychotic symptoms. But that notion has now been disproved, and we know there are additional features of psychosis that appear frequently in people with BPD.

Psychotic Symptoms in BPD: More Than Paranoia and Dissociation?

The new research we introduce above upgrades our understanding of psychosis in borderline personality disorder BPD. In contrast to the traditional consensus that psychosis in BPD was transitory, limited to dissociation triggered by stress-induce paranoia, and relatively uncommon, the new data reveals an entirely different situation.

Psychosis in Borderline Personality Disorder: An Evolving Concept

Psychotic Symptoms: Hallucinations

Hearing things that aren’t there: 40%
Smelling things that aren’t there: 17%
Feeling things that aren’t there (touch): 15%
Seeing things that aren’t there: 11%
Tasting things that aren’t there: 8%

Psychotic Symptoms: Delusions

Belief outside forces can place thoughts in their minds: 100%
Belief outside forces can prevent access to their private thoughts: 90%
Believe externa forces can direct thoughts: 70%
Dissociative experiences: 55%
Distorted thoughts/delusions: 20%

These results confirm the need for reassessing the presence and role of psychosis in BPD. The prevalence of hallucinations and delusion far exceed previous expectations, with delusions of thought reported by all patients with BPD, and auditory hallucinations – i.e. seeing things that aren’t there – present in close to half of people with BPD.

However, when we compare the symptoms of psychosis reported by people with BPD against the symptoms of psychosis reported by people with a disorder such as schizophrenia, we see that patients report significant differences both in their experience of the symptoms and how they understand the symptoms themselves.

Primary differences include:

Patients with BPD report that auditory hallucinations are often “…. critical…malevolent…from a source with higher social power,” in contrast to auditory hallucinations in schizophrenia, which are not always negative/critical.

Disclaimer: In some cases, auditory hallucinations in schizophrenia are negative and can lead to unsafe behavior. However, patients report auditory hallucinations in BPD are more likely to be negative.

Patients with BPD most often report they don’t believe the voices they hear are real, whereas people with schizophrenia often believe the voices they hear are 100% real, and convincing them otherwise can cause conflict with others and disrupt the treatment process.
Delusions in people with BPD are similar to hallucinations: they may be present and common – data from the study we cite indicates all patients with BPD reported some type of delusion – but people with BPD know their delusions aren’t real.
Delusions in people with BPD are not connected to thought distortions or thoughts that are disorganized, like the delusions most often reported by people with schizophrenia.

With new evidence showing the prevalence of psychosis in borderline personality disorder is greater than previously thought, our next step is understanding how the presence of psychosis impacts the overall course of the illness.

How Does Psychosis Affect People With Borderline Personality Disorder?

In a different study on the presence of psychosis in borderline personality disorder, researchers address the difference between auditory hallucinations in BPD and auditory hallucinations in schizophrenia:

“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.”

Despite this fact, and the contrast in experience between people with BPD and people with schizophrenia, data connects the presence of psychotic symptoms – particularly hallucinations – with the following negative outcomes in people with BPD:

Higher prevalence of BPD symptoms
Increased incidence of co-occurring mental health and/or behavioral disorders
Higher prevalence of anxiety symptoms
Higher prevalence of depressive symptoms
Increased loneliness/isolation
Increased frequency of making suicide plans and/or attempting suicide
Higher frequency of emergency psychiatric hospitalization
Increased incidence of admission/repeated admission to inpatient psychiatric treatment programs

The important takeaways from this study include:

Research shows hallucinations in BPD are far more common than previously reported
Psychotic symptoms in BPD increase risk of emotional distress, co-occurring mental health disorders, suicidality, and hospitalization.
Psychotic symptoms in BPD can be used in the future as an indication of disease intensity, severity, and level of disruption.

The researchers offer an incisive analysis of what this new information may mean in clinical practice:

“The historical narrative that psychotic symptoms in BPD are somehow not real, transient, or quasi in nature is a disrespectful myth that is inconsistent with the current evidence regarding the subjective experience of patients.”

We’ll discuss these results – and that analysis – below.

How This New Information Can Help Our Patients

First, it helps us dispel the notion that a person with psychosis doesn’t have BPD, and a person with BPD won’t show psychotic symptoms. We now know a person can have BPD with psychosis, and it’s not uncommon. Again, we’ll quote the study authors:

“As in depression and bipolar disorder, psychotic symptoms are a marker of more severe disorder.”

That means that when we diagnose a person with BPD and they report the presence of hallucinations and/or delusions, we know that they may have a more severe form of BPD than a person without psychotic symptoms. That helps us build a treatment plan that matches their symptom profile. There’s more detail to consider here, too:

“While hallucinations and delusions are common among people with BPD, co-occurring negative and disorganized psychotic symptoms are uncommon and might indicate the presence of an even more extensive illness.”

This fact can help us further optimize treatment to help address the most severe and disruptive symptoms. Finally, the researchers offer another takeaway from their study, which may be one of the most important:

“When planning treatment, clinicians should take into account that individuals with BPD and psychotic symptoms are at a greater risk of developing a wide range of negative outcomes, including suicide.”

The increased awareness of psychosis in BPD can help us help our patients by increasing our diagnostic accuracy, allowing us to differentiate more precisely between symptoms of BPD and schizophrenia, and giving us the insight to create treatment plans that reduce symptoms, minimize functional impairment, and help patients with BPD develop the skills they need to grow and thrive in recovery.