Borderline personality disorder and early psychosis: a narrative review

Abstract

Background
The purpose of the present review was to summarize the main literature contribution on the relationship between borderline personality disorder (BPD) and early psychosis. While retracing the historical path of the term “borderline”, specific attention was paid to psychotic and psychotic-like symptoms in BPD. Its relationship with At Risk Mental State was evaluated, as well.

Methods
This search was conducted on PUBMED/MEDLINE and PsycInfo, looking for “Borderline personality disorder, First Episode Psychosis, Early Psychosis, Ultra-High Risk AND/OR Clinical High Risk” for psychosis.

Results
Eight pertinent papers were identified on this topic. Their main findings were then discussed. The term “borderline” has undergone different changes in meaning and use, despite always referring to states considered on the fence between neurosis and psychosis. However, considering the history of psychopathology and its relationship with diagnostic manuals, little attention has been given to its psychotic features. Being those symptoms highly burdensome, this neglect has often led to misdiagnosis and under-treatment.

Conclusions
Psychotic symptoms in BPD can be severe and distressing. Nonetheless they can be easily neglected, and when found they challenge clinicians in defining a differential diagnosis to distinguish between BPD and Psychosis Spectrum Disorders. Given specific needs and interventions for these different conditions, a dimensional, rather than categorical, approach should be considered, as well as specific care pathways and monitoring should be advised.

Full text

Biancalanietal. Annals of General Psychiatry (2023) 22:44
https://doi.org/10.1186/s12991-023-00475-w
REVIEW
Borderline personality disorder andearly
psychosis: anarrative review
Arianna Biancalani1, Lorenzo Pelizza1* and Marco Menchetti1
Abstract
Background The purpose of the present review was to summarize the main literature contribution on the relation-
ship between borderline personality disorder (BPD) and early psychosis. While retracing the historical path of the term
“borderline”, specific attention was paid to psychotic and psychotic-like symptoms in BPD. Its relationship with At Risk
Mental State was evaluated, as well.
Methods This search was conducted on PUBMED/MEDLINE and PsycInfo, looking for “Borderline personality disor-
der, First Episode Psychosis, Early Psychosis, Ultra-High Risk AND/OR Clinical High Risk” for psychosis.
Results Eight pertinent papers were identified on this topic. Their main findings were then discussed. The term
“borderline” has undergone different changes in meaning and use, despite always referring to states considered
on the fence between neurosis and psychosis. However, considering the history of psychopathology and its relation-
ship with diagnostic manuals, little attention has been given to its psychotic features. Being those symptoms highly
burdensome, this neglect has often led to misdiagnosis and under-treatment.
Conclusions Psychotic symptoms in BPD can be severe and distressing. Nonetheless they can be easily neglected,
and when found they challenge clinicians in defining a differential diagnosis to distinguish between BPD and Psycho-
sis Spectrum Disorders. Given specific needs and interventions for these different conditions, a dimensional, rather
than categorical, approach should be considered, as well as specific care pathways and monitoring should be advised.
Keywords Borderline personality disorder, First episode psychosis, Schizophrenia spectrum disorder, Early psychosis,
Early intervention, Early detection, Psychopathology, Diagnosis
History oftheconcept of“Borderline” disorder
For over a century, since it was first used as a psycho-
analytic concept by Stern in 1938 [1], the term “border-
line” has experienced a continuous change in use and
understanding. In this respect, Stern originally used the
word to describe a cluster of patients who were not likely
to respond well to psychoanalytic therapy and that he
believed was somehow different both from schizophrenia
and neuroses [2]. In 1952, Knight [3] was the first to
define a “borderline state”, which was conceptually very
close to schizophrenia, but also had neurotic features
and identified a temporary “ego state” that the patients
could enter and exit, thus being affected only for a given
time. is idea interestingly resembles a previous one
by Zilboorg [4], a psychoanalyst who at first described
patients with “ambulatory schizophrenia”, in which it was
reported one of the two main roots of the “borderline”
concept: i.e., its psychotic features (shared with schizo-
phrenic disorders).
It was in 1967, then, that the term predominantly
ceased to identify a mild form of schizophrenia, when
Kernberg [5] borrowed it to describe one of the possible
levels of personality organizations (namely, “psychotic”,
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Annals of General Psychiatry
*Correspondence:
Lorenzo Pelizza
lorenzo.pelizza@unibo.it
1 Department of Biomedical and Neuromotor Sciences, Alma Mater
Studiorum, Università Di Bologna, Via Zamboni 33, 40106 Bologna, BO,
Italy
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Biancalanietal. Annals of General Psychiatry (2023) 22:44
“neurotic” and “borderline”). Quite differently from what
Stern had stated, Kernberg used it to qualify a disorder
not likely to change during time and closer to our under-
standing, as well [6].
In the first edition of “A Glossary of Psychoanalytic
terms and Concepts” [7], Moore and Fine defined “bor-
derline” as “a descriptive term referring to a group of
conditions which manifest both neurotic and psychotic
phenomena without fitting unequivocally into either
diagnostic category”. It is probably because of this indefi-
niteness that, despite the many attempts to classify it, it
has always remained vague and hardly harmonized in the
psychiatric field.
After a long journey through different schools of
thought, where a “Borderline Syndrome” [8] and a “Bor-
derline Disorder” [9] were described, in 1979 Spitzer
and Endicott theorized the belonging of the “border-
line patient” (as it was commonly perceived) either to a
Schizotypal Personality Disorder or to an Unstable Per-
sonality Disorder [10]. Indeed, even if the term “border-
line” had been misused for decades, there was no official
description in any previous diagnostic manual. ese two
terms referred to the two main uses of the word “border-
line”, identifying, on one hand, a group of patients more
closely related to schizophrenia, and a group of patients
predominantly characterized by “unstable affect, inter-
personal relationships, job functioning, and sense of
identity” [11]. Later, the task force who worked at the
third edition of the Diagnostic and Statistical Manual of
mental disorders (DSM-III), replaced the term “unstable
personality disorder” with “borderline personality disor-
der”, which was clinically much more usual and wasn’t
subject to misinterpretation on the actual stability of
personality disorders. Despite Spitzer and Endicott [10]
remarked how not mutually exclusive the two diagnoses
were, but dimensionally likely to be integrated, psychotic-
like features formally ceased to be associated with Bor-
derline Personality Disorder (BPD) (for a brief summary
of the history of BPD concept, see Table1) [12–15].
Dening psychotic symptoms inBPD
According to the fifth edition of the Diagnostic and Sta-
tistical Manual of mental disorders (DSM-5), BPD is
described by nine different criteria [16]. Notably, the
ninth point mentions “transient, stress-related paranoid
ideation or severe dissociative symptoms”, which some-
how recalls the historical ambivalence of BPD psycho-
pathology, considered on the fence between psychotic
and neurotic symptoms [17]. However, psychotic fea-
tures have not always been this relevant. It was only in
1994, when the DSM-IV was published, that BPD was
acknowledged again a reference to potential psychotic
experiences, after being strictly set apart from the schizo-
typal personality disorder in DSM-III [18].
For the first time in the history of e International
Classification of Diseases and Related Health Problems,
the 11th revision (ICD-11) includes a description of
psychotic-like symptoms “in situations of high affective
arousal”, when identifying a borderline pattern for per-
sonality disorders [19].
Even if what should or should not be included in the
description of BPD could seem only a theoretical issue,
it is evident how the accuracy of definitions and crite-
ria can affect the quality of diagnosis [20]. Also, even if
the debate around the appropriateness of considering
psychotic aspects a core diagnostic feature is still open,
it is unarguable that these symptoms can be serious for
patients who experience them [21]. What is needed, then,
is an effective effort to address patients’ needs and to
improve specific treatments, accordingly.
Evaluating theburden: thedata sofar
Psychotic symptoms in BPD are often underrated and
considered temporary or mainly associated with stress
[17]. Yet, going deeper into the study of their phenom-
enology and comparing them to the “proper” psychotic
features of schizophrenia, similarities and differences
depict a very specific pattern of characteristics.
On one hand, psychotic symptoms in BPD seem to be
phenomenologically very similar to those experienced
by patients with psychosis spectrum disorders [17, 22].
As a direct consequence, differential diagnosis can be a
challenge, thus leading to potential fluctuations in diag-
nosis and to mistreatment [23]. Also, despite the usual
underestimation of psychotic experience in BPD, these
symptoms can cause an extremely high burden. Among
the most distressing psychotic symptoms in BPD, audi-
tory verbal hallucinations (AVH) play a central role [21]
and up to 50% of patients report them [24]. Indeed, some
of the most worrying data suggest that AVH in BPD
are associated with increased suicidal ideation, suicide
attempts and hospitalizations [18, 22, 25]. If compared
to those in schizophrenia, AVH in BPD have not been
found to differ in frequency, duration, location, loudness,
or conviction [17]. Coherently, misdiagnosis mostly hap-
pens when AVH differ from the common understanding
of the diagnostic manuals and either meet criteria for
“First Rank Symptoms” (FRS), and are perceived as com-
ing from outside the head or when of lasting duration
[20].
On the other hand, psychotic symptoms differ in some
ways between BPD and Psychosis Spectrum Disorders.
First, delusions, conceptual disorganization and nega-
tive symptoms seem not to be as common as in schizo-
phrenia [17]. When describing AVH, patients with BPD
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Biancalanietal. Annals of General Psychiatry (2023) 22:44
Table 1 Brief summary of the history of BPD conceptualizations
BPD borderline personality disorder
Author(s) Quotes
Bleuler (1911) [12] “If we examine some individuals more closely, we often tend to suspect the presence of simple schizophrenia
without, however, being able to make a definite diagnosis at the given time; but very often, after days or years,
our suspicions can be confirmed. Thus, there is no doubt that many simple schizophrenics are at large whose
symptoms are not sufficiently pronounced to permit the recognition of mental disorder. If one observes the rela-
tives of our patients, one often finds in them peculiarities which are qualitatively identical with those of the patients
themselves, so that the disease appears to be only a quantitative increase of the anomalies seen in the parents
and siblings. Such mild cases are often considered to be “nervous” or “degenerated” individuals, etc. But if we fol-
low the anamnesis of those who are admitted to the hospital in later years because of an exacerbation of their
difficulties, a criminal charge, a pathological drinking bout or some such episode, we can usually find through-
out the entire past history of the individual mildly pathological symptoms which in the light of their recent illness
unquestionably have to be considered as schizophrenic. There is also a latent schizophrenia, and I am convinced
that this is the most frequent form, although admittedly these people hardly ever come for treatment. It is not nec-
essary to give a detailed description of the various manifestations of latent schizophrenia. In this form, we can see
in mice all the symptoms and all the combinations of symptoms which are present in the manifest types of the dis-
ease. Irritable, odd, moody, withdrawn or exaggeratedly punctual people arouse, among other things, the suspicion
of being schizophrenic. Often one discovers a concealed catatonic or paranoid symptom and exacerbations occur-
ring in later life demonstrate that every form of this disease may take a latent course”
Freud (1913) [13] “Often enough, when one sees a case of neurosis with hysterical or obsessional symptoms, mild in character
and of short duration, a doubt which must not be overlooked arises as to whether the case may not be one
of insipient dementia praecox and may not sooner or later develop well-marked signs of this disease”
Stern (1938) [14] “It is well known that a large group of patients fit frankly neither into the psychotic nor into the psychoneurotic
group, and that this border line group of patients is extremely difficult to handle effectively by any psychotherapeu-
tic method”
Zilboorg
(1941) [4]“The less advanced cases have been noted, but not seriously considered. When of recent years such cases engaged
the attention of the clinician, they were usually approached with the euphemistic labels of borderline cases, incipi-
ent schizophrenias, schizoid personalities, mixed manic-depressive psychoses, schizoid manics or psychopathic
personalities”
Hoch and Polatin
(1949) [15]“Some psychiatrists concede that the clinical and psychodynamic structure of these cases differs from the neuroses
–although retaining a great deal of resemblance to the neurotic disturbances–and call them "borderline cases. …
Again, others are struck by the similarity of the mental changes and personality structure to schizophrenia and will
diagnose them as schizophrenics. The writers would like to emphasize that this group of patients is not small”
Knight (1953) [3] “Patients with borderline states were falling apart on the couch”
Kernberg (1967) [5] “The ego pathology differs from that found in the neuroses and the less severe characterological illnesses
on the one hand, and the psychoses on the other. These patients must be considered to occupy a borderline
area between neurosis and psychosis. The term borderline personality organization, rather than “borderline states”
or other terms, more accurately describes these patients who do have a specific, stable, pathological personality
organization; their personality organization is not a transitory state fluctuating between neurosis and psychosis”
Moore and Fine (1968) [7] “A descriptive term referring to a group of conditions which manifest both neurotic and psychotic phenomena
without fitting unequivocally into either diagnostic category”
Grinker and co-workers (1968) [8] “This book contains the first reported results of a lengthy research program on hospitalized borderline patients
whose ego-functions were studied through multiple observations on their daily behaviors. In general, the informal
diagnostic term of borderline as well as several synonyms in our nosological classification has long been used with-
out standard definition as a convenient term with which to label cases of clinical unclarity. In this first systematic
investigation of the phenomena clinically observed for at least several decades as borderline, we have attempted
to understand what the term really denotes, define its characteristics, and determine whether it encompasses
subgroups or categories”
Gunderson and Singer (1975) [9] “This review of the descriptive literature on borderline patients indicates that accounts of such patients vary
depending upon who is describing them, in what context, how the samples are selected, and what data are
collected. The authors identify six features that provide a rational means for diagnosing borderline patients dur-
ing an initial interview: the presence of intense affect, usually depressive or hostile; a history of impulsive behavior;
a certain social adaptiveness; brief psychotic experiences; loose thinking in unstructured situations; and relation-
ships that vacillate between transient superficiality and intense dependency. Reliable identification of these
patients will permit better treatment planning and clinical research”
Spitzer and co-workers (1979) [11] “Although there is a large psychiatric literature on various "borderline" conditions, there has been no agreement
as to the definition of the concept. A review of the literature reviewed two
major uses of the term: Borderline Schizophrenia and Borderline Personality. Two item sets were developed to pro-
vide diagnostic criteria for the two concepts. High sensitivity and specificity were demonstrated for both item sets
using data describing 808 borderline and 808 control patients. These criteria will be used in the forthcoming DSM-III
classification for the categories of Borderline Personality Disorder and Schizotypal Personality Disorder”
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Biancalanietal. Annals of General Psychiatry (2023) 22:44
refer a greater distress and negativity in content, yet they
seem to be able to manage them better than patients
with schizophrenia can, where commentary voices are
also more frequent [17]. Given that AVH usually appear
earlier in BPD (mean age at onset = 16 years) [22] and
that these patients show better resistance, early diagno-
sis becomes fundamental in preventing the worsening of
the symptoms and in aiming at the best possible quality
of life.
Interestingly, a recent study [22] compared psychotic
symptoms in adolescents with a full-criteria diagnosis of
BPD to those experienced by subthreshold BPD patients.
e main differences, concerning psychotic symptoms,
psychoticism and occupancy, were observed between the
full-threshold group and the subthreshold group. Despite
the awareness that psychotic symptoms are always a risk
factor for worse functioning, regardless of the diagnosis,
this finding suggests that a diagnosis of BPD should be a
hint for careful management and monitoring.
After defining the significance of psychotic symptoms
in BPD, questions around treatment and management
arise. ere are many reasons why there is a high need for
studies to assess the benefit of psychotherapy and antip-
sychotics in these specific cases [22]. One of the most
relevant is the understanding that neurocognitive impair-
ment is known to be greater in BPD with psychotic fea-
tures [26]. One of the hypotheses is that such impairment
can compromise mentalization, which consequently
makes social cognition weaker and psychotic symptoms
(starting with paranoid phenomena) more likely to arise.
e use of antipsychotic drugs, which a recent review
[27] reported to be effective in these patients, should also
be furtherly discussed. As analyzed in a review by Beat-
son [20], the most studied antipsychotics for AVH in
BPD are olanzapine (2.5–10mg daily), aripiprazole (2.5–
10 mg daily) and quetiapine (50–150 mg daily). Addi-
tional results about the efficacy of aripiprazole compared
to placebo on AVH in young patients (aged 15 to 25years
old) are awaited soon, since a RCT on the topic is on its
way to be published [28].
BPD inat‑risk mental states andrst‑episode
psychoses
Given the challenge of differentiating BPD with psychotic
features from psychosis spectrum disorders, it is evident
that this becomes even more difficult when subtle, sub-
threshold psychotic symptoms are involved (Table 2).
Indeed, since transient psychotic symptoms can be pre-
sent in both BPD and early psychosis, there is a signifi-
cant overlap between “At-Risk Mental States” (ARMS)
and BPD spectrum psychopathology with attenuated
psychotic features at presentation [23].
Starting from this background, the aim of this narra-
tive review was to examine the main findings on BDP in
patients with early psychosis reported in the literature to
date.
Methodology
e search was conducted on MEDLINE/PubMed and
psycInfo, looking for “Borderline personality disorder,
First Episode Psychosis, Early Psychosis, Ultra-High Risk
AND/OR Clinical High Risk” for psychosis. We specifi-
cally analyzed papers written in English and published by
May 31, 2023. We found 8 pertinent papers on this topic.
eir main findings were reported and discussed (see
Table2 for details) [29–34].
Results
Clinical similarity on such psychotic features can be pos-
sibly explained going deeper into the study of psychopa-
thology. According to a study by Zandersen and Parnas
[35], most patients with BPD (considering different stages
of illness) meet criteria for a schizophrenia spectrum dis-
order (which includes Schizotypal Personality Disorder).
is observation gives space to different thoughts. First,
as it is known from a historical perspective, the choice to
differentiate BPD from SPD has long been debated, since
many patients often meet both criteria. All things consid-
ered, it is logical to assume that BPD as a concept ends
up being over-inclusive [36]. is comes as a direct con-
sequence of a methodological shift, which comprises the
use of an atheoretical diagnostic manual, based on behav-
iors rather than personality structure and prototypes
[35]. In addition, time should be taken to reflect upon
the psychopathological concept of BPD and consider a
step “back” to a theoretical understanding of the disor-
der, which was originally very close to schizophrenia.
Specifically, there are some key BPD features, like “iden-
tity disturbance” and “feeling of emptiness”, which might
resemble other symptoms, nonetheless belonging to
the Schizophrenia Spectrum Disorders [35], like the so-
called “disorders of the self”. Given the similarity, it would
be helpful to build back awareness around the meaning
DSM criteria have on a “narrative level” [35] and how
deeply these concepts can be explored on a “core” psy-
chopathological level. Differential diagnosis would then
be easier. Also, this would allow the acknowledgment of
those highly severe cases of BPD, who share a common
psychopathological ground with schizophrenia. Interest-
ingly, some effort has been made to determine whether
different subgroups of BPD could explain its heteroge-
neity. Smits and co-workers [37], for instance, identified
three clusters of BPD patients sharing common charac-
teristics. Among these, a schizotypal/paranoid type was
described as very close to SPD, with introjective and
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psychotic-like features, which inevitably posed questions
around its risk for psychosis. is subgroup was not as
represented as the Core BPD and the Extravert/External-
izing subtypes in the study, yet seemed to be more likely
to present late at mental health services, thus being more
vulnerable to negative outcomes.
So far, when examining ARMS, no predictive mean-
ing towards transition to psychosis has been found
in those patients who presented BPD symptoms [33].
Nonetheless, the severity of BPD psychopathology hasn’t
been associated either with clinical higher or lower risk
for psychosis, thus suggesting how every patient with
BPD having attenuated psychotic symptoms and/or
meeting cognitive-perceptive basic symptoms criteria
(i.e., COGDIS and COPER) should be monitored, regard-
less of the scores [31, 33] (see also Table2, for details on
main empirical findings about BPD psychopathology in
early psychosis). en, this is even more important, since
Table 2 Main empirical findings on BPD psychopathology in patients with early psychosis
BPD Borderline Personality Disorder
Gleeson (2011) [29] Treating co-occurring first-episode psychosis and borderline personality: a pilot randomized controlled trial
“Results: The results showed that it was feasible to recruit and assess a high risk and complex group of patients who were
agreeable to study participation. Specialist first-episode treatment plus specialist early intervention for borderline personal-
ity was an acceptable and safe treatment.” (Gleeson et al. 2012)
Schultze-Lutter (2012) [30] Personality disorders and accentuations in at-risk persons with and without conversion to first-episode psychosis: personal-
ity disorders and psychosis risk
“Conclusions: Unexpectedly, schizotypal PD was infrequent and did not predict conversion. Conversion was best predicted
by schizoid PA, indicating more severe, persistent social deficits already at baseline in later converters. This corresponds
to premorbid social deficits reported for genetic high-risk children and low social functioning in at-risk patients later
converting to psychosis. Further, PDs occurred frequently in at-risk patients irrespective of conversion. As psychopathology
and personality relate closely to one another, this result highlights that, beyond the current narrow focus on schizotypal PD,
personality-related factors should be considered more widely in the prevention of psychosis.” (Schultze-Lutter et al. 2012)
Ryan (2017) [31]Borderline personality pathology in young people at ultra-high risk of developing a psychotic disorder: borderline personal-
ity pathology
“Conclusions: Many UHR patients present with concurrent borderline personality features. The psychotic experiences
reported by UHR patients with borderline personality features were not limited to paranoid ideation, supporting the idea
that borderline personality disorder may include a wider range of psychotic symptoms than previously thought. It is further
possible that the psychotic symptoms experienced in this group could also be indicative of an emerging psychotic disor-
der.” (Ryan et al. 2017)
Francey (2018) [32] Does co-occurring borderline personality disorder influence acute phase treatment for first-episode psychosis?
“Conclusion: Young people with co-occurring clinician-rated BPD and FEP experienced greater difficulty accessing standard
care for FEP and received relatively different treatment, including different pharmacotherapy, compared with those FEP
patients without BPD. There is a need to develop new clinical guidelines and effective treatments for this specific subgroup
with early psychosis and co-occurring BPD that take into account interpersonal and "premorbid" aspects of their present-
ing problems.” (Francey et al. 2018)
Paust (2019) [33] Borderline personality pathology in an at risk mental state sample
“Results: We found a significant correlation between borderline symptomatology and positive symptoms assessed
by the structured interview for prodromal symptoms. There were no associations between basic symptoms for psychosis
and borderline symptoms. In addition, there was no influence of borderline symptomatology on the rate of transition
into a manifest schizophrenic disease. Summary: In conclusion, borderline personality disorder should not be an exclu-
sion criterion for the screening for psychosis or for an early intervention treatment. On the other hand, not every patient
with borderline personality disorder, (especially those not suffering from hallucinations, unusual thought content, or perse-
cutory ideas) should automatically be screened for the risk of developing a psychotic disorder.” (Paust et al. 2019)
Carrasco (2021) [26] Persistent psychotic symptoms and neurocognitive deficits in borderline
personality disorder
“Neurocognitive impairment and its association with psychotic symptoms in BPD suggest that a substrate of impaired
social cognition underlies emotional dysregulation and impulsive behaviors in these patients. In other words, the greater
the social cognitive deficit, the higher is the possibility of primitive and paranoid phenomena, such as auditory hallucina-
tions or delusional explanations. This probably associates with inability for mentalization in these patients, and hence,
the need of specific psychotherapeutic interventions different of non-psychotic BPD.” (Carrasco et al. 2021)
Hayward (2021) [21] A cross-sectional study of auditory verbal hallucinations experienced by people with a diagnosis of borderline personality
disorder
“Conclusion: The findings suggest that AVH is a legitimate and distressing symptom of BPD and a treatment priority
for some patients. The relative independence of AVHs from other BPD symptoms and emotional states suggests that psy-
chological treatment may need to be targeted specifically at the symptom of AVHs. This treatment could be adapted
from cognitive behaviour therapy, the psychological intervention that is recommended for the treatment of AVHs
in the context of psychosis.” (Hayward et al. 2022)
Schandrin (2022) [34] Co-occurring first-episode psychosis and borderline personality pathology in an early intervention for psychosis cohort
“Conclusion: BPP is a common occurrence in psychotic disorders and is associated with more severe hallucinations
and depression with higher risks of self-harm. Specific interventions need to be developed.” (Schandrin et al. 2022)
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it is known that, while keeping in mind that not all peo-
ple with BPD need to be screened for psychosis, their co-
occurrence results in a worse functioning and response
to treatment [38]. Indeed, a possibility of co-occurring
diagnoses of BPD and schizophrenia spectrum disorder
may also occur. In this respect, Bahorik and Eack [38]
reported that at 1-year follow-up, patients with schizo-
phrenia and comorbid BPD showed significantly less
improvement in psychiatric symptomatology (particu-
larly hostility and suspiciousness), as well as global func-
tioning, and were re-hospitalized at significantly higher
rates than individuals without BPD. e authors sug-
gested that the co-occurrence of schizophrenia and BPD
was not infrequent and that BPD had a significant nega-
tive longitudinal impact on the course and outcome of
subjects with schizophrenia.
When it comes to analyzing the impact of BPD on First
Episode Psychosis (FEP), recent findings suggest how the
overlap of the two disorders can lead to an increased risk
for depression and self-harm [34]. Surprisingly, despite a
higher severity, this combination is not associated with a
major number of hospitalizations. One possible explana-
tion is that patients with BPD may undergo a substantial
under-treatment, probably due to a common underesti-
mation of their symptoms.
Considering that, according to Francey and colleagues
[32], the subgroup of patients presenting with FEP and
BPD can represent up to a quarter of the total cases of
FEP, specific attention should be paid to the treatment.
e same study reports how this cluster of patients is
more likely to receive a lower dosage of antipsychotics.
is finding underlies how specific guidelines would be
helpful in avoiding a stigmatizing approach and conse-
quent mistreatment.
Discussion
BPD psychopathology can be found in patients present-
ing with early psychosis. Also, psychotic, or psychotic-
like symptoms can be the main features already at the
first contact of BPD patients with mental healthcare
services. ese statements lead to two main clinical
considerations. First, personality structure and pathol-
ogy should be explored in people presenting with early
psychosis, since it is known personality disorders can
hide specific needs and affect the response to treat-
ment. is may also require developing new clinical
guidelines and effective treatments for young patients
with early psychosis and co-occurring BPD that take
into account “premorbid” and interpersonal aspects
of their presenting problems. Secondly, special atten-
tion should be paid to BPD patients who carry a high
burden of disease, with intense psychological suffering
and bad functioning. Indeed, the severity of symptoms
and functional impairment should alert mental health-
care professionals and lead to a further investigation of
basic symptoms and potential psychotic psychopathol-
ogy (either attenuated or full-blown). In this respect,
psychotic symptoms can be viewed as “trans-diagnos-
tic phenomena” [39], with psychotic experiences in
schizophrenia spectrum disorders and BPD sharing
similarities, which raises the question of whether they
are underlain by the same neural mechanism [40] and
have common risk factors (such as previous traumatic
events, family history of psychotic disorder, substance
misuse) [41]. Taking this into account, theoretical ques-
tions around how BPD should be defined and perceived
inevitably arise. Should BPD meeting psychotic symp-
toms or ARMS criteria be considered more severe and
worthy a personalized approach? If so, should psy-
chotic experiences be reconsidered as core diagnostic
criteria? Since definitions do not always meet the real-
ity of everyday clinical practice, what, anyhow, should
be achieved is the understanding of the high suffering
this kind of patients can go through. Moreover, the evi-
dence that BPD patients with psychotic signs are often
at higher risk of developing a wider range of negative
outcomes (including suicidal thinking and behavior)
cannot be ignored, especially when considering treat-
ment and monitoring.
In conclusion, sometimes understanding this specific
vulnerability requires mental health professionals to
go beyond narrow diagnostic categories and embrace
what is known as a “dimensional approach” to psycho-
pathology and psychiatric disorders. Future studies on
early psychosis and BPD should thus recognize both
the dimensional and dynamic nature of psychopatho-
logical symptoms and evolving phenotypes across the
transition from childhood to adulthood by adopting a
clinical staging approach [42]. Such an approach needs
to include the measurement of personality pathology,
in order to focus on the etiological factors and treat-
ment options for psychotic symptoms in BPD. Also,
taking into account a “network approach to psychopa-
thology” [43, 44], common risk factors, such as trauma
and substance abuse, could be considered as possibly
interacting with each other, thus concurring to overlap-
ping psychopathological categories. is could be the
first step in the complex path to better understand the
relationship between psychosis spectrum disorders and
psychotic experiences being found in severe personality
disorders.
Author contributions
LP had the idea for the review; AB and LP performed the literature search and
analysis. AB wrote the first draft of the manuscript. LP and MM crucially revised
the manuscript.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 7 of 8
Biancalanietal. Annals of General Psychiatry (2023) 22:44
Funding
This review received no specific grant from any funding agency in the public,
commercial or not-for-profit sectors.
Availability of data and materials
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 14 July 2023 Accepted: 22 October 2023
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