An Empirical Study of Psychosis in

Borderline Personality Disorder

Harrison G. Pope, Jr., M.D., Jeffrey M. Jonas, M.D., James I. Hudson, M.D.,
Bruce M. Cohen, M.D., Ph.D., and Mauricio Tohen, M.D.

psychotic experiences . . . are often a feature of Bor-

To assess the nature and prevalence of psychotic derline Personality Disorder (9, p. 87).
symptoms in borderline personality disorder, the Whether psychotic symptoms are a feature of bor-
authors reviewed the cases of 33 patients meeting derline personality disorder is of theoretical impor-
DSM-III criteria for borderline personality disorder, tance. The term borderline was originally based on
using both narrow and broad definitions of the belief that such patients lie on the border of
psychosis. Only eight patients displayed psychotic psychotic functioning (10). This view would lead one
symptoms meeting the narrow DSM-III definition; to predict that, under stress, these patients might
in all of these cases, the symptoms appeared to be display brief dips into typical psychotic symptom-
attributable to either severe drug abuse or major atology. On the other hand, if borderline personality
affective disorder, present simultaneously with disorder is not related to classical psychotic disorders,
borderline personality disorder. The remaining as some recent studies have suggested (4, 6), then
patients displayed only broadly defined psychotic patients with borderline personality disorder would be
symptoms or symptoms that appeared to be under predicted to show few, if any, typical psychotic symp-
voluntary control. These findings weigh against the toms. A systematic study of the nature of psychotic
assumption that borderline personality disorder lies symptoms in patients with borderline personality dis-
on the border of classical psychotic disorders. order would help decide between the two hypotheses.
(Am J Psychiatry 142:1285-1290, 1985) Several phenomenologic studies (1 1-20) have as-
sessed the prevalence of various symptoms, including
psychotic symptoms, in patients with a borderline
I borderline
episodes
personality
of psychotic symptoms?
disorder
Although
characterized
some
by diagnosis.
chotic symptoms
Some have
in these
found
patients
little evidence
(1 1, 16),
for
but
psy-
most
researchers have found psychotic symptoms to be rare have reported finding psychotic symptoms to some
in borderline personality disorder (1), others have degree. However, these studies used widely divergent
considered them common (2) and perhaps even neces- criteria for the diagnosis of borderline and variable
sary for the diagnosis (3). Recently, DSM-III has definitions of the term psychotic. Because of the
proposed an operational definition of borderline per- heterogeneity of these studies, they are difficult to
sonality disorder, which is now supported by some summarize briefly here; elsewhere we have discussed
validating evidence (4-6). Throughout this paper, un- the diagnostic criteria and methodology of each of
less otherwise specified, we will be using the term these studies in detail (21). However, one general
borderline personality disorder as it is defined in observation deserves mention: many of these earlier
DSM-III. Although DSM-III does not include psy- studies included patients who probably would not
chotic symptoms among its criteria for borderline have met DSM-III criteria for borderline personality
personality disorder, it allows that during periods of disorder but who would likely have met DSM-III
extreme stress transient psychotic symptoms of insuf- criteria for schizotypal personality disorder.
ficient severity or duration to warrant an additional Schizotypal personality, although more clearly associ-
diagnosis may occur (p. 322). The most recent avail- ated with psychotic symptoms (14), may be unrelated
able editions of psychiatric textbooks concur (7, 8), to borderline personality disorder (4, 14, 22, 23).
and the DSM-III Case Book comments that transient Furthermore, although most of the available
phenomenologic studies excluded patients with schiz-
ophrenia or organic disorders likely to cause psychotic
ReceivedJune 11, 1984; revised Dec. 3, 1984, and April 24, 1985; symptoms, only one (13) appears to have attempted to
accepted May 23, 1985. From the Mailman Research Center, exclude patients with major affective disorder. If a
McLean Hospital; and the Department of Psychiatry, Harvard
patient displays concomitant borderline personality
Medical School. Address reprint requests to Dr. Pope, McLean
Hospital, 115 Mill Street, Belmont, MA 02178. disorder and major affective disorder (possibly a fre-
Copyright 1985 American Psychiatric Association. quent occurrence [4]), one cannot easily conclude that

Am J Psychiatry I 42: 1 1 November

, 1985 1285
PSYCHOSIS IN BORDERLINE PERSONALITY DISORDER

a given observed psychotic symptom is a feature of clear organic basis, such as hallucinogenic or sym-
borderline personality disorder, since it may be due to pathomimetic drug abuse.
the concomitant axis I disorder. Finally, none of the 2. Functional DSM-III psychosis was diagnosed
reports assessed whether any of the psychotic symp- when the patient exhibited symptoms meeting the
toms seen in borderline personality disorder were DSM-III definition of psychotic that lacked any
under the subjects voluntary control. Psychotic symp- apparent organic etiology and that apparently were
toms that are under voluntary control, not explained not under voluntary control.
by another mental disorder, and apparently produced 3. Factitious psychosis was diagnosed in patients
in order to assume the patient role are categorized in with delusions or hallucinations that appeared to be
DSM-III as a factitious disorder with psychological under voluntary control and that apparently were
symptoms. Thus, they may have different diagnostic produced with the goal of assuming the patient role
significance from ordinary psychotic symptoms. (as opposed, for example, to malingering). These cri-
Given these problems of interpretation of available teria correspond to criteria A and C for factitious
studies, it is difficult to assess the nature and preva- disorder with
psychological symptoms in DSM-III. We
lence of psychotic symptoms in borderline personality did not include DSM-IIIs criterion B (namely, that
disorder or to determine the relationship between bor- the symptoms produced are not explained by any
derline personality disorder and classical psychotic other mental disorder), since this criterion has been
disorders. In an attempt to provide new data on this judged to be unclear and is scheduled to be deleted
subject, we reviewed the cases of 33 patients meeting from the revised version of DSM-III (R. Spitzer, per-
DSM-III criteria for borderline personality disorder. sonal communication). Our criteria for assessing fac-
titious psychotic symptoms, developed in an earlier
study (24), were the presence of at least two of the
METHOD following: admission of voluntary control of the symp-
toms (i.e., admitting to a staff member that the symp-
One rater (H.G.P.) reviewed the charts of 33 pa- toms were voluntary) ; unconventional and fantastic
tients meeting DSM-III criteria for borderline person- symptoms lacking stereotypy (i.e., fanciful or atypical
ality disorder, identified during an earlier study (4). He symptoms in the absence of more typical symptoms
assigned any other appropriate DSM-III diagnoses to such as ideas of reference); and unconventional re-
each patient, and recorded psychotic symptoms (de- sponse of symptoms to the environment (i.e., sudden
fined later) occurring during or before the index ad- appearance or disappearance of the symptoms in a
mission. A second rater (J.M.J.), blind to all chart data, manner that would not be typical of ordinary psy-
obtained 4- to 7-year follow-up data on 27 (81.8%) of chotic symptoms). In addition, per DSM-III, we re-
the 33 patients; 23 were interviewed personally or by quired that there be no apparent goal for the symp-
telephone, and four were rated on the basis of infor- toms other than that of assuming the patient role.
mation from relatives or treatment personnel. This 4. The residual group consisted of patients not
rater assigned DSM-III diagnoses on follow-up, rated qualifying for any of the other groups.
outcome measures on a scale of 0=worst to 4=best The validity of this proposed classification was then
(described in detail in references 4, 24, and 25), and assessed on the basis of phenomenology, family his-
recorded psychotic symptoms occurring during the tory, response to medication or ECT, and outcome
follow-up interval. Two other raters (J.I.H. and measures, using the methodology previously described
B.M.C.), each blind to all other information about the (4, 24, 25).
patient, assessed family history and response to drugs We also recruited a control group of 15 individuals
or ECT, respectively, in each patient. without a history of major psychiatric disorder, ob-
The methods for obtaining and scoring follow-up, tamed from among 22 control subjects who had
family history, and treatment response data, in this participated in an earlier study (26). This control
and other cohorts of patients, have previously been group was closely matched in age and sex to the
described in detail (4, 24, 25). patients with borderline personality disorder (control
The patients were then divided into four groups on subjects: 12 women, three men; mean age=28.S years,
the basis of their current or past history of psychotic range= 17-35 years; borderline patients: 27 women,
symptoms, as noted by either the index admission rater six men; mean age2S.7 years, range= 18-42 years).
or the follow-up rater. These groups were arranged A rater (M.T.) trained in the use of the Diagnostic
hierarchically: if a patient met the criteria for more Interview for Borderlines (DIB) (27), blind to the
than one of the four groups, he or she was assigned to purpose of the study, administered the psychosis
the first group on the list for which he or she qualified. section of the first edition of the DIB (the edition used
For example, a patient displaying both functional for the borderline patients in the original study [4]) to
DSM-III psychosis and factitious psychosis would be the control subjects, either in person (N=7) or by
assigned to the former group. telephone (N=8). Psychosis subscale scores for the
1. Organic psychosis was diagnosed when symp- control group were then compared with those of the
toms, meeting the DSM-III definition of psychotic four proposed subgroups of the original sample of
(pp. 340, 367-368), occurred only in the presence of a borderline patients.

1286 Am J Psychiatry 142:11, November 1985

 POPE, JONAS, HUDSON, ET AL

TABLE 1. Phenomenology, Treatment Response, and Follow-Up Data on Three Subgroups of Patients With Borderline Personality Disorder

4-7-Ye ar Follow-Up
Index Follow-Up
Diagnosis Diagnosis
of Major of Major DSM-III
Affective Response to Neuroleptics Affective Psychotic Global
Disorder . Disorder Symptoms Outcomeb
Not Patients
Groupa N % Tried None Equivocal Definite Followed N % N % Mean Range

Functional DSM-IlI
psychosis (N=7) 7 100.0 3 0 1 3 7 6 83.3 3 42.9 2.1 0-4
Factitious psychosis (N=12) 3 25.0 7 4 1 0 10 S 50.0 0 0 1.7 0-4
Residual group (N=13) 7 53.8 11 2 0 0 9 I 11.1 0 0 1.5 0-3
The organic psychosis group (N= 1) is not included.
bGlobal outcome is scored on a S-point scale where 0=worst and 4=best (4, 24, 25).

Fishers exact test, two-tailed, was used to test the vealed that four of these seven patients had been
significance of differences between groups. treated with antipsychotic medication: three had
shown a definite response and one an equivocal re-
sponse. By comparison, of the other 26 patients, seven
RESULTS had received antipsychotics; one had had an equivocal
response, and six had had no response.
Organic DSM-III psychosis was diagnosed in one The global assessment of outcome in this group was
patient, a 19-year-old man, who experienced psychotic slightly, but not significantly, better than that of the
symptoms meeting the DSM-III definition for several other groups of patients with borderline personality
days after heavy abuse of a collection of unknown disorder (table 1).
drugs. The patient was hospitalized at that time; the Factitious psychosis was diagnosed in 12 patients
psychotic symptoms disappeared promptly after ad- who displayed psychotic symptoms meeting DSM-III
mission and remained absent both throughout his criteria for factitious disorder with psychological
2-year hospitalization and during the S-year follow-up symptoms either during the index admission or on
period. Since this patient was an adoptee (one of five in follow-up. One additional patient with functional
the cohort), family history could not be obtained. The DSM-III psychotic symptoms was diagnosed as also
patient received no psychiatric medications during his having factitious psychotic symptoms; she was classi-
hospitalization. fled with the functional psychosis group.
Functional DSM-III psychosis was diagnosed in Results of blind evaluation of medication response
seven patients with apparently functional symptoms in this group appeared to be consistent with our
meeting the DSM-III definition of psychosis on index diagnostic impression. Seven of the 12 patients had
evaluation and/or follow-up. The index admission never received neuroleptics. Of the five who had been
rater diagnosed all seven of these patients as having treated with neuroleptics, none had shown a definite
concomitant major affective disorder according to response, one had shown an equivocal response, and
DSM-III criteria; all seven appeared to display psy- four had shown no response-a pattern that contrasts
chotic symptoms only at times when they also dis- sharply with that of the group with functional DSM-
played either a DSM-III full manic syndrome (pp. III psychosis.
208-209) or a full depressive syndrome (pp. 213- Personal and family history of major affective disor-
214). It should be noted, however, that when rating for der and global assessment of outcome did not differ-
the presence of affective disorder, the index rater was entiate this group from the other groups.
not blind to the presence of psychotic symptoms and Aside from the drug response data, which must be
vice versa. regarded as only suggestive, it is difficult to offer
The presence of affective disorder in these patients independent support for the controversial diagnosis of
was supported by the evaluations of the other three factitious psychosis. Therefore, the diagnosis must be
raters. On blind follow-up, six of the seven patients considered tentative, particularly in cases where it was
were again given a diagnosis of definite or possible made on the basis of chart review. To illustrate more
major affective disorder. A blind family history evalu- clearly the types of symptoms we rated as factitious,
ation of the 38 parents and siblings of these seven we present the following two examples.
patients found five (13.2%) cases of major affective
disorder, as compared to only three (3.3%) cases
Case 1 . During her index admission, Ms. A, a 19-year-old
among the 92 parents and siblings of the other 26 woman with borderline personality disorder, claimed to hear
patients. This difference approaches statistical signifi- the voices of her good self and bad self talking to her.
cance (p<.lO). She later conceded that these were not really voices, but
Blind assessment of response to drugs or ECT re- rather internal thoughts that she could control. Thus, the

Am J Psychiatry 142:1 1, November 1985 1287

PSYCHOSiS IN BORDERLINE PERSONALITY DISORDER

index rater diagnosed them as factitious psychotic symp- TABLE 2. Scaled Psychosis Scores on the Diagnostic Interview for
toms. In the follow-up interview, she told the rater that she Borderlines in Subgroups of Patients With Borderline Personality
could see figures of people floating in space whom she could Disorder and in Control Subjects
will to be there. However, she denied having more typical
Number of
psychotic symptoms such as ideas of reference or paranoid
Patients With
delusions. There seemed to be no apparent goal of the
Each Score
symptoms other than to assume the patient role. Thus, she
was independently diagnosed by the follow-up rater as Group 0 1 2
having factitious psychotic symptoms. Interestingly, the fol- Borderline personality disorder
low-up rater also noted factitious neurological symptoms With organic DSM-III psychosis (N=1) 0 0 1
(conversion disorder) in the form of factitious seizures. With functional DSM-IIJ psychosis (N=7) 2 1 4
During one seizure she threw a desk across a room. With factitious psychosis (N=12) 4 2 6
Results of a detailed neurological workup of the seizures Residual (N=13) 6 4 3

had been negative. Control subjects (N= 15) 10 4 1

Significantly different from control subjects; Fishers exact test, two-tailed,

Case 2. On follow-up interview, Ms. B, a 32-year-old p<.0s.

bsignjfjcantly different from control subjects; Fishers exact test, two-tailed,
woman with borderline personality disorder, described vi- p<.0s.
sions of 13 women dressed as judges filing into her room. At
other times she claimed to be floating free in space and
looking at herself. She also described periods when she could
recognize only children and not adults. However, she denied distinguishable from the control group on this crite-
having typical psychotic symptoms such as ideas of reference non. It should be noted, however, that this is a
or auditory hallucinations. She displayed no apparent goal comparison of small samples.
for the symptoms other than to assume the patient role. Despite their apparent low prevalence of even
On the basis of the fantastic and nonstereotypic nature and broadly defined psychotic symptoms, patients in the
course of the symptoms, the follow-up rater diagnosed her as residual group displayed the poorest global outcome
having factitious psychosis. Interestingly, the index admis-
rating of any of the three subgroups of borderline
sion rater, although not noting factitious psychotic symp-
personality disorder patients (table 1), although this
toms, did note factitious neurologic symptoms: during her
difference did not approach significance.
admission, a neurologist had diagnosed factitious anesthesia,
present in a nonanatomic distribution. The treatment re-
sponse rater noted that she failed to respond to chlorproma-
zine, thioridazine, lithium carbonate, and amitriptyline. CONCLUSIONS

A residual group of 13 patients did not fall into any In this study we examined the nature and prevalence
of the other three groups. These patients, although of psychotic symptoms in a sample of 33 patients with
they lacked symptoms meeting the narrow DSM-III borderline personality disorder. We proposed four
definition of psychotic, nevertheless displayed some subgroups of this sample on the basis of the presence
features, such as dissociative episodes, periods of re- or absence of various types of psychotic symptoms,
gression during psychotherapy, and impaired reality rated on index admission and/or on follow-up. Blind
testing, that might be considered psychotic by assessments of family history, treatment response, and
broader definitions of the term. follow-up status,
based on a previously developed
In an attempt to assess the extent of such symptoms methodology (4, 24, 25), together with a survey of a
in the borderline personality disorder sample, we ad- normal control group, were used to test the validity of
ministered the psychosis section of the first edition the proposed subgroups. A major limiting factor in the
of the DIB to the 15 normal control subjects and study was the small size of the total sample and the
compared their psychosis scores to those of the four even smaller size of the four subgroups examined.
groups of patients with borderline personality disor- The first subgroup included patients whose psy-
der. The DIB assesses a range of broadly defined chotic symptoms appeared to be directly attributable
psychotic symptoms such as depersonalization, to an organic etiology. Only one patient in our cohort,
derealization, other dissociative symptoms, transient a hallucinogen abuser, met this criterion. His psychotic
paranoid episodes, and regressions in psychotherapy. symptoms disappeared when he lost access to drugs.
Thus, we felt that this instrument might be sensitive to A second group consisted of seven patients with
more subtle symptoms than those subsumed under the borderline personality disorder who displayed psy-
DSM-III definition of psychosis. The DIB psychosis chotic symptoms meeting the DSM-III definition of
section generates a scaled score of 0 (none), 1 (inter- psychosis and lacking
any apparent organic basis. In
mediate), or 2 (highest). addition to meeting DSM-III criteria for borderline
Results of this comparison are shown in table 2. In personality disorder, these patients all met DSM-III
both the functional psychosis group and the factitious criteria for major affective disorder during the index
psychosis group, the number of individuals attaining hospitalization; all displayed a full affective syndrome
the maximum score of 2 was significantly greater than according to DSM-IlI criteria at the time of the
in the control group. However, the residual group with psychotic symptoms. Follow-up, family history, and
borderline personality disorder was not significantly treatment response ratings supported the hypothesis

1288 Am J Psychiatry 1 42: 1 1 November, 1985

 POPE, JONAS, HUDSON, ET AL

that the psychotic symptoms observed in this group presence of factitious seizures (as in our case 1) would
were attributable to major affective disorder, present support a close relationship between borderline per-
simultaneously with borderline personality disorder. sonality disorder and epilepsy.
A third group consisted of 12 patients who received We should note that factitious psychotic symptoms
a diagnosis of factitious psychosis. Although there is may represent autohypnotic phenomena. For example,
no proof that a given symptom was factitious, the studies of patients with multiple personality have
fanciful and nonstereotypic symptoms described by documented a high prevalence of both schizophrenia-
many patients, the absence of more typical psychotic like symptoms and multiple conversion symptoms,
symptoms in the same individuals, and other evidence hypothesized to be due to self-hypnosis (29, 30). The
of voluntary control all favored this diagnosis. Further symptoms described in these patients closely parallel
indirect evidence for the diagnosis included the simul- those of our patients with borderline personality dis-
taneous presence of factitious neurological symptoms order who displayed factitious psychotic and/or
in several patients and the failure of the psychotic medical symptoms. This raises the possibility that
symptoms to respond to neuroleptics. However, the multiple personality and other dissociative disorders
diagnosis of factitious psychosis must be considered may have existed but went unrecognized in some
tentative-particularly when the diagnosis was made members of our cohort.
on the basis of chart review. Indeed, when psychotic symptoms are due to self-
The fourth, residual category included 13 patients hypnosis or other dissociative mechanisms, the term
who did not meet the criteria for any of the three factitious might seem inappropriate: our patients
previous categories. These patients displayed only experienced their symptoms as very real. However, if
broadly defined psychotic symptoms such as disso- we consider self-hypnosis to be a process that the
ciative episodes or regressions in the hospital or in patient can voluntarily perform (although the process
psychotherapy. These symptoms, as measured by the may be unconscious, and the urge to perform it is not
first edition of the DIB, were not significantly more voluntary), then symptoms induced by self-hypnosis
prevalent in the residual group than in 15 control would appear, in DSM-III terminology, to require a
individuals who lacked major psychiatric disorders. diagnosis of factitious. On the other hand, one might
However, we must emphasize the possible insensitivity argue that certain dissociative states in these patients
of this one method of comparison, especially given the were totally involuntary. Thus the older term, hyster-
small numbers in both groups. ical psychosis, might better describe such phenomena
In summary, it appears that functional psychotic (3 1). In any event, these considerations do not affect
symptoms meeting the DSM-III definition, when they our principal conclusion: the factitious or hysteri-
occurred in our patients with borderline personality cal psychotic symptoms experienced by these patients
disorder, probably were attributable to a concomitant are different from the ordinary psychotic symptoms seen
axis I disorder such as substance abuse or major in, say, schizophrenia or bipolar disorder and thus do not
affective disorder. These psychotic symptoms appeared argue for a close relationship between borderline person-
only during periods of substance abuse or episodes of ality disorder and ordinary psychotic disorders.
major affective disorder and not at other times when Finally, although many of our remaining patients
the patients displayed symptoms of borderline person- with borderline personality disorder displayed
ality disorder alone. Thus, barring the possibility that broadly defined psychotic symptoms, we were un-
borderline personality disorder predisposes to psy- able to demonstrate that these symptoms were more
chotic symptoms in substance abusers or in affective prevalent in subjects with borderline personality dis-
disorder, it seems inappropriate to consider such psy- order than in normal control subjects.
chotic symptoms a feature of borderline personality Therefore, despite the common asumption that tran-
disorder itself. sient psychotic symptoms may be a feature of border-
On the other hand, factitious psychotic symptoms, line personality disorder (3, 7-9), our findings do not
as defined byDSM-III, do seem to be a feature of suggest a close relationship between borderline person-
borderline personality disorder. This finding is consist- ality disorder and ordinary psychotic disorders. Given
ent with the converse observations that patients with this, the term borderline-with its implication that
factitious psychotic symptoms display a high preva- such patients lie on the border of psychosis-may not
lence of borderline personality disorder (24) and that be an appropriate term for this group of patients.
patients with chronic factitious disorder score as hay-
ing borderline personality disorder on the DIB (22). It REFERENCES
also seems consistent with an earlier twin study (28)
I . Spitzer RL, Endicott J: Justification for separating schizotypal
that identified a histrionic hysteria factor heavily and borderline personality disorders. Schizophr Bull 5:95-100,
loaded with exhibitionistic, imaginative, and possibly 1979
confabulatory traits. However, the presence of facti- 2. Kernberg 0: Borderline Conditions and Pathological Narcis-
tious psychotic symptoms in borderline personality sism. New York, Jason Aronson, 1975
3. Gunderson JG, Singer MT: Defining borderline patients: an
disorder would not appear to argue for a close rela- overview. Am J Psychiatry 132:1-10, 1975
tionship between borderline personality disorder and 4. Pope HG, Jonas JM, Hudson JI, et al: The validity of DSM-III
ordinary psychotic disorders, any more than, say, the borderline personality disorder: a phenomenologic, family his-

Am J Psychiatry 1 42: 1 1 November

, 1985 1289
PSYCHOSIS IN BORDERLINE PERSONALITY DISORDER

tory, treatment
response, and long-term follow-up study. Arch 18. Soloff P, Ulrich RF: Diagnostic Interview for Borderline Pa-
Gen Psychiatry 40:23-30, 1983 tients: a replication study. Arch Gen Psychiatry 38:686-692,
S. Kroll J, Carey C, Sines L, et al: Are there borderlines in Britain? 1981
a cross-validation of US findings. Arch Gen Psychiatry 19. Kernberg OF, Goldstein EG, Carr AC, et al: Diagnosing bor-
39:60-63, 1982 derline personality: a pilot study using multiple diagnostic
6. Loranger A, Oldham J, Tulis E: Familial transmission of methods. J Nerv Ment Dis 169:22S-231, 1981
DSM-III borderline personality disorder. Arch Gen Psychiatry 20. Koenigsberg HW, Kernberg OF, Schomer J: Diagnosing bor-
39:795-799, 1982 derline conditions in an outpatient setting. Arch Gen Psychiatry
7. Stanton AH: Personality disorders, in The Harvard Guide to 40:49-53, 1983
Modern Psychiatry. Edited by Nicholi AM Jr. Cambridge, 21. Jonas JM, Pope HG Jr: Psychosis in borderline personality
Harvard University Press, 1978 disorder: a review of the literature. Psychiatr Developments
8. Vaillant GE, Perry JC: Personality disorders, in Comprehensive 4:295-308, 1984
Textbook of Psychiatry, 3rd ed, vol 2. Edited by Kaplan HI, 22. Barrash J, Kroll J, Carey K, et al: Discriminating borderline
Freedman AM, Sadock BJ. Baltimore, Williams & Wilkins, disorder from other personality disorders. Arch Gen Psychiatry
1980 40:1297-1302, 1983
9. Spitzer RL, Skodol AE, Gibbon M, et al: DSM-III Case Book. 23. McGlashan TH: The borderline syndrome, I: testing three
Washington, DC, American Psychiatric Association, 1981 diagnostic systems. Arch Gen Psychiatry 40: 13 1 1-1318, 1983
10. Knight RP: Borderline states. Bull Menninger Clin 17:1-12, 24. Pope HG Jr, Jonas JM, Jones B: Factitious psychosis: phenom.
1953 enology, family history, and long-term outcome of nine pa-
1 1. Grinker RR, Werble B, Drye R: The Borderline Syndrome. New tients. Am J Psychiatry 139:1480-1483, 1982
York, Basic Books, 1968 25. Pope HG Jr, Lipinski JF, Cohen BM, et al: Schizoaffective
12. Carpenter WT, Gunderson JG, Strauss JS: Considerations disorders: an invalid diagnosis? a comparison of schizoaffec-
of the borderline syndrome: a longitudinal comparative tive disorder, schizophrenia, and affective disorder. Am J Psy-
study of borderline and schizophrenic patients, in Borderline chiatry 137:921-927, 1980
Personality Disorders: The Concept, the Syndrome, the Patient. 26. Hudson JI, Pope HG Jr, Jonas JM, et al: Hypothalamic.
Edited by Hartocollis P. New York, International Universities pituitary-adrenal axis hyperactivity in bulimia. Psychiatry Res
Press, 1977 8:111-117, 1983
13. Gunderson JG: Characteristics of borderlines. Ibid 27. Kolb JE, Gunderson JG: Diagnosing borderline patients with a
14. Spitzer RL, Endicott J, Gibbon M: Crossing the border into semistructured interview. Arch Gen Psychiatry 37:37-41, 1980
borderline personality and borderline schizophrenia: the devel- 28. Torgersen S: Hereditary-environmental differentiation of gen-
opment of criteria. Arch Gen Psychiatry 36:17-24, 1979 eral neurotic, obsessive, and impulsive hysterical personality
15. Perry JC, Klerman GL: Clinical features of borderline person- traits. Acta Genet Med Gemellol (Roma) 29:193-207, 1980
ality disorder. Am J Psychiatry 137:165-173, 1980 29. Bliss EL: Multiple personalities: a report of 14 cases with
16. Conte HR, Plutchik R, Karasu TB, et al: A self-report borderline implications for schizophrenia and hysteria. Arch Gen Psychi-
scale: discriminative validity and preliminary norms. J Nerv atry 37:1388-1397, 1980
Ment Dis 168:428-435, 1980 30. Bliss EL: Spontaneous self-hypnosis in multiple personality
17. Sheehy M, Goldsmith L, Charles E: A comparative study of disorder. Psychiatr Clin North Am 7:135-148, 1984
borderline patients in a psychiatric outpatient clinic. Am J 31. Hollender MH, Hirsch SJ: Hysterical psychosis. Am J Psychia-
Psychiatry 137:1374-1379, 1980 try 120:1066-1074, 1964

1290 Am J Psychiatry 142:11, November 1985