Psychosis in borderline personality disorder: Web audio at CurrentPsychiatry.com Dr. Schultz: Challenges of treating psychosis in BPD How assessment and treatment differs from a psychotic disorder Evaluate the tone and timing of hallucinations in suspected BPD, emphasize psychotherapy Heather E. Schultz, MD, MPH sychotic symptoms in patients with borderline personality disor- Clinical Instructor der (BPD) are common, distressing to patients, and challenging to Victor Hong, MD treat. Issues of comorbidities and misdiagnoses in BPD patients Clinical Instructor P further complicate matters and could lead to iatrogenic harm. The dis- • • • • sociation that patients with BPD experience could be confused with psy- Department of Psychiatry chosis and exacerbate treatment and diagnostic confusion. Furthermore, University of Michigan BPD patients with unstable identity and who are sensitive to rejection Ann Arbor, Michigan could present in a bizarre, disorganized, or agitated manner when Disclosures under stress. The authors report no financial relationships with any company whose products are mentioned in this article Although pitfalls occur when managing psychotic symptoms in or with manufacturers of competing products. patients with BPD, there are trends and clues to help clinicians navi- gate diagnostic and treatment challenges. This article will review the literature, propose how to distinguish psychotic symptoms in BPD from those in primary psychotic disorders such as schizophrenia, and explore reasonable treatment options. The scope of the problem The DSM-5 criteria for BPD states that “during periods of extreme stress, transient paranoid ideation or dissociative symptoms may occur.”1 The term “borderline” originated from the idea that symptoms bordered on the intersection of neurosis and psychosis.2 However, psychotic symptoms in BPD are more varied and frequent than what DSM-5 criteria suggests. The prevalence of psychotic symptoms in patients with BPD has been estimated between 20% to 50%.3 There also is evidence of frequent audi- tory and visual hallucinations in patients with BPD, and a recent study using structured psychiatric interviews demonstrated that most BPD patients report at least 1 symptom of psychosis.4 Considering that psy- Current Psychiatry IKON IMAGES/MASTERFILE Vol. 16, No. 4 25 Table 1 Which symptoms most likely fit the diagnosis? Borderline personality disorder Primary psychotic disorder Transient, stress-related psychosis Clear negative symptoms, emotional blunting Auditory hallucinations are predominantly negative Only delusions present and critical in tone Psychosis Presence of dissociative symptoms Bizarre ideas in BPD Reduction of psychosis over long-term course Prodromal period common prior to onset of psychosis Increased psychotic symptoms in response Psychotic symptoms improve with consistent to interpersonal stress use of antipsychotic medications chiatric comorbidities are the rule rather self as a “social chameleon” and notes that Clinical Point than the exception in BPD, the presence of she changes how she behaves depending on Antipsychotic psychotic symptoms further complicates who she spends time with. the diagnostic picture. Recognizing the She often hears the voice of her ex- dosages used to symptoms of BPD is essential for under- boyfriend instructing her to kill herself and treat hallucinations standing the course of the symptoms and saying that she is a “terrible person.” Their in primary psychotic predicting response to treatment.5 relationship was intense, with many break- disorder are unlikely Treatment of BPD is strikingly different ups and reunions. She also reports feel- than that of a primary psychotic disorder. ing disconnected from herself at times as to be as effective for a There is some evidence that low-dosage though she is being controlled by an outside patient with BPD antipsychotics could ease mood instabil- entity. To relieve her emotional suffering, ity and perceptual disturbances in patients she cuts herself superficially. Although she with BPD.6 Antipsychotic dosages used to has no family history of psychiatric illness, treat hallucinations and delusions in a pri- she fears that she may have schizophrenia. mary psychotic disorder are unlikely to be Ms. K’s outpatient psychiatrist prescribes as effective for a patient with BPD, and are antipsychotics at escalating dosages over associated with significant adverse effects. a few months (she now takes olanzapine, Furthermore, these adverse effects—such 40 mg/d, aripiprazole, 30 mg/d, clonaz- as weight gain, hyperlipidemia, and diabe- epam, 3 mg/d, and escitalopram, 30 mg/d), tes—could become new sources of distress. but the hallucinations remain. These symp- Clinicians also might miss an opportunity toms worsen during stressful situations, and to engage a BPD patient in psychotherapy she notices that they almost are constant if the focus is on the anticipated effect of a as she studies for final exams, prompting medication. The mainstay treatment of BPD her psychiatrist to discuss a clozapine trial. is an evidence-based psychotherapy, such as Ms. K is not in psychotherapy, and recog- dialectical behavioral therapy, transference- nizes that she does not deal with stress well. focused psychotherapy, mentalization-based Despite her symptoms, she is organized in therapy, or good psychiatric management.7 her thought process, has excellent grooming and hygiene, has many social connections, CASE and performs well in school. Discuss this article at Hallucinations during times of stress www.facebook.com/ Ms. K, a 20-year-old single college student, CurrentPsychiatry presents to the psychiatric emergency room How does one approach a patient with worsening mood swings, anxiety, and such as Ms. K? hallucinations. Her mood swings are brief A chief concern of hallucinations, par- and intense, lasting minutes to hours. Anxiety ticularly in a young adult at an age when often is triggered by feelings of emptiness psychotic disorders such as schizophrenia Current Psychiatry 26 April 2017 and fear of abandonment. She describes her- often emerge, can contribute to a diagnos- tic quandary. What evidence can guide the Table 2 clinician? There are some key features to Treating psychosis in borderline consider: personality disorder • Her “mood swings” are notable in their Evidence is limited for antipsychotics reducing intensity and brevity, making a primary psychotic symptoms mood disorder with psychotic features less If prescribing antipsychotics, use lower likely. dosages • Hallucinations are present in the Avoid using multiple concurrent antipsychotics absence of a prodromal period of functional Avoid statements that imply psychotic decline or negative symptoms, making a pri- symptoms are “not real” mary psychotic disorder less likely. Emphasize psychotherapy as the treatment • She does not have a family history of of choice and medications as adjunctive psychiatric illness, particularly a primary Focus on reducing distress and improving psychotic disorder. ability to cope (rather than focusing on • She maintains social connections, medications) although her relationships are intense and tumultuous. Clinical Point • Psychotic symptoms have not changed Explore the nature with higher dosages of antipsychotics. phrenia are estimated to affect at least 1% of • Complaints of feeling “disconnected the general population.8,9 Patients with BPD and timing of the from herself” and “empty” are common frequently meet criteria for comorbid men- psychotic symptoms symptoms of BPD and necessitate further tal illnesses, including major depressive to determine a exploration. disorder, substance use disorder, posttrau- less ambiguous • Psychotic symptoms are largely tran- matic stress disorder, anxiety, and eating diagnosis and clearer sient and stress-related, with an overwhelm- disorders.10 Because psychotic symptoms ingly negative tone. can present in some of these disorders, the treatment plan • Techniques that individuals with schizo- context and time course of these symptoms phrenia use, such as distraction or trying to are crucial to consider. tune out voices, are not being employed. Misdiagnosis is common with BPD, Instead, Ms. K attends to the voices and is and patients can receive the wrong treat- anxiously focused on them. ment for years before BPD is considered, • The relationship of her symptoms to likely because of the stigma surrounding interpersonal stress is key. the diagnosis.5 One also must keep in mind When evaluating a patient such as Ms. K, that, although rare, a patient can have both it is important to explore both the nature BPD and a primary psychotic disorder.11 and timing of the psychotic symptoms and Although a patient with schizophrenia could any other related psychiatric symptoms. be prone to social isolation because of delu- This helps to determine a less ambigu- sions or paranoia, BPD patients are more apt ous diagnosis and clearer treatment plan. to experience intense interpersonal relation- Understanding the patient’s perspective ships driven by the need to avoid abandon- about the psychotic symptoms also is useful ment. Manipulation, anger, and neediness to gauge the patient’s level of distress and her in relationships with both peers and health impression of what the symptoms mean. care providers are common—stark con- trasts to typical negative symptoms, blunted affect, and a lack of social drive characteristic Diagnostic considerations of schizophrenia.12 BPD is characterized by a chaotic emotional climate with impulsivity