Over the years, there have been various perspectives on psychotic symptoms associated with borderline personality disorder (BPD) and their management. There has been a lack of consistency in defining or classifying these symptoms, as well as an absence of guidelines to assist clinicians in treating these patients in clinical settings. The use of polypharmacy and various medications has occurred without established protocols regarding dosage, treatment duration, or outcome assessment. This narrative review examines the evidence surrounding these symptoms and their management to support clinicians in their everyday practice. Further research is essential for effective long-term management.

• Pseudo-Hallucinations

• True-Psychotic Symptoms

• Borderline Personality Disorder

• Polypharmacy

Aziz VM (2026) Pseudo-Hallucinations, Quasi- and True-Psychotic Symptoms in Borderline Personality Disorder a Narrative Review. Ann Psychiatry Ment Health 14(2): 1217.

Borderline personality disorder (BPD) is one of the most prevalent personality disorders, affecting approximately 1.8% of the general population, 10% of psychiatric outpatients, and 15–25% of psychiatric inpatients [1]. Their clinical presentation is more heterogenous [2].

The term borderline originated in the 1930s when psychoanalyst Adolph Stern introduced it to describe patients whose symptoms did not fit clearly within the established diagnostic categories of neurosis or psychosis but instead appeared to occupy a “borderline” position between the two [3]. In subsequent decades, the concept was also associated with individuals thought to exhibit features of “borderline schizophrenia” [4]. During the 1970s, psychoanalyst Otto Kernberg further developed the concept by proposing borderline personality organization as a personality structure situated between neurosis and psychosis [5].

Contemporary understanding has moved away from these early conceptualizations. BPD is now recognised as a distinct mental disorder characterised by pervasive emotional dysregulation, instability in interpersonal relationships, identity disturbance, impulsivity, and an intense fear of abandonment. Although the term borderline personality disorder continues to be used in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (https://www. psychiatry.org/psychiatrists/practice/dsm ). The only BPD criteria in DSM related to psychotic symptoms is transient, stress-related paranoid ideation.

The International Classification of Diseases adopted the term Emotionally Unstable Personality Disorder to reduce reliance on the historical label (https://icd.who.int/ browse10/2014/en#F60.3). In the current International Classification of Diseases, BPD is no longer classified as a separate personality disorder. Instead, it is diagnosed as a Personality Disorder with a specified level of severity (mild, moderate, or severe) and, where appropriate, the Borderline pattern qualifier (6D11.5), reflecting a dimensional rather than categorical approach to personality disorder diagnosis (https://icd.who.int/en/).

Borderline Personality Disorder is chiefly defined by emotional instability, tumultuous relationships, disturbances in identity, and impulsive behaviour. In contrast, psychosis is characterized by a disconnection from reality, which may manifest as hallucinations or delusions. Although these two mental health conditions are distinct, they can intersect in intricate ways for individuals with BPD. Studies suggest that transient psychotic symptoms occur in a substantial proportion of individuals with BPD, with estimates varying considerably across studies (roughly 20–50%, depending on how psychotic symptoms are defined and measured). These episodes are generally short-lived, persisting for hours to days rather than extending for weeks or months, as is typical in primary psychotic disorders such as schizophrenia. The psychotic experiences associated with BPD are frequently referred to as ‘micro-psychotic’ episodes, often triggered by interpersonal stressors or fears of abandonment. Many individuals retain at least partial insight during or after these experiences, although insight can vary considerably depending on symptom severity. Some individuals temporarily lose insight almost completely during severe episodes. Psychotic symptoms in BPD can present in various forms, but they typically arise during times of significant emotional turmoil.

In individuals with BPD, psychotic symptoms are reliably activated by certain situations, especially those that involve feelings of abandonment, rejection, or criticism. Although stress can exacerbate psychosis in schizophrenia, psychotic symptoms are generally less directly tied to specific interpersonal events than those observed in BPD. Another way to express this is that the psychotic symptoms associated with BPD are often instigated by specific circumstances, particularly those that evoke a sense of abandonment, rejection, or criticism. This discernible pattern is distinct from primary psychotic disorders, in which episodes may manifest without obvious environmental cues or may be triggered by a wider variety of stressors that do not specifically pertain to interpersonal relationships.

Although BPD psychosis can be extremely distressing, it is distinct from disorders such as schizophrenia in several respects such as duration ( psychosis related to BPD is typically brief—often lasting from minutes to hours—and subsides as the emotional turmoil resolves); insight (many individuals with BPD retain a certain level of awareness or insight that their thoughts or experiences may not be based in reality); and triggers as these episodes are closely linked to specific emotional triggers, such as intense relationship conflicts, rather than arising spontaneously without a clear cause [6].

Psychotic symptoms associated with BPD can present in various forms, typically surfacing during episodes of significant emotional turmoil. Visual or Sensory Distortions: Individuals may perceive shadows, flashes of light, or altered facial features. In rarer instances, some may encounter unusual tastes or smells, known as gustatory or olfactory hallucinations. Severe Dissociation may involve a sense of detachment from reality, one’s body, or personal identity (depersonalization), or a feeling that the surrounding world is unreal or dreamlike (derealization). In states of heightened intensity, these experiences can closely resemble psychosis. Paranoia and Suspiciousness as individuals may harbour beliefs that others wish to inflict harm or may experience ‘ideas of reference,’ which is the belief that random occurrences or public remarks are specifically about them. Such thoughts often intensify during periods of acute interpersonal stress or overwhelming fears of abandonment [7].

Auditory Hallucinations may involve hearing voices that criticize the individual or convey feelings of worthlessness. These voices often reflect the person’s own negative self-perceptions and are more likely to arise when the individual is alone or in a state of high emotional dysregulation [8].

Individuals with BPD frequently encounter paranoid ideation during episodes of increased stress or feelings of rejection. These thoughts generally revolve around themes of persecution, betrayal, or abandonment by important individuals in their lives. In contrast to the persistent delusions observed in schizophrenia, the paranoid thoughts associated with BPD are often temporary and closely linked to emotional stimuli. They tend to escalate during interpersonal disputes and may subside when the individual receives reassurance or when the emotional turmoil resolves. This variable nature is a defining feature of paranoia related to BPD. Auditory hallucinations rank among the most prevalent psychotic symptoms reported by individuals with BPD. These hallucinations typically manifest as critical or derogatory voices that reinforce negative self-perceptions and can be extremely distressing. Although many voices reflect themes of self-criticism, abandonment, or worthlessness, some individuals experience auditory hallucinations that closely resemble those found in primary psychotic disorders. They may hear statements such as “you’re worthless,” “nobody will ever love you,” or “you should harm yourself,” which are internal criticisms expressed as auditory phenomena. These hallucinations usually arise during times of isolation, stress, or emotional instability. Dissociation in BPD can occasionally escalate to a level resembling psychosis, leading to considerable distortions in self-perception and environmental awareness. Severe dissociative episodes may manifest as a complete detachment from reality, where individuals experience the world as dreamlike or unreal (derealization), or feel disconnected from their body or sense of self (depersonalization). During these intense dissociative states, individuals may report sensations of observing themselves from an external perspective,perceiving their surroundings as unreal, or finding familiar places suddenly appear strange or threatening. Although these experiences are not formally classified as psychosis, they can significantly hinder reality testing and result in alarming perceptual distortions. The psychotic symptoms associated with BPD are generally shorter in duration and more context-dependent compared to those observed in conditions such as schizophrenia or schizoaffective disorder. Additionally, the severity of symptoms in BPD tends to fluctuate more rapidly. For instance, an individual may seem fully grounded in reality during a therapy session, only to encounter pronounced psychotic symptoms hours later due to a conflict in a relationship. This rapid fluctuation pattern is considerably less prevalent in primary psychotic disorders, where symptoms typically evolve and resolve more gradually and follow a less predictable trajectory in response to external stressors. Compared with primary psychotic disorders, individuals with BPD are generally more likely to retain partial insight into the possibility that their experiences are emotionally driven, although this varies considerably between individuals. They may articulate feelings of being “crazy” or later recognize that their perceptions were shaped by emotional turmoil. This partial insight stands in contrast to primary psychotic disorders, where individuals usually lack awareness that their hallucinations or delusions are not objectively real, making them less inclined to question these experiences even after the acute phase has subsided.

Individuals with BPD, both men and women, exhibit notable differences in their psychiatric comorbidity patterns, dimensional symptom assessments, and quality of-life indicators. Women tend to possess more negative self-perceptions and experience poorer emotional and social role functioning overall. The male participants were found to be significantly older than their female counterparts, with average ages of 34.5 years compared to 30.4 years, although both groups were otherwise comparable in demographic factors. The overall severity of the syndrome, along with the frequency of previous suicide attempts and self-harming behaviours, showed no significant differences between the genders. Women were more frequently diagnosed with anxiety disorders, particularly generalized anxiety disorder, as well as somatoform disorders and histrionic personality disorders. In contrast, antisocial personality disorder was more prevalent among men. Women exhibited elevated dimensional ratings for depression, anxiety, obsessive compulsiveness, work dysfunction, and negative affectivity; they were also more inclined to affirm the “paranoia/dissociation” criterion for BPD. According to the Short Form-36 Health Survey, women indicated significantly poorer emotional role, social role, and mental health functioning compared to men. Contrary to what was anticipated, no significant differences between sexes were found in the utilization of health care resources [9].

Psychotic symptoms, particularly hallucinations, appear to be a significant characteristic of BPD. A Kings College London review of the prevalence, phenomenology and treatment of psychotic features in BPD revealed among patients diagnosed with BPD, approximately 20 50% report experiencing psychotic symptoms. The nature of hallucinations in these individuals can resemble those found in patients with psychotic disorders, particularly regarding their phenomenology, emotional effects, and duration. While further investigation is required to understand the specific characteristics of psychotic phenomena in BPD patients, the use of terms such as pseudo-psychotic or quasi-psychotic is misleading and should be avoided. Childhood trauma may significantly contribute to the emergence of psychotic symptoms in individuals with BPD, similar to its impact in other groups. Additional research is essential to explore the influence of comorbid conditions, particularly posttraumatic stress disorder (PTSD). Further investigation into possible mediators and effective treatment strategies for psychotic symptoms in BPD is essential, and existing diagnostic frameworks may need to be updated to highlight the importance of psychotic symptoms.

Merrett et al. [10], investigated the phenomenology of multisensory hallucinations and delusions in individuals diagnosed with BPD and compared these findings to those observed in individuals with schizophrenia spectrum disorders (SSD). A total of eighty-nine adults participated in the study, which categorized them into four distinct groups: BPD with auditory hallucinations, BPD without auditory hallucinations, SSD with pronounced BPD traits, and SSD with minimal BPD traits. Among the participants with BPD, 81% reported experiencing visual and tactile hallucinations, 75% reported olfactory hallucinations, and 94% experienced delusions. When comparing individuals with BPD who experienced auditory hallucinations to those who did not, no significant differences were noted in terms of nonpsychotic psychopathology. Some minor differences were observed when comparing hallucinations in BPD to those in SSD; however, the overall experiences were found to be similar across the different diagnoses. Furthermore, the BPD group reported significantly higher instances of paranoia/suspiciousness and delusions of guilt compared to the SSD group.

Individuals diagnosed with borderline personality disorder often encounter additional mental health issues, such as depression, bipolar disorder, PTSD, substance use disorder, and psychosis, at rates significantly higher than those observed in the general population; the lifetime prevalence of at least one comorbid mental illness in this group approaches 100% [11].

Borderline personality disorder is frequently misdiagnosed due to symptom overlap with other disorders, including bipolar disorder, depression, and post-traumatic stress disorder (PTSD). Therefore, the term ‘borderline’ may more accurately reflect its position at the intersection of various other conditions, obscuring their individual characteristics [12].

Self-reported identity disturbance and the tendency towards psychosis may serve to distinguish between the DSM-5 diagnoses of BPD and Schizotypal Personality Disorder (SPD). Logistic regression analyses revealed that primitive defenses and disorganization were the most effective in differentiating between the BPD group and the pure SPD group. In contrast, primitive defenses, along with interpersonal factors and perceptual aberrations, were most effective in distinguishing the BPD group from the total SPD group. Although identity disturbance did not serve as a predictor for the diagnostic categories, patients with BPD were notably characterized by primitive defenses, which are closely associated with identity disturbance. Pure SPD was marked by oddness and eccentricity, while the lack of specificity regarding cognitive-perceptual symptoms indicates that positive symptoms do not effectively differentiate BPD from SPD [13].

Disorders of thought and perception, along with social functioning over the past two years, were evaluated in outpatients diagnosed with DSM-IV BPD (n = 28) or Schizophrenia (SC) (n = 28). Quasi-psychotic thoughts, characterized by transient, circumscribed, and atypical psychotic experiences, were observed more frequently in the BPD group (BPD = 82.1%, SC = 50%, p = 0.024). In contrast, true psychotic thoughts, which include Schneiderian first-rank symptoms, prolonged, widespread, and bizarre psychotic manifestations, were more prevalent in the SC group (SC = 100%, BPD = 46.4%, p < 0.001). Nonetheless, both types of psychotic features were common in both cohorts. Non-delusional paranoia, such as excessive suspiciousness and ideas of reference, was widespread but exhibited greater severity in BPD patients compared to those with SC (p = 0.001). Within the BPD cohort, a significant negative correlation was found between personal and social functioning and non delusional paranoia (p = 0.002), with the level of personal and social functioning serving as a significant predictor of non-delusional paranoia severity exclusively in the BPD group (p = 0.008). Patients with BPD reported experiencing less severe psychotic symptoms, characterized by a higher frequency of quasi-psychotic thoughts, a lower frequency of true psychotic thoughts, and more pronounced non delusional paranoia compared to SC patients. Interpersonal functioning appears to be a predictor of non-delusional paranoia in BPD, thereby supporting the concept of “stress-related paranoid ideation” as outlined in the ninth diagnostic criterion for both DSM-IV and DSM-5 BPD [14].

A previous analysis of the evidence investigated whether BPD exists ‘on the border’ of psychotic functioning or if it is unrelated to psychotic disorders. It was indicated that ‘narrowly defined’ psychotic symptoms are rarely found in BPD. Furthermore, when such symptoms have been identified in BPD, they may be associated with a coexisting, potentially independent disorder that the patient experiences, such as substance abuse or major affective disorder. Conversely, broadly defined psychotic symptoms, such as depersonalization, are reported more frequently in BPD; however, many of these symptoms have also been commonly observed in individuals with non-psychotic disorders and in the general population. Finally, the presence of factitious psychotic symptoms in BPD has not been extensively studied. Consequently, the authors concluded that the evidence concerning psychotic symptoms in BPD remains inconclusive [15].

A research study involving a group of 88 inpatients diagnosed with BPD compared their characteristics to those exhibiting borderline traits. The study explored four hypotheses regarding the relationship between BPD and psychotic symptoms: narrowly defined psychotic symptoms are infrequently observed in BPD; broadly defined psychotic symptoms are frequently reported in BPD; narrowly defined psychotic symptoms arise from concurrent disorders; and psychotic symptoms may be factitious. Consecutive admissions to acute inpatient services were evaluated for borderline traits, and patients underwent assessments using the Diagnostic Interview for Borderlines and the Schedule for Affective Disorders and Schizophrenia. Initial psychiatric evaluations indicated that while overt delusions and hallucinations (narrowly reality defined) are rare in isolated cases of BPD, manifestations of distortion (broadly defined)—such as depersonalization, dissociative episodes, and paranoid thoughts—are quite common. Individuals diagnosed with BPD frequently experience psychotic symptoms that are “broadly defined,” which may include intense paranoia or sensations of derealization. Nevertheless, strictly defined hallucinations and delusions are rare and typically correlate with considerable emotional instability. The findings predominantly corroborated the suggested hypotheses regarding the connection between BPD and psychotic symptoms. Merely 13% of the BPD sample demonstrated factitious psychotic symptoms [16].

Psychotic disorders, particularly the psychotic disorder NOS subtype, are frequently observed in patients with BPD, and their occurrence correlates with unfavourable outcomes. This suggests that proper diagnosis and treatment of both conditions are essential for this subgroup with a dual diagnosis. Traditionally, a diagnosis of psychotic disorder is viewed as incompatible with BPD, even though patients may meet the diagnostic criteria for both conditions. The frequency of this occurrence is not well understood, nor is the impact of comorbid psychotic disorders on the prognosis of BPD. Research focusing on isolated auditory verbal hallucinations in BPD patients reveals that these perceptual symptoms can have serious repercussions, including suicidal behaviour and hospitalization, indicating that patients with comorbid psychotic disorders are unlikely to experience better outcomes. To investigate the point prevalence of psychotic disorders in individuals with BPD, their relationship with BPD outcomes, and their predictive value for prognosis, Slotema and colleagues [17,18], conducted a cross-sectional study involving interviews with 84 female outpatients diagnosed with BPD. Psychotic disorders were identified in 38% of the BPD patients. The most prevalent subtype was psychotic disorder not otherwise specified (NOS) at 20%, while the least common types included schizophrenia (2%), substance-induced psychotic disorder (2%), and brief psychotic disorder (1%). Among six categories of comorbid disorders, only psychotic disorders were linked to poor outcomes; they also served as predictors of unfavourable outcomes, alongside comorbid mood disorders, eating disorders, somatoform disorders, the severity of BPD, and, somewhat unexpectedly, a greater number of years of education.

A total of fifty-six borderline patients, 38 individuals diagnosed with cluster C personality disorder, 81 patients suffering from psychotic disorders, and 49 healthy controls were examined to evaluate their perceived subjective stress and the intensity of psychotic experiences. All patient groups exhibited significantly greater increases in psychotic experiences in response to daily life stress compared to healthy controls, with borderline patients showing the highest level of reactivity. Furthermore, borderline patients reported a significantly higher level of hallucinatory reactivity than both healthy controls and individuals with cluster C personality disorder. There was no significant difference in paranoid reactivity to daily life stress among the patient groups. The findings of this study support the notion of stress-related psychosis in borderline personality disorder. However, the psychotic reactivity observed was not confined to paranoia but encompassed a wider array of psychotic experiences, including hallucinations [19].

Pearse and colleagues [20], explored whether psychotic symptoms are inherent to BPD. They studied thirty patients who met the criteria for BPD as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), sourced from a specialized personality disorder service. Those with a prior clinical diagnosis of nonaffective psychotic disorder were excluded. Participants underwent a structured psychiatric interview utilizing the Present State Examination, lifetime version. Approximately 60% of the patients reported experiencing psychotic symptoms that were not related to substance use or affective disorders. Auditory hallucinations emerged as the most prevalent symptom, affecting 50% of the participants, and were persistent in the majority of cases. One-fifth of the patients reported delusions, with half of these individuals (three patients) also fulfilling the DSM-IV criteria for schizophrenia, which had previously gone undiagnosed. The nature of the auditory hallucinations resembled those found in schizophrenia, with the content primarily being negative and critical. Thus, persistent auditory hallucinations are considered intrinsic symptoms of BPD. This finding may influence current diagnostic criteria and have significant implications for both pharmacological and psychological treatment approaches. The occurrence of delusions may suggest the presence of a comorbid axis I disorder.

A subsequent study [6], aimed to explore the connections between hallucinations and delusions, and the processing of trauma, emotion regulation, distress tolerance, and interpersonal sensitivity. Both auditory hallucinations and delusional thoughts, particularly paranoid delusions, are relatively prevalent among individuals with BPD. However, distinguishing these phenomena in BPD from similar experiences in psychotic disorders and schizophrenia remains challenging, despite numerous efforts to clarify the differences. The occurrence of auditory hallucinations may adversely influence the progression of BPD. Psychotic symptoms in BPD appear to be closely linked to contextual factors, typically arising or intensifying in response to stressful situations. The impact of certain co-occurring disorders on the likelihood of experiencing psychotic symptoms in BPD is still not well understood.

A research study examined the similarities and  differences in the experiences of auditory hallucinations, paranoia, and childhood trauma among individuals with schizophrenia and BPD. A total of 111 patients were involved in the study; 59 were diagnosed with schizophrenia, 33 with BPD, and 19 with both conditions. The groups exhibited similarities in their experiences of auditory hallucinations, particularly regarding the perceived location of the voices, yet they showed differences in the frequency of paranoid delusions. Patients diagnosed with BPD, including those who also had schizophrenia, reported a higher incidence of childhood trauma, particularly emotional abuse. The coexistence of BPD and schizophrenia is common, and this comorbidity has significant implications for diagnostic classification and treatment approaches. The levels of reported childhood trauma are notably elevated in individuals with a BPD diagnosis, regardless of whether they also have schizophrenia, necessitating thorough assessment and appropriate management [21].

To understand hallucinations more in BPD, Gras and colleagues [22], reported occurrence in approximately 30% of patients, primarily in the auditory form. Most of these experiences are temporary, often triggered by intermittent stressors; however, their chronic nature remains a significant concern. It was noted that the hallucinatory experiences in BPD exhibit phenomenological similarities to those found in the schizophrenia spectrum, particularly regarding vividness, duration, spatial localization, and beliefs about malevolence or omnipotence. In contrast, the content of these hallucinations tends to be more negative and potentially more distressing. Importantly, this literature review has also highlighted that these symptoms have historically been labelled as “pseudo-hallucinations” or “hallucination-like symptoms.” This classification has been deemed scientifically invalid, contributing to the stigma surrounding BPD patients by casting doubt on the legitimacy of their experiences and dismissing the associated distress. Nevertheless, hallucinations alone are insufficient for a schizophrenia diagnosis, and comorbid substance use disorders and mood disorders do not account for all instances of hallucinations in BPD. The authors have suggested a “psychotic-reactivity-to-stress” model to elucidate hallucinations in BPD, linking them to hyperactivity of the hypothalamic-pituitary-adrenal axis and the dopaminergic system under stress. Childhood trauma may play a pivotal role in this model. The incidence of childhood trauma is notably high in individuals with BPD, and this factor has also been significantly associated with hallucinations in non-clinical populations. Both the models of psychotic reactivity to stress and the influence of childhood trauma within the framework of a gene environment interaction seem to offer valuable insights for future research.

Psychotic symptoms frequently persisted over an extended period and disrupted both physical and emotional functioning. It has been proposed that the diagnostic classification of BPD needs to be updated to encompass psychotic symptoms. The use of terms like pseudo- and quasi-psychotic symptoms is ambiguous, and a revaluation of these terms is warranted [23].

In individuals with BPD, auditory verbal hallucinations (AVHs) are linked to severe manifestations of the disorder and elevated levels of suicidality. Incorrectly treating these patients as if they are afflicted with schizophrenia or another primary psychotic disorder, while neglecting to address BPD, can lead to considerable iatrogenic harm. We present a distinct pattern of symptoms and phenomenology that can enhance diagnostic precision in such cases. A targeted review has identified the following characteristic pattern: AVHs in BPD are phenomenologically indistinguishable from those in schizophrenia, frequently fulfil the criteria for First-Rank Symptoms (FRSs), are closely related to stress, and are significantly associated with dissociative experiences and childhood trauma. Formal thought disorder is rare, negative symptoms are typically absent, bizarre delusions are not present, affect remains reactive, and sociability is generally preserved. Enhancing diagnostic accuracy can be achieved by evaluating the overall clinical presentation, which is crucial for improving the prognosis for these patients. In such instances, psychotropic medications might demonstrate reduced efficacy for AVHs, whereas these symptoms may improve or resolve during psychotherapy for BPD [24,25].

The persistent VAH reported by participants with BPD and schizophrenia, as examined by Barrera and colleagues [26], revealed notable similarities and differences. Both groups reported comparable intensity, location— whether inside or outside the head—and frequency of these hallucinations, often describing them as a third person experience. However, the attitudes of the patients towards their VAH diverged significantly. BPD patients characterized their hallucinations distinctly in terms of gender and age, expressing a clear dislike for them. In contrast, schizophrenia patients described their VAH in a more ambiguous manner, acknowledging them as more disruptive yet simultaneously engaging with them in a more positive light; they also tended to incorporate their VAH into their delusions. The contrasting perspectives of the two groups were particularly evident, with BPD participants viewing their hallucinations as identifiable and distinctly unpleasant, while schizophrenia participants perceived them in a more vague and ambiguous fashion.

A research study investigated the phenomenological characteristics of AVH and other psychotic symptoms in young individuals diagnosed with BPD [27]. The study involved sixty-eight outpatients, aged between 15 and 25 years, who were divided into three groups based on their primary diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) and their AVH symptom profiles: BPD + AVH (n = 23), schizophrenia spectrum disorder (SZ) + AVH (n = 22), and BPD without AVH (n = 23). The findings revealed no significant differences in AVH between the BPD + AVH and SZ + AVH groups. However, when compared to the SZ + AVH group, those in the BPD + AVH group exhibited lower scores in delusions and abstract thinking difficulties, while demonstrating higher levels of hostility. Additionally, the BPD + AVH group reported more severe instances of self harm, paranoid ideation, dissociation, anxiety, and stress compared to the BPD group without AVH. The presence of AVH seems to indicate a more severe manifestation of BPD.

Interpersonal schemata were investigated in outpatient adolescents and young adults (ages 15-25) diagnosed with early-stage BPD and Auditory Verbal Hallucinations (AVH). The researchers compared three groups: youths with BPD and AVH (n = 23), youths with schizophrenia spectrum disorder accompanied by AVH (SZ+AVH, n = 20), and youths with BPD who did not experience AVH (BPD no AVH, n = 23). The BPD+AVH group reported a higher prevalence of negative self-schemata and fewer positive self-schemata compared to the SZ+AVH group. Additionally, they perceived themselves as more socially inferior to others than the SZ+AVH group; however, there were no differences in self or other appraisals when compared to the BPD no AVH group. Among youths experiencing AVH (combining BPD+AVH and SZ+AVH), the indirect influence of beliefs about self or others, mediated by negative appraisals of voices on depression, was not significant. Conversely, a significant indirect effect was observed where negative appraisals of voices influenced depression through negative beliefs about self. The occurrence of AVH during adolescence and young adulthood, a period when identity is still being shaped, may have a more significant impact on the developing self than during later adulthood, when the self tends to be more stable and resilient. Therefore, addressing negative self-appraisals may serve as a crucial target for early intervention in youths experiencing distressing voices, including those with BPD [28].

BPD is often not adequately recognized in individuals experiencing First-Episode Psychosis (FEP), and its psychotic features can be challenging to distinguish from those of Schizophrenia Spectrum Disorders (SSD). In a study involving 356 FEP participants, 49 were diagnosed with BPD. When compared to the FEP/SSD group (n = 307), patients with FEP/BPD exhibited a higher prevalence of employment, current substance use, and a history of attempted suicide. Additionally, they were prescribed a lower equivalent dose of antipsychotic medication upon entry and displayed fewer negative symptoms. Furthermore, this group experienced a higher dropout rate over two years and demonstrated significant improvements in psychopathological scores, which were primarily observed within the first year of treatment. As a distinct categorical entity, BPD represents a specific subgroup within FEP that presents unique clinical challenges. Therefore, there is a need for tailored treatment guidelines for this subgroup of FEP patients [29].

In a cohort of 457 young individuals in Australia experiencing their first episode of psychosis (FEP, average age 19.5 years, 56% male), 18.4% exhibited borderline personality pathology (BPP). When compared to those with FEP alone, individuals with FEP + BPP were more frequently female, younger, and born in Australia. Furthermore, those with FEP + BPP were more likely to receive a diagnosis of Psychosis NOS, exhibit more severe hallucinations, and have issues with alcohol abuse. Additionally, young people with FEP + BPP faced greater relationship challenges at the time of presentation and were more prone to depression and self-harm during the follow-up period. Regarding outcomes, FEP + BPP did not correlate with differing rates of remission or relapse; however, these individuals were less likely to require hospitalization at presentation or to be admitted involuntarily during their treatment episode [30].

Some research has indicated that individuals with BPD experience voices similarly to those with schizophrenia; for instance, these voices are often perceived internally and frequently include persecutory themes. Conversely, other research has highlighted distinctions between the voice experiences of schizophrenia and borderline personality disorder, noting that the voices in borderline personality disorder tend to be more derogatory and self critical, with the individuals’ reactions to these voices being more emotionally resistant. Additionally, one study found that the voices experienced by the schizophrenia group led to greater disruption in their daily functioning. Nonetheless, it is important to note that the number of studies on this topic is limited, and they do not provide conclusive evidence regarding these differences [31].

Hallucinations have been consistently linked to traumatic experiences in childhood. This connection appears to be most pronounced between physical and sexual abuse and auditory verbal hallucinations (AVH). It remains uncertain whether these traumatic experiences primarily influence the content of AVH or if childhood trauma increases the susceptibility to experiencing hallucinations overall. To explore the relationship between hallucinations, childhood trauma, and the emotional content of these hallucinations, a study was conducted involving 127 non-psychotic individuals with frequent AVH, 124 healthy controls, and 100 psychotic patients exhibiting AVH. Both non-psychotic individuals with AVH and psychotic patients with AVH reported higher instances of sexual and emotional abuse compared to the healthy control group. However, no significant differences in the prevalence of traumatic experiences were found between the two groups experiencing AVH. Furthermore, no specific type of childhood trauma was able to differentiate between the positive or negative emotional valence of the voices or the associated distress. No correlations were identified between sexual abuse, emotional abuse, and other characteristics of AVH. These findings indicate that sexual and emotional trauma in childhood may increase an individual’s vulnerability to experience AVH in general, which can manifest as either positive voices without distress or negative voices associated with a psychotic disorder [32].

The estimated lifetime prevalence of Visual Hallucinations in the general population varies from 1% to 16% among adult nonclinical groups and from 2% to 41% in healthy adolescent samples. Longden and colleagues [33], posited that the existing evidence indicates that experiences of Visual Hallucinations, including those associated with psychotic disorders, are best interpreted as dissociated or disowned aspects of the self (or self other dynamics) arising from trauma, loss, or various interpersonal stressors.

In a cross-sectional study, the phenomenological features of auditory verbal hallucinations (AVH) in 38 patients with BPD were compared to those in 51 individuals diagnosed with schizophrenia or schizoaffective disorder, as well as to AVH experienced by 66 non-patients. BPD patients reported experiencing AVH for an average duration of 18 years, with a frequency of at least once daily, lasting several minutes or longer. The level of distress associated with these experiences was notably high. No significant differences in the phenomenological characteristics of AVH were found between BPD patients and those with schizophrenia or schizoaffective disorder, except for ‘disruption of life’, which was reported to be greater in the latter group. When compared to non patients who also experience AVH, BPD patients exhibited higher scores across nearly all evaluated items. The AVH experienced by BPD patients are phenomenologically akin to those in schizophrenia, yet distinct from those in healthy individuals. Since the AVH in BPD patients meet the criteria for true hallucinations, the authors advocate for the use of the term AVH rather than ‘pseudohallucinations’ to avoid trivialization and to encourage appropriate diagnosis and treatment [35].

Tschoeke and colleagues [36], found that the characteristics of AVH were comparable in terms of commenting voices, location, and foreign voices. However, significant differences emerged in the frequency of negative symptoms, bizarre delusions, and formal thought disorder. These traits were more prevalent in schizophrenia and exhibited a negative correlation with childhood trauma. In contrast, a history of childhood trauma and dissociative symptoms was notably more common in BPD. The AVHs observed in BPD and schizophrenia cannot be differentiated based on the historically established criteria in the DSM-4 Revision for diagnosing schizophrenia. Other symptoms, including delusions, negative symptoms, formal thought disorder, and dissociative psychopathology, may assist in distinguishing between the two groups.

A study conducted at a tertiary care centre examined the characteristics of psychotic symptoms in individuals diagnosed with BPD and those diagnosed with schizophrenia, alongside the prevalence of self-harm, suicide attempts, and hospitalizations within these populations. A total of 50 individuals with BPD and 50 with schizophrenia, aged between 18 and 45 years, were evaluated for the intensity of their psychotic symptoms. According to the Psychotic Symptom Assessment Scale (PSYRATS), the schizophrenia cohort exhibited higher scores in terms of auditory hallucinations and the number of voices heard, whereas in the BPD cohort, the score for auditory hallucinations was significantly correlated with the number of suicide attempts (P=0.025). Furthermore, on the Cardiff Abnormal Perceptions Scale (CAPS), the BPD group demonstrated elevated scores on positive abnormal perceptions across all dimensions when compared to the schizophrenia group (P=0.002). The findings indicate that individuals with BPD endure a more significant burden of psychotic-like experiences than those with schizophrenia, reporting greater frequency, interference, and distress. While the schizophrenia group achieved higher scores on the PSYRATS, the scores from the BPD group were also significant, and a correlation was found between auditory hallucinations and suicide attempts within the BPD group [37].

A follow-up investigation was carried out involving 326 outpatients diagnosed with BPD (median duration between the initial assessment and follow-up = 3.16 years) to examine the occurrence and characteristics of delusions, as well as the stability of hallucinations and delusions. The point prevalence of delusions was recorded at 26%, accompanied by a median strong conviction regarding these delusions. The findings indicated that both the presence and severity of hallucinations and delusions remained stable at the follow-up assessment. Participants who experienced persistent hallucinations were found to have a higher incidence of comorbid psychiatric disorders, distinguishing them from those with intermittent or sporadic hallucinations, which were characterized by greater frequency, increased intensity of distress, and more significant disruption to daily or social activities. Delusions are commonly observed in patients with BPD and contribute to their distress. Contrary to the belief that these experiences are unwavering, hallucinations and delusions in individuals with BPD frequently manifest in either intermittent or persistent patterns. Persistent hallucinations can be particularly severe, leading to significant life disruptions [38].

In a cross-sectional observational study, the incidence of persistent psychotic symptoms among patients with BPD and their correlation with specific neurocognitive deficits were examined in a cohort of 120 individuals diagnosed with BPD according to the DSM IV TR criteria. Among the BPD patients, 43.3% (52 individuals) exhibited psychotic symptoms lasting longer than six months. Of those with psychotic symptoms, 25 patients (48%) experienced hallucinations, 35 patients (67.3%) had delusional thoughts, and 8 patients (15%) presented both symptoms. Patients with psychotic features demonstrated a higher global severity on the Clinical Global Impression (CGI) scale compared to their non-psychotic counterparts (p = 0.02). Furthermore, psychotic BPD patients showed more significant impairments in attention and executive functions, which encompass working memory and cognitive flexibility. No notable differences in neurocognitive performance were found between patients experiencing hallucinations and those with delusional thoughts. Persistent psychotic symptoms are observed in approximately one-third of BPD patients and are likely linked to neurocognitive and social dysfunction [39].

The presence of ‘lifetime’ manic-hypomanic mood dysregulations is associated with features of the psychotic spectrum in patients diagnosed with BPD. Evaluating these psychotic spectrum features in borderline patients could be beneficial for guiding treatment decisions [40]. This study aims to explore the connection between lifetime mood and psychotic spectrum features in individuals with BPD. The authors examined a sample comprising BPD patients with (n=39, BPD-M) and without (n=21, BPD-no M) lifetime mood disorders. The BPD-M group exhibited significantly higher scores than the BPD-no M group in the ‘lifetime’ mood spectrum subdomains of ‘depressive mood’ and ‘depressive cognition’. However, the two groups did not show significant differences in psychotic spectrum scores, except for the BPD-no M group, which had elevated scores in ‘hypertrophic self-esteem’. In the BPD-no M group, both the depressive and manic-hypomanic components of the mood spectrum were significantly correlated with the ‘delusion’ subdomain of the psychotic spectrum. The depressive component was linked to ‘depersonalization/ derealization’, while the manic-hypomanic component correlated with ‘hypertrophic self-esteem’. In contrast, for the BPD-M group, the manic-hypomanic component of the mood spectrum was associated with various subdomains of the psychotic spectrum, including ‘hypertrophic self esteem’, ‘self-reference’, ‘interpretive attitude’, ‘anger/ over reactivity’, ‘unusual and odd thoughts’, ‘illusions’, ‘delusions’, ‘hallucinations’, and ‘catatonia’. Notably, the depressive component of the mood spectrum showed no correlation with the subdomains of the psychotic spectrum.

Preliminary evidence indicates that there are variations in how psychotic experiences affect daily functioning. Tschöke et al. [41], sought to explore the influence of psychotic experiences on daily functioning in individuals with BPD in comparison to those with schizophrenia. The study found no significant differences in the frequency, intensity, or life disruption associated with auditory verbal hallucinations, nor in the levels of preoccupation and conviction regarding delusions. However, notable differences were observed in the extent of life disruption caused by delusions. These findings highlight that while the nature of psychotic experiences in BPD and schizophrenia may be similar, the effects of delusions on everyday life differ, which could enhance the accuracy of differential diagnosis.

There is substantial evidence indicating that comorbid BPD adversely affects the clinical trajectories and outcomes of substance use disorders (SUD). In contrast, there is minimal evidence suggesting that concurrent SUD worsens the clinical features of BPD. Lee et al. [42], aimed to investigate whether the presence of current substance dependence in BPD patients correlates with heightened BPD-related personality traits and behavioural characteristics. Female BPD patients without current substance dependence (BOR; n = 37) were compared to those with current substance dependence (BSUD; n = 19), as well as female non-BPD/SUD controls (CON; n = 48), focusing on impulsivity, affective lability, affective intensity, externalizing behaviours, and self-harming/ suicidal tendencies, while accounting for their comorbid mood disorders, anxiety disorders, and antisocial personality disorder. The findings revealed that both the BOR and BSUD groups scored higher than the CON group on most measures; however, significant group differences between BOR and BSUD were not observed, particularly when the impact of comorbid psychopathology was excluded. The overall pattern of results remained consistent even when comparing BPD patients with and without a history of lifetime substance dependence. These findings do not support the idea that individuals with BPD and SUD exhibit more severe BPD characteristics than those with BPD alone.

Medication approaches for BPD with psychotic features remain somewhat controversial, as research specifically targeting this presentation is limited. Low-dose atypical antipsychotics are sometimes prescribed off -label to reduce the intensity of psychotic symptoms and help with emotional regulation.

Individuals diagnosed with BPD face a heightened risk of being prescribed multiple psychotropic medications and are less frequently subjected to a review of their medication regimens within the past year, especially concerning tolerability. This situation is alarming, considering the significant probability that BPD patients may be prescribed a Second-Generation Antipsychotic (SGA), which can lead to adverse effects, including metabolic issues and extrapyramidal symptoms. Therefore, it is prudent to exercise caution when suggesting the incorporation of an SGA in the treatment plan for BPD, as there is insufficient robust evidence to support such a recommendation [43].

Antipsychotic medications have not been specifically examined for their impact on AVH; however, they are recognized for significantly reducing both the intensity and occurrence of hallucinations in general. CBT can alleviate the distress associated with AVH, although it does not diminish their intensity or frequency. Electroconvulsive Therapy (ECT) may be beneficial for treating psychosis that does not respond to medication, yet its effects on AVH or other forms of hallucinations have not been specifically investigated. Repetitive Transcranial Magnetic Stimulation (rTMS) has shown effectiveness in treating drug-resistant AVH, although the positive outcomes appear to be of limited duration [44].

Mobascher et al. [45], propose a possible application of atypical antipsychotics for managing psychotic symptoms, impulsivity, and potentially affective symptoms. While these medications were generally well tolerated, the clinical evidence does not endorse the commonly practiced polypharmacy. Nevertheless, findings indicate that a treatment strategy integrating atypical antipsychotics with psychotherapy could demonstrate synergistic benefits.

Antiepileptic medications such as valproate, lamotrigine, and topiramate have yielded inconsistent outcomes in the management of BPD symptoms. They may offer some improvement in anger and aggression, albeit with low evidence levels [46]. Lamotrigine, when used alone, has proven ineffective in mitigating aggressiveness, impulsivity, and emotional dysregulation [47]. Second generation antipsychotics, including Aripiprazole, have shown modest effect sizes in enhancing anger management and emotional regulation [48]. Antidepressants appear to provide minimal or no advantage in alleviating overall BPD symptoms, and their application is not endorsed for addressing emotional dysregulation and impulsivity [46,48].

The Cochrane review conducted in 2022 indicated that, in comparison to placebo, medication may have minimal to no impact on the severity of BPD symptoms, although the certainty of this evidence is very low (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD −0.27, 95% CI −0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD −0.07, 95% CI −0.43 to 0.57; 4 trials, 265 participants). The evidence regarding the effect of medication versus placebo on self-harm is also highly uncertain, suggesting minimal to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI −10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). Furthermore, the evidence remains very uncertain regarding the impact of medication compared to placebo on suicide-related outcomes, indicating little to no effect (antipsychotics: SMD 0.05, 95 % CI −0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD −0.26, 95% CI −1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD −0.36, 95% CI −1.96 to 1.25; 2 trials, 44 participants). Lastly, very low-certainty evidence suggests there is little to no difference between medication and placebo concerning psychosocial functioning (antipsychotics: SMD −0.16, 95% CI −0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD −0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD −0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence indicates that antipsychotics may have a minor effect in alleviating interpersonal issues (SMD −0.21, 95% CI −0.34 to -0.08; 8 trials, 907 participants), while mood stabilisers might contribute to a decrease in this outcome (SMD −0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants appear to have minimal to no impact on interpersonal problems, although the evidence supporting this is highly uncertain (SMD −0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The certainty of evidence regarding dropout rates in comparison to placebo for antipsychotics is also very low (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Furthermore, low-certainty evidence suggests that there is likely no significant difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants) when compared to placebo. The reporting of adverse events was inadequate and largely non-standardised. The evidence regarding non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). No data concerning adverse events for antidepressants were found.

Benzodiazepines (BDZs) can lead to a loss of control, which may include self-harming behaviours, in patients with BPD. Alprazolam exhibited an unusually high incidence of behavioural deterioration [49]. Methylphenidate indicated a non-significant tendency towards heightened impulsivity among BPD patients [50].

Meta-analyses of randomized controlled trials investigating mood stabilizers, antidepressants, and antipsychotics assessed the efficacy of these medications in addressing depression and anger symptoms in individuals with BPD. The findings indicated that mood stabilizers, except for divalproic acid, exhibited a significant pooled effect size of -1.75 (95% CI = -2.77 to -0.74) for anger management. Divalproic acid and carbamazepine demonstrated a moderate impact on depressive symptoms. Antidepressants were found to have a moderate effect on reducing anger, while their effect on depression was minimal. Antipsychotics also showed a moderate effect on anger; notably, aripiprazole presented a considerably larger effect size compared to other antipsychotic medications. However, antipsychotics did not demonstrate any significant effect on depression. Variability among the studies was attributed to factors such as treatment duration (ranging from 5 to 24 weeks), dropout rates (between 5% and 65%), the percentage of patients receiving psychotherapy (from 0% to 100%), and the presence of comorbid mood disorders (also from 0% to 100%). It is important to note that most studies excluded participants with issues related to alcohol and substance abuse, suicidality, and self-harming behaviours [51].

Targeted drug therapy addressing specific symptom domains can yield positive outcomes in BPD. In the short term, antipsychotic medications may significantly alleviate cognitive-perceptual symptoms, anger, and mood instability; however, the extensive and prolonged use of these medications in such patients is still a matter of debate [52].

There is some evidence suggesting that atypical antipsychotics can be effective in addressing specific symptom domains associated with personality disorders, particularly those involving psychotic-like symptoms, impulsivity, aggression, and anger. However, there is no evidence to support that these medications enhance the overall severity of the illness. Considering the high prevalence of comorbidity between personality disorders and axis I disorders, atypical antipsychotics are most beneficial when these symptom domains are significant and there exists a comorbid axis I condition for which an atypical antipsychotic is warranted [53].

Longitudinal studies suggest that BPD tends to improve, but it is not clarified whether long-term pharmacotherapy make the naturalistic recovery occur more rapidly [54]. 27% of individuals diagnosed with BPD experience auditory and visual hallucinations. Phenomenologically, these perceptual experiences are indistinguishable from those encountered by individuals with schizophrenia spectrum disorders. Among patients with BPD, 50% exhibited hallucinations across various modalities. The average duration of AVH experiences was 17 years, with a mean frequency of several minutes each day. The level of distress was significant, and the impact on the patients’ lives was moderate. A notable issue is that evidence based treatment approaches, including antipsychotics, cognitive-behavioural therapy, and transcranial magnetic stimulation, have not been systematically investigated for this patient population [55].

Slotema and colleagues [18], conducted a systematic review of research concerning AVH in individuals with BPD, emphasizing the effectiveness of treatments for psychotic symptoms. Among hospitalized BPD patients, 27% reported experiencing auditory hallucinations; this figure was 25% for all patients and 24% for outpatients. Of those who experienced hallucinations, 78% reported having AVH at least once daily, with episodes lasting from several days to many years. Generally, BPD patients perceived their auditory experiences as malevolent and omnipotent. When compared to individuals with schizophrenia, the phenomenological aspects of AVH were found to be similar, and the associated distress was equal to or even greater, while scores for other positive symptoms were lower. The psychotic symptoms observed in BPD patients bear resemblance to those in schizophrenia patients, although delusions, negative symptoms, and disorganization are less frequently encountered. Consequently, AVH in BPD seem to exist on a continuum that includes individuals without psychiatric diagnoses and those with schizophrenia. This aligns with the original interpretation of the term ‘borderline disorder,’ which was coined to describe a condition situated in the intermediate zone between neurotic and psychotic disorders, allowing for occasional crossings of this boundary in either direction. The occurrence of AVH in BPD was linked to an increase in suicidal ideation and attempts, as well as more frequent hospitalizations. Furthermore, AVH within the context of BPD were correlated with higher rates of post-traumatic stress disorder and emotional abuse. The effectiveness of antipsychotic medications was examined across 21 studies. The authors concluded that both typical and atypical antipsychotics generally exhibit positive effects on AVH occurring in individuals with BPD. In cases where side effects are minimal or non-existent, there is no justification for restricting these patients from higher dosages if lower dosages do not provide sufficient therapeutic effects. Individuals with BPD and AVH may also benefit from alternative treatments for psychotic disorders, including CBT and non-invasive brain stimulation techniques. CBT can facilitate symptom and problem management through a tailored case formulation. Notably, the frequent occurrence of command hallucinations in BPD is of particular concern, as it may result in suicidal behaviour. These patients could gain from CBT specifically tailored to address command hallucinations. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are believed to normalize heightened brain activity through a rapidly fluctuating magnetic field and a low-intensity electrical current, respectively. Patients receive these treatments while fully conscious. When administered in accordance with international safety standards, rTMS and tDCS are considered safe, with any side effects being temporary and mild. Furthermore, non-invasive brain stimulation has shown to be advantageous for patients exhibiting psychotic features and AVH.

Most patients with BPD who encounter AVH perceive their voices as malevolent and all-powerful, often considering them to hold a higher social status than themselves. Additionally, these patients typically exhibit a strong resistance to the voices. These characteristics are positively and significantly correlated with elevated levels of distress associated with the AVH. The necessity for hospitalization is linked to high ratings of the voices’ omnipotence and the distress caused by AVH.

Nevertheless, these results could not be substantiated through regression analyses. Given that negative beliefs can be modified through cognitive-behavioural therapy (CBT), we anticipate that CBT will prove advantageous in treating AVH in patients with BPD, regardless of whether it is administered alongside antipsychotic medication [34].

BPD impacts between 0.4% and 3.9% of the population in Western nations. At present, no medications have received approval from regulatory bodies for the treatment of BPD. However, as many as 96% of individuals diagnosed with BPD are prescribed at least one psychotropic medication. Despite the prevalent use of pharmacological treatments among BPD patients, existing evidence does not substantiate the effectiveness of these medications alone in alleviating the severity of BPD. In general, the findings suggest that the effectiveness of pharmacotherapies for BPD treatment is quite limited. Second-generation antipsychotics, anticonvulsants, and antidepressants have not consistently demonstrated the ability to lessen the severity of BPD. Evidence of low certainty suggests that anticonvulsants may alleviate certain symptoms related to BPD, such as anger, aggression, and emotional instability, although this evidence is primarily derived from individual studies. While second-generation antipsychotics showed minimal impact on the severity of specific BPD symptoms, they did enhance overall psychiatric symptoms in BPD patients [46].

Previous evidence indicates that clozapine, with average dosages ranging from 43 to 421 mg, may provide individual benefits in managing self-injurious behaviours and aggression towards others in patients with BPD. Additionally, improvements have been observed in total scores on the Brief Psychiatric Rating Scale (BPRS) and the Clinical Global Impression (CGI) scale, along with a reduction in the duration of hospital stays. The most significant changes tend to manifest within the initial six months of clozapine treatment [56].

A systematic review conducted by Han et al. [57], examined the efficacy of clozapine in treating severe BPD and found that most studies indicated positive outcomes associated with clozapine for severe BPD. Numerous studies concentrated on the application of clozapine in BPD patients who are at a heightened risk of suicide. The findings from these uncontrolled studies and case reports endorse the utilization of clozapine for patients with severe BPD who are at significant risk of suicide and experience frequent hospitalizations.

The administration of antipsychotic medications for BPD is still prevalent, with quetiapine, risperidone,and olanzapine frequently prescribed for this condition [58,59].

Zanarini et al. [60,61], indicated that there is potential evidence supporting the use of Olanzapine for addressing target symptoms in BPD, including depression, anxiety, intense anger, hostility, aggression, affective instability, impulsivity, and transient paranoia or dissociation. Moderate doses ranging from 5 to 10 mg per day tend to be more effective in alleviating overall symptom severity compared to lower doses of 2.5 mg per day, although even these lower doses can provide some benefit. Olanzapine is frequently utilized during acute episodes of emotional distress or for short-term management to assist in stabilizing a patient in conjunction with psychotherapy, such as Dialectical Behavioural Therapy.

In the sole double-blind, placebo-controlled trial (N = 95), participants administered 150 mg or 300 mg of quetiapine ER exhibited measurable improvements in BPD symptoms as assessed by the ZAN-BPD, with the 150 mg/d group reporting fewer adverse effects.29 Additionally, open-label studies have investigated quetiapine at average dosages ranging from 251 to 540 mg/d. The findings indicated that quetiapine significantly improved symptoms of aggression/hostility, anxiety, and depression [62]. Nevertheless, another open-label study, along with a double-blind, placebo-controlled trial, failed to demonstrate a significant enhancement in impulsivity when compared to placebo.29,33 The existing data on quetiapine primarily consist of small-scale studies involving fewer than 50 patients, apart from one randomized, placebo-controlled trial. The limited number of large-scale trials further complicates the ability to generalize findings from this restricted evidence [63].

Findings indicate that numerous symptoms associated with BPD may be improved using risperidone. In an open label study involving 15 participants, the administration of risperidone (with a final average dosage of 3.27 mg/d) resulted in a statistically significant reduction of 21% in BPRS scores from baseline after an 8-week period. Additionally, a notable decrease was recorded in the domains of hostility and suspicion (30% change from baseline), as well as in depression and anergia (18% and 15% change from baseline, respectively). Comparable outcomes have been observed, suggesting that risperidone may be effective in managing symptoms of aggression and anxiety. It is important to note that these findings are derived from open-label studies, as there are currently no randomized, placebo-controlled trials available. Moreover, the small sample sizes in these studies pose challenges in generalizing the observed trends [64,65].

A double-blind, placebo-controlled trial (N = 52) revealed that a dosage of 15 mg/d over an 8-week duration led to significant enhancements in BPD symptoms, as assessed by the SCL-90-R, Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and State-Trait Anger Expression Inventory. Notable improvements were observed in symptoms related to obsessive-compulsive traits, depression, anxiety, aggression/hostility, social insecurity, paranoid thinking, and psychoticism. Two subsequent follow-up studies indicated that the improvements remained stable across all scales for the aripiprazole group compared to the placebo group, as well as in cases of augmentation therapy with sertraline [66-68). Given the positive outcomes of these preliminary smaller studies, aripiprazole may represent a promising treatment option.

Initial research provided preliminary findings that suggested ziprasidone might be beneficial in addressing symptoms of BPD. However, the encouraging results from these early studies could not be confirmed in a double blind, placebo-controlled trial (N = 60) that assessed an average dosage of 84.1 mg/d, leading to scepticism about the effectiveness of ziprasidone [69,70].

A study [71], with an open-label design (N = 12) demonstrated a notable enhancement in CGI-BPD and BPRS scores among participants administered asenapine (average dosage of 9.2 mg/d) over a period of 8 weeks. Additionally, the research indicated significant improvements in symptoms related to impulsivity, affective instability, and feelings of emptiness, while depressive symptoms showed no such improvement. It is crucial to highlight that during the study, only one participant was treated with asenapine as a standalone therapy. The remaining 11 participants received asenapine as an adjunct to their existing psychotropic treatments, complicating the ability to directly link clinical improvements to asenapine alone.

A study [71], with an open-label design (N = 12) demonstrated a notable enhancement in CGI-BPD and BPRS scores among participants administered asenapine (average dosage of 9.2 mg/d) over a period of 8 weeks. Additionally, the research indicated significant improvements in symptoms related to impulsivity, affective instability, and feelings of emptiness, while depressive symptoms showed no such improvement. It is crucial to highlight that during the study, only one participant was treated with asenapine as a standalone therapy. The remaining 11 participants received asenapine as an adjunct to their existing psychotropic treatments, complicating the ability to directly link clinical improvements to asenapine alone.

Almeida and colleagues [73], conducted a review on the use of Long-Acting Injectables for Borderline Personality Disorder. Their six-month study involving IM risperidone revealed significant improvements, while LAI Aripiprazole also showed positive results in patients with BPD and Substance Abuse. Moreover, palmitate paliperidone LAI was effective in reducing impulsive-disruptive behaviours and enhancing overall functioning in individuals with BPD. The comparison between oral and LAI antipsychotics suggests that LAIs may have a role in the treatment of BPD. Thus, the administration of LAIs may be essential for achieving clinical and functional improvements in patients diagnosed with BPD.

Given that the duration of hospitalization should be minimized due to its limited effectiveness and economic implications, Yamada and colleagues [74], discovered that the use of high-dose antipsychotic medications (daily doses exceeding 400 mg equivalent to chlorpromazine) could serve as an indicator for the readmission of inpatients diagnosed with BPD.

The cognitive model concerning auditory hallucinations emphasizes the significance of appraisals in perpetuating distress. Cognitive behavioural therapy (CBT) aimed at addressing such beliefs has demonstrated effectiveness in treating psychosis. A study investigated the appraisals related to voices among individuals experiencing psychosis and those with BPD to determine the potential clinical benefits of CBT for voices in the BPD population. The study involved 45 patients suffering from distressing auditory hallucinations, who were recruited from the National Health Service. Among them, ten participants (22%) met the criteria for BPD, 23 (51%) were diagnosed with schizophrenia, and 12 (27%) fulfilled the criteria for both disorders. Multivariate analyses revealed no significant differences between the groups regarding beliefs about the malevolence or omnipotence of voices, nor in their behavioural resistance or engagement. However, individuals with BPD and those with both diagnoses exhibited significantly higher emotional resistance compared to those diagnosed with schizophrenia. Conversely, those with schizophrenia showed significantly greater emotional engagement with their voices. Auditory hallucinations in both psychosis and BPD do not exhibit differences in their phenomenology or cognitive responses, particularly concerning beliefs about the power and malevolence of their predominant voice. The primary distinction lies in the affective response. CBT that concentrates on appraisals and the dynamics of the relationship with voices may prove beneficial for individuals with BPD experiencing distressing auditory hallucinations, as well as for those with psychosis [75].

Psychotic symptoms associated with BPD include a variety of transient and stress-induced experiences, such as auditory verbal hallucinations, feelings of persecution, and delusional episodes. Historically considered “quasi-psychotic” and of minimal clinical significance, recent studies indicate that nearly half of those with BPD encounter hallucinatory voices, with a notable number reporting mild to moderate delusional thoughts. These experiences typically arise in situations of emotional dysregulation, interpersonal challenges, or the recollection of trauma, and may coexist with comorbid disorders like post-traumatic stress disorder. The psychotic experiences observed in BPD are phenomenologically and temporally distinct from those found in primary psychotic disorders. They are generally transient, closely linked to emotional instability and interpersonal triggers, and tend to resolve as emotional regulation improves. However, these symptoms can lead to considerable distress, increase the risk of suicide, and complicate diagnostic clarity, especially in early intervention contexts. Thus,the effective identification and management of psychotic symptoms in BPD require a comprehensive approach that addresses both the fundamental personality pathology and the emerging psychotic features. Clinical strategies may include careful administration of antipsychotic medications, trauma-informed psychotherapy, and focused cognitive-behavioural techniques. Acknowledging the spectrum of psychotic phenomena across diagnostic categories is essential for best practices and aids in the formulation of personalized treatment plans (https:// www.nature.com/nature-index/topics/l4/psychotic symptoms-in-borderline-personality-disorder).

Practice guidelines endorse psychotherapies as the initial treatment approach. Crotty et al. [1], systematically evaluated the comparative effectiveness of commonly employed psychotherapies against treatment as usual (TAU) or against other psychotherapies for the management of BPD. Both TAU and the psychotherapies included were effective in addressing the severity and symptoms of BPD. Moderate certainty of evidence indicates that systems training for emotional predictability and problem solving is more effective than TAU for BPD treatment; low certainty of evidence suggests that dialectical behaviour therapy, schema therapy, transference-focused psychotherapy, acceptance and commitment therapy, manual-assisted cognitive therapy, and cognitive behavioural therapy are more effective than TAU in treating BPD. We were unable to draw conclusions from direct comparisons of psychotherapies, which were confined to single studies with very low to low certainty of evidence.

Historically, the concept of borderline personality disorder has been closely linked to psychosis; however, psychotic symptoms experienced by individuals with borderline personality disorder have often been dismissed as unreal, fleeting, or ‘pseudo’ in nature. Modern research increasingly recognizes that hallucinations in BPD can be clinically significant rather than merely “pseudo hallucinations”. Earlier psychiatric literature often minimized these experiences, but more recent studies suggest that many hallucinations in BPD are genuine perceptual phenomena that can be as distressing as those experienced in schizophrenia, even if they differ in their typical triggers, duration, and overall clinical context. In fact, psychotic symptoms, particularly auditory verbal hallucinations, in individuals with BPD exhibit more similarities than differences when compared to those in individuals with psychotic disorders. Furthermore, the presence of both BPD and psychotic symptoms serves as an indicator of severe psychopathology and an increased risk for adverse outcomes, including suicidality [76]. There is a pressing need for targeted interventions aimed at preventing the onset of severe mental disorders, as well as the establishment of management guidelines. Additionally, further research is essential to assess the effectiveness of various interventions for BPD patients experiencing psychotic symptoms. Future trials should study larger sample sizes over a longer period to establish the required dose and the optimal treatment duration. There is also a need to investigate the interactions between psychosis, BPD psychopathology and neurocognitive impairment. For individuals with BPD who experience psychotic symptoms, having a crisis management plan is essential. These plans should be developed collaboratively with mental health professionals and outline specific steps to take when psychotic symptoms emerge.

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