If we are unfortunate enough to develop BPD following a traumatic childhood, in some cases (NOT all) we may, especially during periods of acute stress, be prone to what psychologists and psychiatrists refer to as brief psychotic episodes.
Such brief psychotic episodes can entail experiencing, for periods of short duration, symptoms such as paranoid delusions and hallucinations. However, these are likely to be of relatively minor intensity compared to how they might be experienced by someone suffering from acute schizophrenia.
What is Psychosis?
Psychosis can involve :
– seeing things that are not there (visual hallucinations)
– hearing things which are not there eg the sufferer might believe they can hear voices telling them to harm, or even kill, themselves
– having the feeling of touching things that are not there (somatic hallucinations)
– smelling things that are not there (olfactory hallucinations)
– derealization (a change of perception in which the world seems ‘unreal’)
– depersonalization (a change of perception in which one’s own self seems unreal).
Note: Both derealization and depersonalization are what are known as ‘dissociative’ symptoms.
– holding on to extremely odd and unusual beliefs that others cannot dissuade the sufferer from believing, especially paranoid beliefs, such as their family, or strangers, are trying to kill them; believing they are irredeemably evil; believing they don’t exist; believing the government is going to kill them and they are being pursued by MI5 (UK) or the CIA (US); believing aliens have placed an implant in their brains which broadcasts all their thoughts. Sometimes, too, the bizarre belief may be a delusion of grandeur, such as the belief that one is God.
– an inability to settle and relax / agitated pacing
– loss of interest in appearance and hygiene/lack of self-care
– severe mood swings
– disrupted, disordered, and disjointed thinking
Whilst such experiences can sometimes be severe, most frequently they are not long-lived. However, such symptoms are also a sign that the illness (BPD) is worsening, and, therefore, a person who has psychotic symptoms should always seek expert help as quickly as possible.
The depression which accompanies BPD can become so acute that it leads to psychotic symptoms. Extended dysphoria (the word ‘dysphoria’ refers to a highly distressing state in which the sufferer feels extreme emotional pain, restlessness, emptiness, and agitation) can tip over into psychotic experiences; These may include: feelings of extreme, irrational guilt and false beliefs about being responsible for things that are, in fact, in no way responsible for (such as the abuse they suffered).
BPD AND REALITY TESTING
Reality testing, a concept originally introduced by Sigmund Freud (1856-1939), can be described as the capacity of an individual to perceive the external events going on around him/her objectively, accurately, and based on conventional interpretation rather than in a way distorted by internal mental factors. The Medical Dictionary defines it as: ‘The objective evaluation of the external world and differentiation between it and the ego or self.’
Impaired Reality Testing :
Reality testing is most obviously impaired in individuals, such as some schizophrenics, who are in the grip of florid psychotic symptoms such as hallucinations (e.g. ‘hearing voices’ or ‘seeing things that aren’t there) and delusions (e.g. believing one’s thoughts are being broadcast / audible to others).
Borderline Personality Disorder, Brief Psychotic Episodes, And Reality Testing :
Individuals with borderline personality disorder (BPD) generally do not have such dramatically impaired reality testing (although they can suffer from brief psychotic episodes when experiencing extreme stress). However, their reality testing can fluctuate to a significantly greater degree than is found in relatively ‘psychologically healthy’ individuals.
For example, particularly when experiencing significant levels of stress, individuals suffering from BPD may lapse into a paranoid style of thinking or experience an impaired ability to self-reflect in a realistic fashion.
Problems That May Arise As A Result Of Impaired Reality Testing :
An impaired ability to reality test can lead to various problems, including :
- the inappropriate judgment of important situations
- failure to challenge irrational negative thoughts
- blaming of oneself for / feel shame about things that were not one’s fault
- loss of awareness of one’s authentic self, thoughts, and feelings (due to defense mechanisms such as denial, repression, and suppression)
- a restricted and blinkered view of the world
Improving Impaired Reality Testing :
Studies (e.g. Landa et al., 2006) suggest that cognitive-behavioral therapy (CBT) can be an effective means of improving a person’s ability to reality test.
BPD AND HALLUCINATIONS
Hallucinations are PERCEPTIONS that people experience but which are NOT caused by external stimuli/ input. However, to the person experiencing hallucinations, these perceptions feel AS IF THEY ARE REAL and that they are being generated by stimuli/ input outside of themselves (in fact, of course, the perceptions are being INTERNALLY GENERATED by the brain of the person who is experiencing the hallucination).
Different Types Of Hallucination :
There are several different types of hallucination and I summarize these below :
- VISUAL HALLUCINATIONS – these involve ‘seeing’ something that in reality does not exist or ‘seeing’ something that does exist in a DISTORTED / ALTERED form.
- AUDITORY HALLUCINATIONS – these, most often, involve ‘hearing’ voices that have no external reality (though other ‘sounds’ may be hallucinated, too).
- TACTILE HALLUCINATIONS – these occur when an individual feels as if s/he is being touched when, in fact, s/he isn’t (for example, feeling the sensation of insects crawling over one’s skin).
- GUSTATORY HALLUCINATIONS – these occur when a person perceives a ‘taste’ in his/her mouth in the absence of any external to the person causing the taste.
- OLFACTORY HALLUCINATION – this type of hallucination is sometimes also referred to as phantosmia and involves perceiving a smell that isn’t actually present.
Mild Hallucinations :
Mild hallucinations are actually not uncommon even amongst people with no mental illness (e.g. believing one has heard the doorbell ring when it hasn’t). If the person who has the experience of hallucinations such as those listed above is aware that the sounds, visions, etc are not real but are being generated from his/her own mind then experts do not consider them to be suffering from full-blown psychosis. Such experiences are only classified as psychotic if the person is adamant that they are real. As stated already, psychosis of this nature, involving a complete departure from reality, is rare in those with BPD.
Severe Hallucinations :
At the other end of the scale, however, are fully-blown hallucinations that involve the person who is experiencing them being psychotically detached from reality; for example, someone experiencing a psychotic episode might hear, very clearly and distinctly, voices that s/he fully believes are coming from an external source (such as ‘the devil’ or a dead relative). A person suffering from such hallucinations cannot in any way be convinced that the ‘voices’ are being generated within his/her own head/brain.
It is uncommon for people suffering from borderline personality disorder (BPD) to suffer from the most serious types of hallucinations (as described above); however, under acute stress (and those with BPD are, of course, far more likely to experience acute stress than the average person), the BPD sufferer may experience hallucinations that fall somewhere between the mild and severe types.
For example, if s/he (the BPD sufferer) was constantly belittled and humiliated by a parent when growing up, s/he may, when experiencing severe stress, ‘hear’ the ‘parent in their head’ saying such things as ‘you’re useless’ or ‘you’re worthless.’
However, unlike the person suffering unambiguously from psychosis, when this occurs s/he is not completely detached from reality but is aware the ‘voices’ are being generated within his/her own mind and are imaginary as opposed to real.
Severe hallucinations may be indicative of schizophrenia but can also have other causes which include: delirium tremens (linked to alcohol abuse), narcotics (e.g. LSD), and sensory deprivation.
If a BPD sufferer is unlucky enough to experience a psychotic episode, when is it most likely to occur, and how can that person minimize their risk?
Sufferers of BPD are at the greatest risk of experiencing a psychotic episode following a significant stressor that acts as a ‘psychosis trigger‘. Such experiences are sometimes referred to as ‘reactive psychosis.’ It follows from this, of course, that those with BPD should avoid stress as far as it is possible.
AGITATED PACING / PSYCHOMOTOR AGITATION
Another symptom of psychosis, which those suffering from BPD and other serious mental disorders may display, is psychomotor agitation.
We have seen that those who have suffered significant childhood trauma are at an increased risk of developing anxiety disorders in their adult lives. In extreme cases, this may lead to what is known as psychomotor agitation. I explain what is meant by this term below. However, I wish to start by recounting my own experience of this most distressing psychological condition.
For at least three years in total, off and on, I could not take a bath. The reason for this was that when I was in this state (each episode could last several months) I was too agitated to do so – I couldn’t relax enough to lie down in the water, or even sit in it, any more so than I could voluntarily immerse myself in molten iron.
So I showered instead, right? Wrong. I felt too agitated to even indulge in this activity, even though most people find showering extremely relaxing and pleasurable.
Instead, I carried out my ablutions with a damp flannel; however, I confess that even this frequently proved to be a challenge I could not meet. Anti-social? Well, yes, if I saw anyone: but I didn’t. I was living as a virtual recluse.
Of course, for people who haven’t experienced severe agitated depression, it is extremely difficult to imagine how acutely distressing it is to have to endure such psychological torment on a constant and unremitting basis.
I couldn’t even sit back in an armchair; I was, quite literally, always on the ‘edge of my seat’ (so it seems the expression is not merely a metaphor).
In other words, I existed in a perpetual and unrelenting state of the most intense kind of agitation – permanently distracted and distraught. This led to a suicide attempt which left me in a coma in intensive care for five days, followed by hospitalizations and several courses of electro-convulsive shock therapy (ECT).
The name for this kind of profound, and highly distressing, restlessness is psychomotor agitation. I describe what is meant by this term below:
Symptoms Of Psychomotor Agitation:
– unintentional/ involuntary/ purposeless movement driven by an irresistible compulsion to do so, feelings of inner tension, restlessness, anxiety, and intense mental anguish and distress. These involuntary movements may include:
– pacing around the room
– hand wringing
Psychomotor agitation is found particularly frequently in those with bipolar disorder, substance abusers, and those with psychotic depression.
Doctors may treat the disorder pharmacologically (i.e. with medication) but it also often treated non-pharmacologically by means of other therapies such as meditation, mindfulness, yoga, and other relaxation techniques.