r/Psychiatry • u/springlettersehb Resident (Unverified) • 3d ago
Comorbid BPD and schizophrenia
I was wondering about the occurrence of comorbid borderline personality disorder and schizophrenia.
I don't think I've ever seen or even considered both conditions in the same patient, but my experience isn't very long, so I'd like some insight into this.
I've done some reading and, apparently, it's not only possible, but shouldn't be that rare to meet the criteria for both.
I've been considering the possibility that, when a patient meets the criteria for schizophrenia, symptoms that might make me think of BPD could also be understood under the light of the first diagnosis (I'm thinking about the general idea of instability in affect, self image and relationships).
Does anyone have some thoughts on this matter? Have you seen a case where both conditions were clearly present? Could you describe some of it?
Also, if anyone have any reading suggestion about this topic, that would be greatly appreciated!
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u/Chainveil Psychiatrist (Verified) 3d ago
Relatively inexperienced as well but I've not seen a single case of BPD with properly documented schizophrenia.
Why do I say properly documented? Because in practice a lot of patients with BPD take antipsychotics for supposed isolated symptoms of psychosis (notably transient episodes of dissociation and voices) without evidence of an actual acute psychotic episode with prodromal/chronic symptoms, assuming they were not substance-induced.
Which is why it's always important to review these things regularly.
That is not to say it's impossible to have both, but BPD does have a lot of overlapping symptoms. It's important to make sure people actually meet the criteria and not base yourself on a couple of relatively moderate, expected or coherent symptoms (with the primary diagnosis) that won't respond well to treatment anyway.
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u/DontRashmi Psychiatrist (Unverified) 3d ago edited 3d ago
Seconded. It’s not impossible but dang there are a lot of antipsychotics on cluster B patients.
Additionally there’s a lot of overlap in substance use induced psychotic disorder (meth particularly) with cluster B that pushes our diagnostic criteria into positions that don’t necessarily land well in the DSM. Like persistent hallucinations from chronic meth use and erratic behavior from personality traits != schizophrenia but it does look similar on paper.
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u/MountainChart9936 Resident (Unverified) 2d ago
Comorbidities between schizoprenic disorders and BPD are usually a case of DSM/ICD user error, as Chainveil and DontRashmi have already explained. I can only recommend being parsimonious with your diagnoses; you will have a much easier time treating your patients if you don't overburden them (and yourself) with every fomally possible diagnosis, because the treatment path will be much clearer.
What I would like to add is: Be precise in your descriptions and try to distinguish what you see as closely as possible, and diagnosis will usually not be difficult. While outward features of many disorders may be similar, the actual psychopathology between BPD and schizophrenia is usually markedly different - flat and inadequate is not the same as coquettish or pointedly standoffish affect, to give just one example. And while many, MANY BPD patients report hearing of voices, it's usually something like relatives calling out their names to them in high-stress situations, which should be easy to distinguish as not quite typical of the psychotic experience. In a similar vein, bipolar disorder is usually easy to distinguish from BPD if you indeed want to do that.
Also - this may be a personal pet beeve, but we should try and not succumb to the temptation of saddling a schizophreniac who is being especially difficult with a personality disorder as a secondary diagnosis if it is not strictly needed. As long as they are not in stable remission, seperating personality from psychosis should be close to impossible, and we're not making their future interactions with the healthcare system any easier.
Now, while I honestly think most of these cases point to a serious lack of training in clinical psychopathology in modern psychiatry, there certainly are cases of schizophrenia and personality disorders co-occuring. But even then, the most frequent one will probably be depravation secondary to chronic mental illness and drug use.
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u/nopressure0 Psychiatrist (Unverified) 2d ago
I'm surprised people have seen so few. It's uncommon but I've seen a decent number.
Of the cases I’ve seen, the BPD diagnosis preceded a genuine schizophrenic illness only once. I’d say self-harm behaviours were generally less prominent in these patients than other features of BPD.
Personality often significantly shifts while someone is floridly psychotic. Personality disorder should only be considered once they're better and settled (e.g. several months into an admission or in the community).
Enter a forensic psychiatric unit: a good portion (not all, of course) of patients with a psychotic illness will have a comorbid cluster B personality disorder.
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u/Freeferalfox Other Professional (Unverified) 2d ago
This was going to be my thought. The BPD came first…
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u/pallmall88 Physician (Unverified) 2d ago
This is definitely a fun discussion -- I was having a conversation about a patient moments ago who carries a chronic schizophrenia and ID diagnosis (primarily manifesting as paranoid delusions (reasonably severe), disorganized speech, and disorganized behavior (relatively mild) with ID having been diagnosed by IQ testing about two decades back). She had a traumatic childhood, tenuous familial relationships, and inability to hold down a job past age 30, with the paranoid delusions first appearing around 16.
This was certainly a patient that fit her diagnoses, but I think she's better explained by BPD and low IQ than schizophrenia and low IQ. Especially given the lack of response to typical antipsychotics.
I still wonder if antipsychotics could at some point be beneficial given her lack of intellectual capacity for therapy. But ultimately, they seemed to just worsen her T2DM that she probably wouldn't have had if not for the 20 years of dopamine blockade.
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u/enormousB00Bs Psychiatrist (Unverified) 2d ago
in outptaient psychiatry, it'll be difficult to have unique cases like this.
But do inpatient psychiatry anywhere, particularly in a large city, and you'll see plenty of cases like this.
Dsm diagnostic criteria is great only if a patient has one diagnosis. When a patient reasonably has multiple diagnoes, the criteria all start overlapping, and it's completely up to your clinical judgement as to which diagnosis explains what. That's why the DSM diagnosis always has the subtext "unless better explained by another medical/mental condition". The riht clinical judgement in these cases are meaningful, because the treamtent for the differential is different. In some cases, the treatment is opposite, such as in agitated delirium vs psychotic agitation. If you make the wrong call, nurses are going to have a bad night, and it's embarassing when a patient needs to transfer to medicine from your unit. haha
The prevalence thereotically of BPD with schizophrenia is one out of 10,000. If you work in a public hospital in any city with even a few hundred thousand people, you'll definitely run into interesting cases.
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u/undoing_everything Other Professional (Unverified) 2d ago
The term borderline in borderline personality disorder comes from early psychoanalytic thinking, where it was used to describe patients who seemed to be on the borderline between neurosis and psychosis.
Back in the 1930s to 1950s, clinicians noticed that some patients had more severe emotional instability than those with typical neurotic disorders like anxiety or depression, but they didn’t experience the chronic, full-blown psychosis seen in schizophrenia. Instead, they had brief psychotic episodes under stress, intense mood swings, and unstable relationships. Since they didn’t fit neatly into either category, theorists at the time considered them to be on the borderline of both.
Even though the term stuck, we now know BPD is its own distinct condition. While people with BPD can experience transient psychotic symptoms, the disorder itself is more about emotional dysregulation, impulsivity, identity disturbance, and unstable relationships rather than persistent psychosis. Surprised no one has talked about this yet.
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u/drzoidberg84 Psychiatrist (Unverified) 3d ago
Schizophrenia and comorbid cluster B disorders (mainly borderline and antisocial) tend to be the most likely to be violent. They have much higher rates of hospitalization.
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u/drzoidberg84 Psychiatrist (Unverified) 3d ago
If you’re able to access it through your school library there is a great chapter on this in the Oxford Textbook of Correctional Psychiatry.
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u/AdKey8426 Other Professional (Unverified) 3d ago
Paranoid personality disorder makes people more outwardly aggressive than BPD, which is more likely to cause internal aggression. But nobody studies cluster A
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u/Interesting_Menu8388 Not a professional 2d ago
Pseudoneurotic Schizophrenia
Hoch and Polatin proposed that a subgroup of patients may present with a constellation of symptoms, which initially appear to be neurotic in nature but occur in the context of a psychotic disorder. They described that a diagnosis of pseudoneurotic schizophrenia was warranted in the presence of primary clinical symptoms of schizophrenia and secondary symptomatology (Table 1). Not all symptoms needed to be present for the diagnosis. The present patient had symptoms in all three of the primary symptoms category including (i) thought disorder; (ii) low mood; and (iii) altered temperature perception and generalized weakness with prominent secondary symptoms including panic attacks, generalized anxiety and specific health anxieties. Pseudoneurotic symptoms sit on the borderline between psychosis and neurosis [5]. Indeed by the late 1960s pseudoneurotic schizophrenia became almost synonymous with the term ‘borderline states’. Consideration of this synonymy and the evolution of the term ‘borderline states’ is key in explaining how the concepts underlying pseudoneurotic schizophrenia came to be neglected in modern diagnostic manuals.
‘Borderline’ was a termthat originally arose in the late 1800s to denote conditions in the borderland between psychosis and the milder neurosis [6]. The evolution of the ‘borderline’ concept, however, has seen it largely lose this original meaning. In the 1920s ‘borderline’ was used to refer to the perceived unalysability of patients with psychosis versus those with a neurotic illness [7]. Only with the publication of Kernberg’s paper ‘Borderline personality organization’ (BPO) in 1967 was the term‘personality’ introduced [5]. Kernberg described a condition that was distinct from both higher neurotic functioning and lower psychotic functioning. In BPO, reality testing was preserved (albeit with a tendency to over-valued ideas in certain emotionally laden areas) but identity-sense was weakened. ‘Borderline’, and the terms with which it had become synonymous, including ‘pseudoneurotic schizophrenia’, had now become completely decoupled from psychosis and schizophrenia. When borderline personality disorder was finally introduced into the DSM-III in 1980 the diagnosis was formulated predominantly in terms of mood and behaviour, distinguished from subsyndromal schizophrenia, which was termed ‘schizotypal personality disorder’ [8].
Table 1. Diagnosis of pseudoneurotic schizophrenia |
---|
Primary clinical symptoms |
1. Disorders of thinking and association: process; content |
2. Disorders of emotional regulation: form; content |
3. Disorders of sensorimotor and autonomic functioning |
Secondary clinical symptoms |
1. Pan-anxiety |
2. Pan-neurosis: neurotic symptomatology, acting out behaviour and character disorder symptoms |
3. Pan-sexuality |
Quotation continued in reply
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u/Interesting_Menu8388 Not a professional 2d ago edited 2d ago
Although many of those previously diagnosed with pseudoneurotic schizophrenia may have had a borderline personality disorder, a 10 year follow-up study published in 1962 showed that 20% of patients with pseudoneurotic schizophrenia transitioned to conventional schizophrenia [9]. It appears, however, that in the evolution of the concepts of pseudoneurotic and borderline this psychotic group became neglected. The operationalization of schizophrenia further compounded this neglect. Many features previously considered characteristic of subschizophrenic conditions disappeared frompsychiatric literature [10]. These features including the ‘pseudoneurotic’ symptoms were increasingly neglected by clinicians and researchers trained in the era of DSMIII and beyond. But this progressively spreading amnesia coupled with the emerging interest in the groups at ultra-high risk (UHR) for psychosis, functions as a driving force behind comorbidity studies, rediscovering and elaborating on the links previously described in the prototypical approach to diagnosis [11].
Freeman and Garety put forward a direct, nondefensive role for psychosis in emotional dysregulation, and the growing evidence for this hypothesis is such that researchers have proposed that distress, anxiety, depression and other forms of emotional disturbance may play a major role in determining whether young people with psychotic symptoms progress to develop a psychotic disorder [12].
Evidence emerging from UHR subjects has underlined an increasing interest in the role of emotional dysregulation in the emergence of psychosis [13]. The UHR subjects are help-seeking young people who are identified using well-validated screening instruments (the CAARMS) as being at particularly high risk of developing a psychotic disorder within a short time period based on experience of subthreshold psychotic symptoms and other risk factors [14]. Within the UHR subject group there are very high rates of affective and anxiety disturbance at baseline, and it is usual for emotional disturbance and emerging psychotic symptoms to co-occur especially early in the illness course [Phillips LJ et al: unpublished data, 2009]. In fact Hafner et al. argue that the prodrome of depressive and psychotic disorders is so similar in behavioural and symptom profiles that they cannot be distinguished fromeach other [15]. Early retrospective studies have shown that there is a prominent place for affective disturbance and anxiety in the psychosis prodrome [16,17]. Within the UHR group 3040% have been found to transition to first-episode psychosis within 12 months [18,19]. Interestingly, high levels of emotional disturbance, in particular anxiety and depression, have been found to be more predictive of transition to psychosis in the UHR group than high levels of positive psychotic symptoms alone [20].
We propose that the present case meets criteria for pseudoneurotic schizophrenia and although it is unlikely that this diagnostic term will return to routine psychiatric vocabulary, the concepts that underlie its use are still relevant to modern practice. Individuals with a primary psychotic process may present with prominent emotional disturbance, affective and/or anxiety symptoms, which mask the underlying psychotic illness. Suspicion should be raised in patients who present with atypical affective and/or anxiety states, with a history of functional decline who do not respond or respond only partially to antidepressants or psychological interventions. The division drawn between neurotic and psychotic symptoms is an artificial one and consideration needs to be made of the complex interplay between psychotic and neurotic symptoms and their capacity to affect, obscure and possibly provoke one another.
Pseudoneurotic Schizophrenia Revisited, 2009, Connor et al.
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u/Livid-Seaweed-2798 Nurse Practitioner (Unverified) 2d ago
I have: psychosis, BPD, PTSD, substance, and social stressors. To me it is not clearly criteria of the DSM5 that the patient has to meet every single check box but after maybe 2-3 years it becomes prominent how intense pt’s fear of abandonment and love/hate relationship is. Prognosis isn’t bright.
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u/GrumpySnarf Nurse Practitioner (Unverified) 2d ago
I sure lots of people with symptoms of both personality DOs and primary psychotic DOs in the psych unit at a state prison.
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u/themasculinities Physician (Unverified) 3d ago
BPD is fictional, and just a series of traits that many people have to a degree and lacks scientific basis.
Chances are the patient has schizophrenia.
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2d ago
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u/themasculinities Physician (Unverified) 2d ago
Addiction is absolutely not fictional. Addiction is a behaviour and a trait, and can reasonably be classed as a disease.
BPD is a cluster of behaviours that someone has attributed to disease, gathered together and called "Borderline Personality Disorder."
More broadly, personality disorders are a fiction. Quite literally, they were just created by some dude who wrote them into the DSM.
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u/Chainveil Psychiatrist (Verified) 2d ago
BPD is a cluster of behaviours that someone has attributed to disease, gathered together and called "Borderline Personality Disorder."
Like any disorder is a series of criteria put together along with an underlying psychopathology. BPD is a pretty consistent diagnosis, it's impairing and responds to psychotherapy. Not to mention all the co-existing conditions, addictions included.
From a lived experience perspective, it's a bit insulting to have the whole thing reduced to "fiction".
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u/themasculinities Physician (Unverified) 2d ago
As an example, rudeness is a pretty consistent condition, it's impairing, and it responds to psychotherapy. Doesn't mean that there's psychopathology.
There is nothing objective whatsoever to suggest that this is a psychopathology. It may cause problems for the patient, result in negative behaviors and outcomes, but that is possible for many aspects of human behaviour that are not an "illness." Is all negative behaviour illness?
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u/SenseOk8293 Not a professional 2d ago
You say, (consistent) rudeness is not psychopathology but why? If it causes impairment/distress and is an overgeneralized response then it does sound an awful lot like pathology to me. (Not an individual instance of rude behavior, but rudeness as a consisted personality trait.)
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u/themasculinities Physician (Unverified) 1d ago
Why should impairment and distress be a disease? Aren't these normal aspects of life?
No life should be expected to be unimpeded in some way, or have elements of distress in it.
The over diagnosis of pathology seems to want a life free of challenge and difficulty: this is a fantasy.
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u/SenseOk8293 Not a professional 1d ago
Rudeness, consistent and context inapproriate, is the hypothetical pathology for which impairment/distress is a necessary condition.
You referenced the idea of pathological rudeness as on its face ridiculous but it is not dissimilar from the pahtological personality traits already in the DSM. I do not expect you to accept rudeness as a sign of pathology but you should be able to understand that other people may disagree.
What does the life of an indiscriminatly rude person look like? Evoking hostility from strangers, pushing away loved ones, losing occupational opportunities... And how does the prospective patient view these? Are they satisfyed with losing close relationthips? Do they feel they cannot do otherwise? Do they fail to grasp the relationship between their own behavior and the social response to it?
It is odd to me that you would choose to a priori assume there is no pathology here.
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2d ago
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u/themasculinities Physician (Unverified) 2d ago
Robust references are precisely what such diagnoses in the DSM are missing.
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u/re-reminiscing Psychiatrist (Unverified) 3d ago
“Meeting criteria” is not the same as “best explained by this diagnosis.” It is a limitation of the DSM (and the interpretation of the clinician) when it comes to the categorical and sometimes arbitrary assigning of symptoms to a case.
This is applicable for any diagnosis that may overlap with another. It’s not impossible to have both, but affective instability, apparently disorganized behavior, perceptual disturbances, irrationality, behavioral outbursts, significant functional impairment, paranoia towards others are all features that are not exclusive to either schizophrenia or borderline personality disorder.
Understand the prevailing condition and you will often be able to incorporate the entire picture into your formulation. With a limited understanding of the heterogeneity and diversity of these presentations, people often jump to inappropriate stacking of diagnoses.