Borderline Personality Disorder and Psychosis: A Case Managed by Transference-Focused Psychotherapy
Abstract
Transient stress-related paranoia is the descriptive definition of psychotic phenomena associated with borderline personality disorder. Although psychotic symptoms usually do not qualify patients for a separate diagnosis in the psychotic spectrum, statistical probabilities predict the co-occurrence of cases with comorbid borderline personality disorder and major psychotic disorder. This article presents three perspectives on a complex case of borderline personality disorder and psychotic disorder: one from a medication prescribing psychiatrist who is a transference-focused psychotherapist responsible for care, one from the anonymous patient, and one from a specialist in psychotic disorder. A discussion of clinical implications concludes this multidimensional presentation of borderline personality disorder and psychosis.
After more than a year of personality disorder–focused inpatient treatment, a 25-year-old woman, “Molly,” was referred to transference-focused psychotherapy (TFP) for severe borderline personality disorder. She had left inpatient treatment against medical advice to pursue graduate studies. Although she was actively engaging in self-harm, the inpatient program directors determined that they could not hold her against her will. The referring psychiatrist from the inpatient program called Molly the program’s “scariest patient.” The psychiatrist reported that Molly was transported by ambulance to the emergency room more than monthly because of self-harm that disrupted the milieu. During one hospitalization, Molly collapsed into a psychotic depression that was relieved by electroconvulsive therapy (ECT). The clinical team’s concern was that outside of a structured environment, the self-harm would worsen and culminate in death by suicide.
Transference-Focused Psychotherapist’s Perspective
On referral, the TFP therapist took the patient’s history and confirmed the borderline personality disorder diagnosis. Molly’s relationships had worsened after middle school, with many dramatic fallings-out with close friends. Molly also had strained relationships with family members. She had developed an eating disorder and significant self-loathing focused on her physical appearance. She avoided sexual intimacy because of fear of rejection. Molly’s excellent school performance led to a successful career, but in her early twenties, her tumultuous relationships began to affect her performance. Molly saw a psychiatrist who diagnosed her with borderline personality disorder, but he concluded that her neediness exceeded his capacity to treat her. After matriculating to a new postgraduate program, Molly became clingy toward her assigned roommate, who went to the dean and accused her of stalking, triggering Molly into a rapid descent into suicidality. A brief inpatient hospitalization occurred at a program known for its sensitivity to personality issues, where her diagnosis of borderline personality disorder was again confirmed. In short order after discharge, she entered the referring program.
In TFP, Molly received psychoeducation that the treatment was contract centered and would operate differently from her inpatient program, particularly regarding self-harm and its treatment. No effort would be made to keep her from harming herself. If the patient harmed herself, no matter how superficially, she would need a note from an internist saying the injury had been evaluated and was considered medically safe before she could return to session. Molly held sole responsibility for the decision to go to the psychiatric emergency room between sessions if she needed help in tolerating her self-harm impulses without acting on them.
In the 3 years of treatment, she never self-harmed. Molly reported that once the psychiatrist lost interest in self-harm, she did too, and she began trying to provoke attention from him in ways within the established limits. This behavior included extended periods of silence, in which she would “withhold her thoughts” from him. Molly’s interpersonal relationships remained fraught. She often took offense to real and perceived slights and rejections.
Things changed at the 1-year mark. For several months, the TFP therapist had been concerned that Molly was not progressing as he would have expected. The long periods of verbal withholding were more reminiscent of thought blocking than usual personality disorder–driven provocations. The patient’s complete lack of sexual activity was remarkable for a young woman with borderline personality disorder. Molly’s fallings-out with friends seemed more severe and sinister than the typical pattern observed in borderline personality disorder. Finally, he realized that her use of the phrase “I’m a bad person,” to explain why she thought people were rejecting her was characteristic of patients with schizophrenia, as she seemed to believe it was a metaphysical fact rather than an interpersonal one. He then recalled what had seemed a small detail in her initial presentation: that she had been treated with ECT for a psychotic depression. Only now, a year into treatment, did he begin asking about psychotic symptoms, and a profusion of symptoms came spilling out. Molly believed the food supply of the city was poisoned. Molly believed her supervisor, and later her psychiatrist, were sending her coded messages that she was a bad person and should kill herself. She felt her ex-partner was spying on her, that her computer was bugged, that things in her apartment were being subtly rearranged while she was away to send her obscure messages, and that her cat was sometimes against her for being a bad person. It was hard for Molly to leave the house because she thought that her movements were being observed by some sort of sinister organization. It even emerged that many of Molly’s self-harm episodes at the inpatient program had been driven by a concern that there were spiders under her skin that had to be dug out with a razor blade.
When informed by the TFP therapist that he had belatedly realized that she was experiencing intense symptoms of psychotic disorder, Molly said that this was not true, that she just had anxiety characteristic of borderline personality disorder. She became angry with him for “trying to take away” a diagnosis with which she had grown comfortable. The TFP therapist told her that he did not believe this was mere anxiety related to separation fears and wanted her to start on a second-generation antipsychotic. He did not offer room for disagreement, on the grounds that having an untreated psychotic disorder was a form of self-harm. In the context of their now strong alliance, she agreed to take the medicine. The medication intervention was an immediate success. Her supervisor’s coded messages went away, Molly was able to eat food again, she stopped receiving secret signs by way of the arrangement of items in the house, and her cat reemerged as a kindly pet. Over the next few months, Molly experienced conflict with the diagnosis, because she regarded having a psychotic disorder as a kind of social death sentence. This reaction was striking given the improvement in her social functioning.
The TFP therapist learned to see the signs of this conflict in her functioning. Anytime Molly seemed to decompensate, careful questioning would reveal that she had electively decided to stop her medication because she thought the diagnosis was wrong, she was “just borderline,” and/or she was gaining weight. He also transferred her into a supportive treatment and out of TFP. Support through text messaging and kind words of advice that she had long asked for, and treasured when given inadvertently, now became a mainstay of the treatment and clearly improved her functioning. With a little bit of coaching between sessions, she could avoid problems that would otherwise have festered. It was at this point that she was referred to an expert in psychotic disorders for further clarification and advice.
Patient’s Perspective
The first time I remember having thoughts that might be considered unusual is when I was a child, at around 9 years old. I remember being tormented by intrusive thoughts that I might poke my eye out or stab my brother with scissors. These thoughts were disturbing and terrifying. I confided in my mother about these thoughts; she told me they were “ridiculous.” Around that time, my family was under a lot of stress. I was generally anxious and tearful most of the time, with a range of somatic complaints such as stomachaches and headaches. These disturbing thoughts were dismissed as part of the experience of these stressors. [Alt]hough my primary care provider recommended I seek the support of a therapist, my parents never pursued this option.
As a teenager, I was, in some senses, well-adjusted. I excelled academically and was involved in sports and music. I was well liked and had a core group of close friends. However, I was interpersonally volatile and suspicious. I had frequent arguments with my friends, parents, and siblings. I had an unsettling feeling that I was being talked and conspired about. These thoughts were relatively innocuous—I believed my friends were plotting to exclude me from social gatherings or talking about my appearance. When I would get especially distressed or anxious, I would slam my fingers in drawers, and later claim it was an accident—this was never doubted as far as I know. I also experienced very high levels of anxiety, particularly centered around fears of my parents becoming sick or dying, that I was a “bad person” because of thoughts or impulses that I had, and that my worth was entirely intertwined with my academic achievement. My emotion dysregulation and suspiciousness appeared to be dismissed as developmentally appropriate, and we didn’t seek any professional input.
When I was 17, I finished high school [and] took a year off to travel. During this time, I became obsessed with my weight and with food. I developed a preoccupation with the thought that food would make me sick. I believed I was intolerant of anything taken by mouth, including, for some time, water and medications. I stopped eating and drinking, losing a dramatic amount of weight and requiring brief hospitalization for dehydration.
I entered a program that required me to regulate my food intake and maintain my weight to stay, but I remained suspicious so began purging everything I ate, either by vomiting, diuretics, or laxatives. For the next decade, I at certain times believed, when at a low weight, that the scale [was] wrong and people [were] staring at me and disgusted by me. For a time, I believed almost all food may be poisoned, and at that time, reached my lowest weight.
Throughout university, I completed a rigorous double degree successfully, volunteered and worked part-time, and secured highly sought-after postgraduate employment. These successes obscured a time of intense suffering. [Although] I had friends, they were pursuing romantic relationships, something I felt incapable of. I desired intimacy but was fearful and suspicious of anyone who showed interest. I began having panic attacks occasionally, which were at times uncued and at time[s] triggered by social situations. I was referred to a psychologist who diagnosed me with generalized anxiety disorder and took a cognitive-behavioral approach, but my disturbing thoughts and my relationship turmoil persisted. Many of my childhood friends disconnected from me because I was emotionally volatile. My psychologist began suggesting that I had “borderline traits.” I was self-harming frequently to elicit care and attention from my psychologist and as a coping mechanism. After an incident [in which] I became so enraged by my psychologist’s suggestion that I had [borderline personality disorder] that I crushed a water glass in my hand (breaking it unintentionally), my psychologist decided to end treatment. I eventually received an e-mail response saying that I required a higher level of care, but he said it was “unethical” to make a referral to another clinician because I could not be contained in private practice.
I felt betrayed and abandoned, but soon I found a psychologist who was comfortable working with [borderline personality disorder]. He was validating, consistent, reliable, and had appropriate boundaries. A condition of our treatment was that I consult with a psychiatrist, who diagnosed me with [borderline personality disorder] and prescribed a number of medications intended to stabilize my mood. He did not evaluate psychotic symptoms, but he provided me with a framework for stability. He made short inpatient stays available to me in place of self-harm and made communicating with him about self-harm and suicidal ideation a part of the treatment contract.
At this time, I decided to leave the country for graduate school. [Although] I was not stable, I began to believe that a change was all I needed. My roommate and I began a very intense friendship. I had never allowed myself to be so close to someone—I felt a little bit crazed by obsession.
This is when things started to fall apart. I was lonely again, so I clung to her desperately. Eventually, she moved out and told the dean that I was making her uncomfortable. What I heard is that the dean accused me of stalking. I was deeply humiliated and feared there m[ight] be legal repercussions. I felt I couldn’t show my face anywhere, and I became deeply suspicious of everyone, reading subtext in every statement, allowing every comment to reinforce my belief that I was defective, repulsive, bad. I didn’t go out. I didn’t attend class. The only thing I would do is walk for hours at night.
One night, I called the student crisis hotline. They immediately called an ambulance, and I was hospitalized involuntarily for a week. When I was discharged, I searched frantically for treatment. Eventually, the student health center told me I should voluntarily admit myself, and the social workers on the inpatient unit would facilitate my continued treatment. I believed that I would be on an inpatient unit for a week, but was not discharged until almost 8 weeks later, with a plan for further inpatient treatment at a private hospital in another state.
I was placed on a unit for “severe personality disorders.” The environment was chaotic. Many of the patients were extremely behaviorally dysregulated. There were constant alarms and crises. Claiming to be suicidal and suicide attempts were incentivized by greater attention from staff. I was judged to be high risk and placed on a one-to-one, which remained throughout my admission. I was suspicious of my psychiatrist, to whom I directed intense anger. I believed that he wanted to harm me and felt he retaliated against me when he took items away so that I wouldn’t hurt myself. I had distressing, intrusive thoughts about hurting myself. A consulting psychiatrist believed there was a mood component to my case and offered that I might have bipolar disorder. [Although] I was noted to be interpersonally paranoid, there was no suggestion of a psychotic disorder. During the next 3 months on an inpatient unit, my [medical record said] that my thoughts ha[d] a “bizarre and disturbing quality.” Yet, my primary diagnosis remained [borderline personality disorder], with no suggestion of comorbid psychotic disorders. There was speculation that there might be a trauma element to my presentation, yet I didn’t have the symptoms of [posttraumatic stress disorder]. Eventually, I was discharged to a residential treatment facility.
I suddenly had access to everything I dreamed of hurting myself with. I began viciously cutting myself with razor blades, often requiring stitches. At one point, I began to be convinced that the psychiatrist in charge wanted me to kill myself. I kept this a secret for some time, avoiding him and being angry and suspicious when he talked to me.
I was in and out of inpatient units 12 times over the next year, culminating in a course of ECT for “psychotic anxiety.” I eventually started to feel better and more secure, allowing myself to engage in a romantic relationship for the first time. I left to begin a new graduate program [and] was referred to my current therapist and psychiatrist [Dr. F.] as a severe [case of borderline personality disorder].
At my first meeting, I knew working with him made sense. When I told him about my symptoms, he said, “Suicide is boring. I want to know what else there is to you.” I don’t think I had ever felt that level of interest from anyone before; it seemed like I had kept other clinicians hanging on with threats. He also said that if I did decide to proceed, suicide and self-harm were off the table. If I did choose to self-harm, he wouldn’t see me until I had a doctor’s note saying that I was medically cleared. This was a pretty big deterrent, since by this time I was absolutely terrified of being hospitalized, having had several distressing experiences. I haven’t self-harmed in over 3 years. I just know that’s not something I do anymore.
This foundational agreement, combined with my therapist’s availability, has contained me over the past 4 years. I have remained out of the hospital. More importantly, I have finished a master’s degree and started a doctoral program, [in which] I am thriving, and [although] I still struggle with social isolation and loneliness, I have built long-lasting, trusting, and steady friendships. I trust myself not to self-destruct when faced with a setback.
We have come to understand many of my symptoms as related to an underlying psychotic disorder that waxes and wanes, particularly when I stop taking my medication, but is mostly stable now at a level that allows me to function normally. When it is bad, I even become suspicious of Dr. F, but usually he is my “safe” person. This diagnosis has been hard for me to accept because I had come to identify with [borderline personality disorder], and because I always had this feeling that I could “turn off” my mental illness if I chose to. I realized that managing this disorder would always need to be intentional. I need to take my meds [sic], I need to take care of myself, and I need routine and structure. Those are nonnegotiable, and it feels unfair that for other people these things come easily, or don’t need to come at all.
Psychotic Disorder Specialist’s Perspective
Molly experienced delusions that her psychiatrist wanted her to kill herself, that Internet influencers were sending her coded messages, and that her belongings were being moved. Early on in her illness, the delusions were “encapsulated” within her personality, logically constructed, and internally consistent. Thinking was not disordered, deterioration of personality and cognition was not prominent, and her general functioning was unimpaired. Such features are not characteristic of schizophrenia.
This case displayed many typical features of delusional disorder. The disorder is distinct from schizophrenia in terms of the natural course of the disease and function level (1). Rather than presenting with a first-episode psychotic break, onset may be insidious and not associated with appreciable decline in function. As Kraepelin (2) observed, patients remain coherent, sensible, and reasonable. Unlike in schizophrenia, hallucinations are not usually present and, if present, are not prominent. Delusional disorder is much less common than schizophrenia, with a lifetime prevalence 0.2% versus schizophrenia’s 1% (3). The disorder has been divided into five subtypes distinguished by the particular content of the delusion, with this case fitting into the persecutory subtype. Onset can be from late adolescence to old age (4).
That said, Molly’s self-referential mode of thinking and thought broadcasting had features in common with schizophrenia. Because clinicians seldom see these disorders, the diagnostic stability of delusional disorder is unclear; it can deteriorate to schizophrenia (5). Because patients normally lack insight into their delusions, resistance to receiving psychiatric treatment is almost always present. Typically, patients with delusional disorder reach psychiatric attention only when a crisis arises; for example, when their spouse is threatening to leave, or they have run-ins with the law. This case was unusual in that the patient was in treatment but for another mental illness, namely self-injurious behavior.
This patient was in treatment for many years before delusions were suspected. As is the case in most patients with delusional disorder, she had sufficient insight to keep her delusions concealed. In this case, an outside informant, especially a family member, can be very helpful in recognizing subtle changes in thinking or behavior. These might include a display of secretiveness or resentment. Sometimes a patient is less guarded with a family member and will confide the delusional belief.
Although delusional disorder is widely regarded as difficult to treat, this case was typical in that the delusions responded to antipsychotics (1). The problem is persuading the patient to accept treatment. Response rate is greater than 50% and, because lack of response may be caused by nonadherence to antipsychotic medication, the clinician should always explore the possibility of nonadherence in the absence of improvement. Treatment is indefinite, because the illness is generally chronic. If the patient has been symptom-free for a year and insists on discontinuation, the antipsychotic should be withdrawn only very gradually and under careful supervision.
Once delusions are less prominent, psychotherapy can begin in earnest. In this case, as in most people with delusional disorder who reach treatment, the patient had been immersed in a delusional narrative for many years. Memories of delusional thoughts and feeling that the world is a treacherous and malevolent place may persist even when the patient is no longer currently experiencing delusions. A long interval may be required before the patient is able to reshape their narrative. As long as the patient is benefitting from treatment, challenging their beliefs may not be productive. This case is a suitable example of how enormously helpful good psychiatric management with a skilled clinician can be.
What is one to make of the co-occurrence of personality disorder and delusional disorder in this patient? There is an excess of personality disorders in delusional disorder (6). Sometimes features and behavior attributed to personality resolve with the introduction of antipsychotic medication and aspects attributed to personality are better understood as features of the psychotic illness. In the present case, the interaction between personality and psychotic symptoms remained an open question.
Conclusions
This article presented three different perspectives—that of a personality disorder–oriented specialist psychiatrist, that of the patient, and that of a psychotic disorder expert. Together these perspectives illustrate the unique complexities of individual patients who often experience symptoms of multiple psychiatric disorders. This article reminds psychiatric professionals to maintain broadly good enough psychiatric management skills to diagnose significant co-occurring disorders. Borderline personality disorder and delusional disorder each separately impair therapeutic alliance building for patients in need of care. This case illustrated the necessity of stabilizing significant psychotic symptoms that interfere with the process of understanding that painful realities are normally experienced as an internal process, rather than as the product of relentlessly persecutory external agents. The paranoia Molly experienced resulted in her feeling that there was no escape from evil, both within herself and her environment. With willingness by all parties to see Molly as a unique person with two separate but serious problems, she was able to learn to manage reality and her inner life, enabling the potential for her to flourish in a life that solved her sense of being eradicable because of inherent badness.
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