Key Takeaways
Although psychosis isn’t part of the diagnostic criteria for borderline personality disorder (BPD), it’s common for people with BPD to experience brief psychotic episodes.
Auditory verbal hallucinations, one of the more common symptoms of BPD with psychosis, have been linked to an increased distress, hospitalizations, and suicidal thoughts and behaviors.*
Treatment for BPD with psychosis focuses on reducing distress, strengthening coping skills, and improving daily functioning through therapy and medication.
If severe symptoms occur alongside emotional instability, BPD therapy can help with structured support and care.
Psychosis refers to a set of symptoms that cause a person to lose touch with reality. While psychosis is most often linked to conditions like schizophrenia or bipolar disorder, borderline personality disorder (BPD) can cause psychotic symptoms to appear — particularly during periods of intense emotional stress.
Research suggests that up to 50% of people with BPD experience psychotic symptoms, like hallucinations and delusions. Having BPD with psychosis can lead to severe mental health concerns, making it important to seek professional support as soon as you or a loved one begins to notice symptoms.
*The 988 Suicide and Crisis Lifeline offers 24/7 confidential support through trained crisis counselors. If you or someone you care about is experiencing emotional distress, self-harm, or a suicidal crisis, please call or text 988. For life-threatening emergencies or immediate assistance, call 911.
What is BPD psychosis?
BPD is not a psychotic disorder. However, some people with BPD can experience psychotic symptoms, especially during periods of intense stress.
Mental health professionals often describe these symptoms as transient or brief stress-related psychosis. This means the symptoms come on quickly, are closely linked to emotional overwhelm, and usually fade when stress decreases or treatment begins.
In BPD, psychotic symptoms may include paranoia, suspicious thoughts, or brief hallucinations. These experiences are real and distressing, even when they are temporary, and they signal a need for professional support.
Symptoms of psychosis with BPD
Psychosis is not a core diagnostic criteria for BPD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, many people with BPD experience brief episodes of intense stress that resemble psychosis, which can include paranoid thoughts and/or dissociation. While psychotic episodes are often brief and related to stress, they can be intense and significantly impact a person’s well-being.
A common psychotic symptom seen in people with BPD are auditory verbal hallucinations. Compared with auditory verbal hallucinations in people with schizophrenia, BPD auditory verbal hallucinations tend to be more distressing, negative in content, and controlling. Hallucinations can also relate to the remaining senses, including sights, sounds, smells, and tastes.
Other psychotic symptoms that can develop in people with BPD include:
Delusions: Delusions are fixed, false beliefs. Examples include delusions about being threatened, controlled, or targeted by others.
Dissociation: This is when you feel detached from yourself and your surroundings. It’s a common symptom of BPD and can create the sense of being disconnected from reality.
Paranoia: This can include intense suspiciousness, paranoid thoughts and behaviors, and difficulty trusting other people.
Does psychosis always mean BPD?
No, various conditions involve psychosis. BPD is a mental health condition, while psychosis is a symptom of various mental health conditions. Psychosis is a key characteristic of psychotic disorders like schizophrenia, schizoaffective disorder, and delusional disorder.
It’s also associated with mood disorders like bipolar disorder and severe depression. Psychosis can also be triggered by specific factors, like ongoing substance use, severe sleep deprivation, and childbirth.
Examples of BPD psychosis
During periods of intense emotional stress, some people with BPD may experience changes in how they perceive reality. These moments can feel confusing, frightening, or isolating — especially when the thoughts or sensations don’t match what’s actually happening around them.
Examples of what BPD-related psychosis can feel like include:
Feeling suddenly convinced that someone you care about is angry with you or about to leave, even when nothing has changed
Hearing a harsh or critical voice during moments of overwhelm that feels intrusive or hard to ignore
Interpreting small changes in tone, facial expression, or behavior as proof that you’ve done something wrong
Feeling unreal, detached, or as if you’re watching yourself from the outside
Becoming intensely suspicious or fearful in social situations, even when you know part of you wants to trust others
These experiences are often brief and closely tied to emotional overload. They aren’t a personal failure or a sign that you’re “broken.” With support, grounding strategies, and treatment, many people find these symptoms become less intense and less frequent over time.
Can BPD cause psychosis?
Certain risk factors may cause psychotic symptoms in people with BPD. While there’s limited research on the link between psychosis and BPD, experts believe that psychosis can be triggered by extreme stress and trauma.
Studies show that BPD is strongly associated with a history of trauma — particularly childhood trauma, which over 70% of people with BPD report experiencing. This history of trauma can increase vulnerability to psychotic symptoms, such as hallucinations, which are also commonly seen in post-traumatic stress disorder (PTSD).
It’s common for people with BPD to develop a co-occurring substance use disorder, which may lead to drug-induced psychosis. Plus, BPD and psychosis both involve a genetic component, which can play a role in developing psychotic symptoms.
Treating BPD and psychosis
BPD with psychotic symptoms is a serious mental health condition that typically requires prompt medical attention and appropriate support. BPD and psychotic features tend to first appear between puberty and a person’s mid-20s. Both are manageable with access to timely interventions and support.
Adults with BPD who experience hallucinations have an increased risk of suicidal thoughts and behaviors, making it crucial to seek help as soon as symptoms arise.
It can be difficult to differentiate between BPD and psychotic disorders, so it’s important to meet with a mental health professional to review your symptoms and health history. With this information, they can create a treatment plan that targets all of your symptoms.
Treatment for BPD and co-occurring psychosis may involve a combination of talk therapy, self-management strategies, and social support. Similar to other personality disorders, BPD can be effectively managed with therapeutic techniques like cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). Working with a therapist can show people how to understand their thoughts and behaviors and better manage their emotions. Group therapy is another way for people to develop additional skills in a group setting.
Additionally, there are various self-management strategies that can empower people to cope with their symptoms and improve their overall quality of life. These include:
Practicing mindfulness: Mindfulness techniques, like focusing on your breath, can help you remain grounded and present in the moment.
Keeping a journal: Daily journaling is an effective way to identify and process your emotions, experiences, and triggers.
Following your treatment plan: This includes attending therapy appointments, taking medication as prescribed, and reporting any changes to your mental health, even when you’re not experiencing psychotic symptoms.
Clinician's take
One effective coping strategy I recommend is grounding techniques, like focusing on your breath or describing your surroundings in detail. These strategies can help you reconnect with the present moment and reduce the intensity of hallucinations or paranoid thoughts.
Find care with Rula
If you or someone you care about is dealing with borderline personality disorder (BPD) and experiencing psychotic symptoms, know that you’re not alone. While psychosis isn’t a core feature of BPD, it can occur during times of intense stress. Seeking professional support can make a significant difference in your ability to manage these symptoms, so remember that help is available.
Many Rula therapists accept major insurance plans, which can help reduce out-of-pocket costs. Explore providers who accept:
At Rula, we’re here to help you feel better. Rula makes it easy to find a licensed therapist or psychiatric provider who takes your insurance. That way, you don’t have to choose between great care and a price you can afford.
Rula patients pay about $15 per session with insurance, and 93% say they feel better after getting care through Rula. We have 21,000+ providers, and appointments are available as soon as tomorrow. We’re here to help you take the next step — wherever you are in your mental health journey.
