Psychology – Theories of Personality Assignment

**PLEASE READ INSTRUCTIONS ATTACHED FOR FULL DETAILS. Message if you have questions. Summary below**

This assignment has four parts, total length between 13 – 16 pages. It will all be in one Microsoft Word document. A minimum of 3 – 5 reference is required. The format needs to be in APA style, with a title page, subheadings, in-text citations and a reference page. Please read the details for each part.

Part 1: Summary and Analysis

Use the following link to read the article and provide a two-page summary and analysis that addresses the questions listed in the instructions.

https://www.wrtv.com/news/working-for-you/dangerous-new-tiktok-trend-encourages-teens-to-diagnose-themselves-with-rare-personality-disorders

Part 2: Research Article Application

Using the attached article (labeled as Part 2 Article), write a three-page summary, analysis, and application of the journal article that addresses the following questions listed in the instructions.

Part 3: Connection to Personality Theory

The third step is to analyze the article from Part 1 in relation to the three listed psychodynamic theories in the instructions. For each theory, you will want to explore the relevance (or lack thereof) for understanding the article from Part 1. One – two pages for each theory.

Part 4: Personal Relevance

The last step is to reflect upon the article, research, and personality theory in relation to your own life.

Write a three-page reflection and analysis that addresses the questions listed in the instructions.

Overall structure should look something like this:

Title page
Body of Assignment
Summary and Analysis (2p)
Research Application (3p)
Personality Theory

Theory 1 (1-2p)
Theory 2 (1-2p)
Theory 3 (1-2p)

Personal Reflection (3p)
Reference page

PSYC Theories of Personality Assignment

This assignment is a four-part paper, total length between 13 – 16 pages. It will all be in one Microsoft Word document. A minimum of 3 – 5 reference is required. The paper needs to be in APA style, with a title page, subheadings, in-text citations and a reference page. Please read the details for each part.

Part 1: Summary and Analysis

Use the following link to read an article and provide a two-page summary and analysis of the article/event that addresses the following questions:

https://www.wrtv.com/news/working-for-you/dangerous-new-tiktok-trend-encourages-teens-to-diagnose-themselves-with-rare-personality-disorders

· What is the focus of the article/event?

· Why is this article/event relevant now?

· What is the relationship between this article/event and personality psychology?

· What are the key conclusions, questions, or issues relevant to this article/event?

· What questions remain unanswered in relationship to this article/event?

Part 2: Research Article Application

Using the attached article (labeled as Part 2 Article), write a three-page summary, analysis, and application of the journal article that addresses the following questions:

· What is the purpose of this research?

· How did the researchers investigate their research question?

· Are the conclusions of the study appropriate? Has the author overemphasized or under-emphasized any findings?

· What are the key strengths and weaknesses of this study?

· How does this research add to our understanding of personality or personality theory?

· How does this study inform your popular article/event?

· Do the conclusions of this research align with the message of your article/event?

Part 3: Connection to Personality Theory

The third step is to analyze your article from Part 1 in relation these three different psychodynamic theories:

· Karen Horney: Theory of Neurotic Needs

· Erich Fromm: Psychosocial Personality Theory

· Henry Stack Sullivan: Interpersonal Theory of Nursing

If you don’t like these three theories, any other theory can be picked, whatever you see fit. For each theory, you will want to explore the relevance (or lack thereof) for understanding the article from Part 1.

Write a one- to two-page analysis for each of your three theories that includes the following information:

· Brief overview of theory (up to two paragraphs with appropriate citations)

· Discussion of how the theory either supports and explains your article/event OR how the theory offers an alternate understanding of your article/event

· Analysis of the value of the theory for understanding personality in the context of your article/event

Part 4: Personal Relevance

The last step is to reflect upon the article, research, and personality theory in relation to your own life.

Write a three-page reflection and analysis that addresses the following questions:

· How is the material in this article/event relevant to your life?

· What can you learn from the personality theories or research relevant to this article/event?

· Does the article/event or research challenge any of your old opinions? Or does it challenge you to form any new opinions?

· How can you apply what you have learned about personality research or theory to better understand your life? What is the practical value to understanding personality research or theory?

· What concerns do you have about the article/event, personality research, or personality theory?

The idea is that the first two articles are relevant to each other. Overall structure of the paper should look something like this:

· Title page (1 page)

· Body of paper

· Summary and Analysis (2 pages)

· Research Application (3 pages)

· Personality Theory

· Theory 1 (1-2 pages)

· Theory 2 (1-2 pages)

· Theory 3 (1-2 pages)

· Personal Reflection (3 pages)

· Reference page (1 page)

Vol.:(0123456789)

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European Child & Adolescent Psychiatry (2019) 28:985–992
https://doi.org/10.1007/s00787-018-1257-2

O R I G I N A L CO N T R I B U T I O N

Psychotic symptoms in adolescents with borderline personality
disorder features

Katherine N. Thompson1,2 · Marialuisa Cavelti1,2,4 · Andrew M. Chanen1,2,3

Received: 23 April 2018 / Accepted: 14 November 2018 / Published online: 3 December 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Psychotic symptoms have been found to be relatively common among adults with borderline personality disorder (BPD),
and to be a marker of BPD severity, but are not recognised in daily clinical practice in these patients. This study is the first
to examine the prevalence of psychotic symptoms in 15–18-year olds with BPD features. It was hypothesised that adoles-
cents with full-threshold BPD would have significantly more psychotic symptoms than adolescents with sub-threshold
BPD features, and that both these groups would have significantly more psychotic symptoms than adolescents with no BPD
features. A total of 171 psychiatric outpatients, aged 15–18 years, were assessed using a structured interview for DSM-IV
personality disorder and categorised into three groups: no BPD features (n = 48), sub-threshold BPD features (n = 80), and
full-threshold BPD (n = 43). The groups were compared on measures of psychopathology and functioning (e.g. Youth Self
Report, Symptom Check List-90-R, SOFAS). Adolescents with full-threshold BPD reported more psychotic symptoms
than the sub-threshold BPD group (p < .001), and both these groups reported more psychotic symptoms than those with no BPD features (p < .001). Adolescents with full-threshold BPD reported more confusion (p < .01), paranoia (p < .001), visual hallucinations (p < .001) and strange thoughts (p < .01), than the other two groups. Psychotic symptoms predicted group membership, determined by BPD severity, after adjusting for other psychopathology and functional impairment (p < .01). Assessment of unusual perceptual experiences, paranoia or odd thoughts is highly clinically relevant in adolescents with BPD features, as these symptoms are associated with a more severe clinical presentation of BPD.

Keywords Adolescence · Borderline personality disorder · Psychosis · Hallucinations · Paranoia

Introduction

Psychotic symptoms are commonly reported among adult
individuals with borderline personality disorder (BPD) [1,
2]. Historically, their clinical significance has often been
dismissed, in part because they were believed to be of short
duration, transient in nature, and to not significantly affect
patients’ lives [2]. Consequently, there is little information
about the frequency and character of psychotic symptoms,
and their functional consequences, during the clinical onset
of BPD. This is especially important for early detection and
treatment because the transition from childhood to adult-
hood is the peak period for the onset of BPD and the major
psychotic disorders and it is also the period during which
BPD features are at their most severe [3–5].

Recent studies of adults with BPD have used standard-
ised instruments assessing for psychotic symptoms. Audi-
tory verbal hallucinations (AVHs) were found to occur in
22–50% of patients with BPD and to be phenomenologically

* Andrew M. Chanen
andrew.chanen@orygen.org.au

Katherine N. Thompson
katherine.thompson@orygen.org.au

Marialuisa Cavelti
marialuisa.cavelti@orygen.org.au

1 Orygen, The National Centre of Excellence in Youth Mental
Health, Locked Bag 10, Parkville, VIC 3052, Australia

2 Centre for Youth Mental Health, University of Melbourne,
Melbourne, Australia

3 Orygen Youth Health, Melbourne, Australia
4 Translational Research Centre, University Hospital

of Psychiatry and Psychotherapy, University of Bern, Bern,
Switzerland

http://orcid.org/0000-0003-4468-622X

http://crossmark.crossref.org/dialog/?doi=10.1007/s00787-018-1257-2&domain=pdf

986 European Child & Adolescent Psychiatry (2019) 28:985–992

1 3

indistinguishable from, and significantly more distressing
and negative in content than, AVHs among individuals with
schizophrenia [2, 6–9]. When present in BPD, AVHs were
also found to be associated with greater suicidal ideation and
more suicide attempts and hospitalisations [10]. Retrospec-
tive assessment indicates that the mean age of onset AVHs
in BPD is 16 years and that they are commonly enduring,
and not transient in nature [2, 6, 11].

Delusions and unusual thought content have also been
found to be correlated with AVHs among adults with BPD
[12]. One study found that sub-threshold and full-thresh-
old psychotic symptoms were most prevalent earlier in the
course of BPD, when BPD features were at their most severe
and which diminished over 16-year follow-up [13].

Among samples of adolescents in the community and in
psychiatric outpatient and inpatient settings, psychotic symp-
toms (attenuated or full-threshold) have been reported to be
common across multiple diagnoses and to be an important
marker of severity of psychopathology, poor functioning,
greater number of co-occurring disorders, and suicidality
[14–17]. Among youth meeting ‘ultra-high-risk’ criteria for
transition to psychosis, the presence of co-occurring BPD
was not associated with any change in the rate of transition
to psychosis, thereby suggesting that these diagnoses might
co-occur and progress independently [18]. However, com-
paratively, little is known about the precise rates of psychotic
symptoms in adolescents with BPD. This is in part due to
the dismissal of these symptoms as being pseudo or quasi
in nature, as they have not been recognised as true psychotic
symptoms [13].

This study is the first to examine psychotic symptoms
among three groups of 15–18-year olds: those with no
BPD features, those with sub-threshold BPD features, and
those with full-syndrome BPD. It was hypothesised that:
(1) the sub-threshold BPD and full-threshold BPD groups
would have significantly more psychotic symptoms than
the no BPD group; (2) the full-threshold BPD group would
have significantly more psychotic symptoms than the sub-
threshold BPD group; (3) psychotic symptoms would be a
significant predictor of group membership (i.e. no BPD, sub-
threshold BPD, full-threshold BPD) after adjusting for other
psychopathology and functional impairment.

Method

Participants

The sample is described in detail elsewhere [19]. Briefly,
participants were outpatients recruited from Orygen Youth
Health, the State Government-funded specialist mental
health service for western metropolitan Melbourne, Aus-
tralia between March 1998 and July 1999 (n = 101), and

between November 2000 and September 2002 (n = 76).
Participants were aged between 15 and 18 years at baseline
assessment. They were excluded if they met DSM-IV cri-
teria for mental retardation, psychotic disorder other than
psychosis NOS. A further six participants were excluded
because they had missing values for the Youth Self Report/
Young Adult Self Report, reducing the sample to N = 171.
Participants were categorised into three groups, based on
the number of DSM-IV BPD criteria: 48 with no BPD (0
criteria), 80 with sub-threshold BPD (1–4 criteria), and 43
with full-threshold BPD (≥ 5 criteria).

Procedure

This study was approved by the North-Western Men-
tal Health Behavioural and Psychiatric Research and
Ethics Committee (E/98/003), and Melbourne Health
(HREC1999.008). Participants, and their parent/guardian
(if under 18 years) provided written informed consent. Eli-
gible participants underwent a comprehensive psychopathol-
ogy interview that included the collection of demographic
data, administration of the Structured Clinical Interview for
DSM-IV (SCID) Axis I and Axis II disorders, the Social and
Occupational Functioning Assessment Scale (SOFAS), the
Symptom Checklist-90-Revised (SCL-90-R), and depend-
ing on the participant’s age, either the Youth Self Report
questionnaire (YSR; < 18 years), or the Young Adult Self Report Questionnaire (YASR; ≥ 18 years).

The DSM-IV SCID II is a reliable and valid measure of
BPD in adolescents and young people [20, 21]. A personal-
ity disorder feature was scored positive if it had been present
for 2 years and did not occur exclusively during a DSM-IV
Axis I disorder. This is 1 year longer than what is normally
required for adolescents in the DSM-IV. Criterion A of
antisocial personality disorder (age ≥ 18 years) was ignored
in making a diagnosis. Personality disorder not otherwise
specified was defined as nine positive personality disorder
features across any personality disorder domain, or if a par-
ticipant lacked only one feature to meet a specific personality
disorder diagnosis but had two additional features from any
other personality disorder domain. These criteria are more
stringent than what is specified in the DSM-IV.

At 2 years, participants were followed up using the SCID
I and SCID II to reassess for a diagnosis for psychotic dis-
order and for the number of BPD criteria, to explore the
transition rates to psychosis over time.

Measures

Residential postcode was used to determine socioeconomic
status according to a social disadvantage scale ranking every
postcode in the state of Victoria, Australia. The tertiles of

987European Child & Adolescent Psychiatry (2019) 28:985–992

1 3

the ranks (i.e. low, middle, and high socioeconomic status)
were used for analyses.

The DSM-IV SCID I and SCID II were administered to
determine diagnosis. General psychosocial functioning was
assessed using the SOFAS [22]. The YSR [23] is a self-
report questionnaire that measures a wide range of child and
adolescent psychopathology, including psychotic symptoms,
among 11–18-year olds. It includes 112 items addressing
emotional and behavioural problems in the past 6 months,
rated on a 3-point Likert scale (0 = not true, 1 = somewhat or
sometimes true, 2 = very true or often true). The YASR [24]
was constructed to assess psychopathology for young adults
between 18 and 28 years, and has comparable items to the
YSR. In accordance with recent studies [25–27], the thought
problems subscale of the YSR/YASR was used to measure
psychotic symptoms. This subscale reflects the mean score
of the following nine items: ‘I can’t get my mind off certain
thoughts’ (item 9), ‘I deliberately try to hurt or kill myself’
(item 18), ‘I hear sounds or voices that other people think
aren’t there’ (item 40), ‘Parts of my body twitch or make
nervous movements’ (item 46), ‘I repeat certain acts over
and over’ (item 66), ‘I see things that other people think
aren’t there’ (item 70), ‘I do things other people think are
strange’ (item 84), ‘I have thoughts that other people would
think are strange’ (item 85), and ‘I have trouble sleeping’
(item 100).

In addition, single items were selected for analysis that
had face validity for psychosis [27, 28] (5, 21), like ‘I feel
confused or in a fog’ (item 13), ‘I feel that others are out to
get me’ (item 34), ‘I hear sounds or voices that other people
think aren’t there’ (item 40), ‘I see things that other people
think aren’t there’ (item 70), ‘I do things other people think
are strange’ (item 84), ‘I have thoughts that other people
would think are strange’ (item 85), and ‘I am suspicious’
(item 89).

The SCL-90-R [29] is a self-report questionnaire, which
assesses for severity of psychopathology during the previous
7 days in individuals aged at least 13 years. It contains 90
items, which are rated on a 5-point Likert scale (0 = not at
all to 4 = extremely). In this study, the paranoid ideation and
psychoticism subscales were used as measures of psychotic
symptoms, and the Global Severity Index (GSI) was used as
a measure of overall psychopathology.

Data analysis

Based on N = 171, all variables showed less than 5% miss-
ing values. Missing values in the SOFAS, the SCL-90-R
GSI, the SCL-90-R paranoid ideation and the SCL-90-R
psychoticism were replaced using the expectation–maximi-
sation method. The YSR/YASR thought problems subscale
and items, as well as the SCL-90-R paranoid ideation and
psychoticism subscales, were tested for univariate outliers.

Outliers defined as a z score of ≥ 3.29 were identified and
excluded for the YSR/YASR thought problems subscale (one
outlier), item 40 (one outlier), and item 70 (six outliers), as
well as for the SCL-90-R psychoticism (three outliers).

Group comparisons were conducted for descriptive
demographic and clinical variables. The Pearson’s χ2 test
was applied for categorical variables and the Kruskal–Wallis
H test for continuous variables. A non-parametric test was
chosen for continuous variables, because they were not nor-
mally distributed, as indicated by a significant Shapiro–Wilk
test. Group analyses of single YSR/YASR items were col-
lapsed from, 0 = not true, 1 = somewhat or sometimes true,
and 2 = very true or often true, into 0 = not true and 1 = true.
Group differences in response proportions (not true/true)
were tested using Pearson’s χ2 test. Post hoc cell-wise com-
parisons were performed, using adjusted residuals to calcu-
late exact p values and a Bonferroni-adjusted alpha level of
.0083 to control for inflated Type-I error.

A sequential multinomial logistic regression was per-
formed to predict group membership (no BPD, subthreshold
BPD, full-threshold BPD), first on the basis of overall psy-
chopathology (SCL-90-R GSI) and functional impairments
(SOFAS), and then after the addition of psychotic symptoms
(YSR/YASR thought problems). No multicollinearity was
evident, as determined by tolerance values above the usual
cut-off of .20. Using the Box–Tidwell approach, a viola-
tion of the assumption of linearity of the logit was detected
for the YSR/YASR thought problems. Thus, the square root
transformed variable was used for the regression analyses.

Results

The three groups did not differ in sex, age, or socioeconomic
status (see Table 1). In contrast, a significant group effect
was found for occupation, the number of current DSM-
IV Axis I diagnoses, the number of current DSM-IV Axis
II diagnoses, the number of BPD criteria, the SCL-90-R
GSI, and the SOFAS score. Post hoc pairwise comparisons
revealed that the full-threshold BPD group was less likely to
be studying or working than the sub-threshold BPD group
or the group with no BPD criteria (p = .004); whereas, no
significant difference was found between the sub-threshold
BPD group and the group with no BPD criteria. The two
BPD groups presented with significantly more current
Axis I diagnoses (p ≤ .05) and current Axis II diagnoses
(p < .05), and significantly higher levels of overall psycho- pathology (p < .05), than the group with no BPD criteria. The full-threshold BPD group had significantly more cur- rent Axis I diagnoses and current Axis II diagnoses, as well as significantly higher levels of overall psychopathol- ogy (p < .01) than the sub-threshold BPD group (p < .001). The sub-threshold and full-threshold BPD groups showed

988 European Child & Adolescent Psychiatry (2019) 28:985–992

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significantly lower SOFAS scores than the group with no
BPD criteria (p ≤ .005). No significant differences in SOFAS
score were found between the sub-threshold BPD group and
the full-threshold BPD group (p = .145).

Group differences in psychotic symptoms

There was a significant group effect for the YSR/YASR
thought problems subscale as a general index for psychotic
symptoms, as well as for the SCL-90-R Paranoid Ideation
and Psychoticism subscales (see Table 1). Post hoc pairwise
comparisons revealed that the two BPD groups reported
significantly more psychotic symptoms than the group with
no BPD criteria (p ≤ .001). The full-threshold BPD group
reported more psychotic symptoms than the subthreshold
BPD group (p < .001). In addition, the full-threshold BPD group experienced significantly more paranoid ideation and psychoticism than both the sub-threshold BPD group (p = .001) and the no BPD group (p < .001). No significant group differences in paranoid ideation and psychoticism were found between the sub-threshold BPD group and the no BPD group (p = .822 and p = .218, respectively). The full-threshold BPD group presented with higher psychoti- cism scores than the no BPD group (p = .001). No signifi- cant group differences were found for psychoticism when comparing the sub-threshold BPD group with the no BPD group (p = .131), or the full-threshold BPD group with the sub-threshold BPD group (p = .143).

When the single YSR/YASR psychosis items were
analysed, there was a significant group effect for items

13, 34, 40, 70, 84, 85, and 89 (Table 2). Post hoc cell-
wise comparisons revealed that the full-threshold BPD
group responded significantly more frequently with true
to feeling confused (item 13, p = .003), feeling others are
out to get them (item 34, p < .001), having visual hallu- cinations (item 70, p = .001), and strange thoughts (item 85, p = .003), than the two other groups. In addition, the groups with sub-threshold or full-threshold BPD endorsed the auditory hallucination item significantly more fre- quently (item 40, p = .004), than the group with no BPD criteria. No significant post hoc cell-wise differences were found regarding strange behaviour (item 84) and suspi- ciousness (item 89, p > .0083).

The regression analysis based on overall psychopathol-
ogy and functional impairments only showed an adequate
model fit, χ2(330) = 322.75, p = .602, using the Pearson cri-
terion. After the addition of psychotic symptoms, the model
fit was χ2(334) = 322.28, p = .516, Nagelkerke R2= .36.
Comparison of log-likelihood ratios for the models, with
and without psychotic symptoms, showed statistically sig-
nificant improvement with the addition of psychotic symp-
toms, χ2(2) = 35.00, p < .05. Correct classification rates were 54.2% for the no BPD group, 66.3% for the sub-threshold BPD group, and 37.2% for full-threshold BPD; the overall correct classification rate was 55.6%. Table 3 shows that the full-threshold BPD group was significantly more likely to have higher levels of functional impairment, overall psycho- pathology, and psychotic symptoms than the no BPD group, and was significantly more likely to have higher levels of psychotic symptoms than the sub-threshold BPD group.

Table 1 Sample characteristics for participants with no BPD (n = 48), sub-threshold BPD (n = 80) and full-threshold BPD (n = 43)

Mdn Median, SCL-90-R GSI Symptom Checklist-90 General Severity Index, SOFAS Social and Occupational Functioning Assessment Scale
*p = .05,**p = .01, ***p < .000

No BPD (Mdn, n/%) Sub-threshold
BPD (Mdn, n/%)

Full-threshold
BPD (Mdn, n/%)

χ2 Df P

Gender, % female 29 (60.4) 54 (67.5) 33 (76.7) 2.78 2 .249
Age 16.0 16.0 16.0 4.26 2 .119
Occupation % Yes (employment, studies) 46 (95.8) 73 (91.3) 31 (73.8) 11.79 2 .003**
Socioeconomic status
Low 25 (52.1) 51 (63.7) 23 (53.5) 8.18 4 .085
Middle 18 (37.5) 13 (16.3) 12 (27.9)
High 5 (10.4) 16 (20.0) 8 (18.6)

Number DSM-IV Axis I diagnoses 1 2 3 45.91 2 < .001*** Number DSM-IV Axis II diagnoses 0 1 2 63.99 2 < .001*** Number BPD criteria 0 3 6 150.94 2 < .001*** SOFAS 73.5 65 60 220.87 2 < .001*** SCL-90-R GSI .56 .85 1.39 27.09 2 < .001*** SCL-90-R paranoid ideation 3 4 8 18.71 2 < .001*** SCL-90-R psychoticism 3 4.5 9 24.20 2 < .001*** YSR/YASR thought problems .22 .56 .78 43.15 2 < .001***

989European Child & Adolescent Psychiatry (2019) 28:985–992

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2‑year follow‑up

At baseline, one participant met criteria for both full-
threshold BPD and psychotic disorder not otherwise
specified (NOS). At 2-year follow-up, this participant
still met criteria for psychotic disorder NOS, but had
only sub-threshold BPD. A total of 7/171 (4.1%) made
the transition to a diagnosis of psychotic disorder NOS at
2 years. Two of these had full-threshold BPD at baseline,
one of whom still met BPD criteria at 2 years, with the
other becoming sub-threshold over time. Three of these
participants had sub-threshold BPD at baseline, two of
these continued to have sub-threshold BPD at 2 years, and
the other developed full-threshold BPD.

Discussion

This study is the first to examine psychotic symptoms
among adolescents with sub- or full-threshold BPD, pro-
viding important information about the early stages of
BPD, proximal to its clinical onset. The study hypoth-
eses were supported by the major findings: (1) a high
proportion of 15–18-year olds with BPD either sub- or
full-threshold BPD experienced psychotic symptoms; (2)
that psychotic symptoms predicted group membership,
defined by BPD severity; (3) that greater BPD severity (i.e.
number of BPD criteria) was associated with more severe
psychotic symptoms. These results validate the experi-
ence of adolescents with BPD who experience psychotic

Table 2 Proportion of participants who responded positively to psychotic symptoms on the YSR/YASR

YSR Youth self-report, YASR young adult self-report
*p = .05,**p = .01, ***p < .000

YSR/YASR items Item number No BPD (N, % yrs) Sub-threshold
BPD (N, %
yrs)

Full-threshold
BPD (N, %
yrs)

χ2 p

I feel confused or in a fog 13 28 (58.3) 57 (71.3) 40 (93.0) 14.14 .001***
I feel that others are out to get me 34 14 (29.29) 33 (41.3) 31 (72.1) 18.00 < .001*** I hear sounds or voices that other people think are not

there
40 2 (4.3) 18 (22.5) 16 (37.2) 14.77 .001***

I see things that other people think are not there 70 1 (2.2) 2 (2.7) 8 (18.6) 13.06 .001***
I do things other people think are strange 84 10 (20.8) 24 (30.0) 22 (51.2) 9.99 .007**
I have thoughts that other people would think are

strange
85 10 (21.7) 26 (32.9) 24 (58.5) 13.40 .001***

I am suspicious 89 22 (45.8) 55 (68.8) 28 (65.1) 6.98 .03*

Table 3 Multinomial logistic
regression analysis of group
membership as a function of
functional impairments, overall
psychopathology, and psychotic
symptoms

The reference category is full-threshold BPD
SOFAS Social and Occupational Functioning Assessment Scale, SCL-90-R GSI Symptom Checklist-90
General Severity Index, YSR youth self-report, YASR young adult self-report
*p = .05,**p = .01, ***p < .000

B SE Wald Df Sig. Exp (B) 95% CI

No BPD
Intercept − .97 1.60 .37 1 .546
SOFAS .08 .02 13.08 1 .000*** 1.08 1.04–1.13
SCL-90-R GSI − 1.03 .49 4.49 1 .034* .36 .14–.93
YSR/YASR thought problems − 4.14 1.08 14.78 1 .000*** .02 .01–.13

Sub-threshold BPD
Intercept 1.18 1.33 .79 1 .375
SOFAS .03 .02 3.38 1 .066 1.03 1.0–1.07
SCL-90-R GSI − .48 .33 2.06 1 .151 .62 .32–1.19
YSR/YASR thought problems − 2.42 .89 7.46 1 .006** .09 .02–.51

990 European Child & Adolescent Psychiatry (2019) 28:985–992

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symptoms, and highlight the need for these symptoms to
be clinically recognised and treated.

As hypothesised, the full-threshold BPD group had
higher scores on the thought problems subscale, compared
with the sub-threshold BPD group, and both these groups
had higher thought problems scores than the no BPD group.
The full-threshold BPD group also reported higher scores on
the paranoid ideation and psychoticism subscales, along with
more confusion, paranoia, visual hallucinations and strange
thoughts, than either the sub-threshold or no BPD groups.
Both BPD groups had significantly more auditory hallucina-
tions than the no BPD group.

These findings are consistent with growing evidence
that many adult patients with BPD report psychotic symp-
toms, even though these symptoms are not core diagnostic
features of this disorder. In the current study, the reported
rate of auditory hallucinations among adolescents with full-
threshold BPD was 37.2%, and 18.6% of these young peo-
ple reported visual hallucinations. This rate is comparable
with the rates reported among adults with BPD for auditory
(22–50%) and visual (30%) hallucinations [8, 9]. Similarly,
72.1% of young people with full-threshold BPD reported
paranoid ideation and 65.1% reported suspiciousness, which
is comparable with rates reported among adults with BPD of
29–87% [8, 13] and 71% [13], respectively. There was also a
high rate of general thought problems, including confusion
(93%) and strange thoughts (58.5%) among those with full-
threshold BPD, which is consistent with the rates reported
among adults with BPD for odd thinking (86%) [13]. These
findings demonstrate that psychotic symptoms are common
among young people with BPD, early in the course of the
disorder.

The current findings highlight and extend previous find-
ings that young people with sub-threshold BPD features
have more severe mental illness and poorer social and occu-
pational functioning than individuals with no BPD features
[30] by also demonstrating the higher likelihood of psychotic
symptoms among young people with sub-threshold BPD
features. Psychotic symptoms predicted group member-
ship, defined by BPD severity (i.e. number of BPD criteria),
after adjusting for overall psychopathology and functional
impairment and greater severity of BPD was associated with
greater overall psychopathology, including greater number
of DSM-IV Axis I and Axis II disorders and poorer psycho-
social functioning. These findings are consistent with those
from population studies indicating that psychotic symptoms
are important risk markers for a wide range of non-psychotic
psychopathological disorders, in particular for severe psy-
chopathology characterised by multiple co-occurring diag-
noses [15], and that young people with psychotic experi-
ences are known to have worse global functioning than those
without, even when compared with young people with psy-
chopathology who do not report psychotic experiences [31].

Importantly, persistent psychotic experiences have been
associated with increased risk of non-suicidal self-injury
and suicide attempts among school-based adolescents [32],
poor functioning and coping in adolescents with mental ill-
ness [33]. More specifically, AVHs have been associated
with greater suicidal ideation and more suicide attempts and
hospitalisations among adults with BPD [10], together with
a self-reported history of childhood abuse and neglect [8].

The 2-year follow-up data did not reveal any relationship
between the number of BPD criteria and emerging psychotic
disorder. This is consistent with the findings from a study
of young people meeting ‘Ultra-High Risk’ criteria for psy-
chosis (i.e. attenuated psychotic symptoms), in which co-
occurring BPD or BPD features did not influence the risk of
short-term transition to psychosis or the risk of developing
a non-affective psychotic disorder [18].

The current study has several limitations. This study was
not primarily designed to assess for psychotic symptoms
and was limited to the YSR/YASR and SCL-90-R at base-
line, and it did not include a measure of symptom severity.
The DSM-IV SCID I was the only measure used to assess
for these symptoms at 2-year follow-up. Furthermore, par-
ticipants were initially excluded if they had a schizophrenia
spectrum or other psychotic disorder, which prevented the
investigation of co-occurring BPD and psychotic disorder
in this patient group. However, a strength of this approach
was that clinical controls were similarly excluded and no
participant met diagnostic criteria for a DSM-IV psychotic
disorder. Future studies in this age group would benefit from
more comprehensive measurement of psychotic symptoms,
along with longitudinal assessment given the bidirectional
associations between psychotic experiences and DSM-IV
mental disorders [34].

The primary clinical implication of these findings is the
need for further studies using more appropriate instruments
for the assessment of psychotic symptoms and also for treat-
ment studies in young people. A previous pilot study of com-
bined specialist BPD and first-episode psychosis early inter-
vention treatment in this age group demonstrated that this
was feasible [35]. As yet, no study has explored the effec-
tiveness of antipsychotic medication for these symptoms,
even though it is regularly prescribed [36], or conducted a
randomised controlled trial of cognitive behaviour therapy
for the treatment of auditory verbal hallucinations. This is a
much needed area of investigation.

Overall, these findings indicate that psychotic symptoms,
such as hallucinations, paranoia, and thought problems are
present early in the course of BPD, are common, and occur
at comparable rates to those reported among adults with
BPD. Moreover, psychotic symptoms are clinically impor-
tant among young people with BPD features, as these symp-
toms appear to be an indicator of more severe psychopathol-
ogy and greater functional impairment. Future studies need

991European Child & Adolescent Psychiatry (2019) 28:985–992

1 3

to investigate appropriate treatments for these symptoms and
whether reducing these symptoms might lead to improved
psychopathological and functional outcomes for young peo-
ple with BPD.

Acknowledgements Dr. Marialuisa Cavelti is supported by the
Swiss National Science Foundation, and the Gottfried and Julia
Bangerter-Rhyner-Foundation.

Funding Funding was received for Dr Marialuisa Cavelti as stated in
the acknowledgements.

Compliance with ethical standards

Conflict of interest All Authors declare that they have no conflict of
interest.

Ethical standards All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.

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Psychotic symptoms in adolescents with borderline personality disorder features

Abstract
Introduction
Method
Participants
Procedure
Measures
Data analysis
Results
Group differences in psychotic symptoms
2-year follow-up
Discussion
Acknowledgements
References

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