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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 [email protected]

Katherine N. Thompson [email protected]

Marialuisa Cavelti [email protected]

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

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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

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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

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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***

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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

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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 p

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