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Section 11
BPD: Psychosis & Interpersonal Relations

Question 11 found at the bottom of this page
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The survey of a wide variety of psychotic symptoms reveals that the borderlines do not have any continuous or severe psychotic experiences. Some of the borderlines report possible hallucinatory experiences of both auditory and visual types. These are unrelated to drug usage and prove difficult to evaluate clinically. Most commonly the borderlines report psychotic ideation in the depressed area- namely, extended periods of feeling worthless or hopeless. It is rare to find a more outright delusional depressive percept such as the belief of having hurt someone or committed a crime. The only other psychotic symptom reported with frequency is ideas of reference. Many patients have had periods when they felt unduly suspicious of others' intentions. They characteristically feel uncertain or uncomfortable about any psychotic experience. The interviewers generally noted that the psychotic percept is at least not bizarre and totally unfeasible. There are virtually no nihilistic or religious delusions, delusions of thought-insertion, interference, or broadcasting, or delusions of somatic passivity. Many borderline patients had been hospitalized or treated in individual psychotherapy. As predicted, they often report that these experiences made them worse. Contrary to expectations, these patients rarely experience severe or continuous dissociative experiences of any kind. Depersonalization experiences are somewhat more likely than derealization. The least common dissociative experience is feeling things are changing size or shape and the most common is feeling physically separated from one's feelings.

Figure 4 shows that, in addition to their surprisingly low frequency, derealization experiences actually discriminate the schizophrenics, who experience them more frequently (p .023). No significant differences are apparent for depersonalization. Nor does any difference appear for psychotic depressive symptoms. The borderline sample has more brief paranoid experiences than the neurotic group (p = .014) but not than the schizophrenics. The latter group, however, is much more likely to have widespread delusional beliefs in other areas (Ji <.001), which makes clinical discrimination quite easy. Although borderlines are slightly more likely to report psychotic experiences from marijuana or alcohol or persisting psychotic symptoms after psychotomimetics, this occurs too infrequently in these samples for any significant differences to surface. As expected, the schizophrenic sample presents significantly more of those psychotic symptoms specifically felt to be unlikely in borderlines, i.e., hallucinations, nihilistic and grandiose delusions, and patently absurd or bizarre delusional content (~ <.001). In hearing about past psychiatric contacts, the interviewers judged that the borderlines develop transient psychotic experiences within psychotherapy or have had a behavioral regression after hospitalization with much more frequency than either the schizophrenics (p = .003) or the neurotic depressives (p = .004). The section total score is significantly higher for the borderlines than for the neurotics (p = .012) but not than for the schizophrenics.

INTERPERSONAL RELATIONS
Borderlines associate with many people and spend most of their time in the presence of others. They feel a need to have people around and report being bothered when alone. They consider that they have close friends and manage to keep in touch with these people. Almost all of them tend to feel sorry for and make efforts to take care of others. Yet they decidedly do not like having others take care of them and find this uncomfortable when it occurs. This apparent paradox continues in their commonly describing having someone in their lives whom they feel they need but less often having someone who they feel needs them. They usually find it uncomfortable to live with their families of origin and yet they often long to be with their parents when they are away from home.

Their most intense current relationships are frequently troubled by breakups. Their relationships are strongly dependent, masochistic, and marked by devaluation and conscious manipulative efforts. The interviewers could frequently see similarities between these interactional patterns and those described in the patient's relation to one of his parents -usually the mother. The current interactions seem to serve a substitutive function.

During the research interviews, the borderlines are often quite suspicious and problems in rapport are common. Their past psychiatric hospitalizations often include a history of presenting special problems for the staff.

The summary statements all discriminate between one or both groups in this section (see Figure 5). The borderlines differ from schizophrenics both in their disinclination to and their difficulty in being alone (p = .0 1). The schizophrenics are more often judged to be socially isolated "loners" (p <.001). The borderlines seek anaclitic relations in which they act as care givers, yet they are in active conflict about giving and receiving care. These patterns are less common for both the scbizophrenics (p = .006) and the neurotics (p = .029). The quality of borderlines' close relationships are more intense and unstable than for either the schizophrenic (p = .001) or neurotic sample (p = .02). Problems with devaluation, manipulation, and hostility are so characteristic and discriminatory that they contrast with both comparison groups (p <.001). Problems with dependency and masochism are also highly characteristic but only differ significantly from the schizophrenic sample (p .006). After reviewing past relations with therapy persons, the interviewers concluded that the borderline patients have almost always been involved in some problem with staff splitting, countertransference problems, or "special" relations to their past therapist (p <.001 with the schizophrenics, p = .005 with the neurotic depressives). This section is highly discriminatory over-all between borderlines and both schizophrenics (p <.001) and neurotics (p= .005).
- Hartocollis, Peter, Borderline Personality Disorders: The Concept, the Syndrome, the Patient, International Universities Press: New York. 1977.

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Personal Reflection Exercise #5
The preceding section contained information about BPD psychosis and interpersonal relations. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 11
How do borderlines differ from schizophrenics? Record the letter of the correct answer the Answer Booklet.