Paranoia and Suspicion in Borderline Personality Disorder

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Young people with borderline personality disorder often experience episodes of paranoia and feelings of suspicion towards other people. These experiences can cause distress and affect young people’s ability to form relationships and learn from their social interactions.

While borderline personality disorder is a serious mental health disorder, it is treatable, and with effective support, young people can manage and overcome feelings of paranoia, suspicion, and mistrust. 

This blog offers some information on paranoia, delusions, suspicion, and mistrust as symptoms of BPD. It also explores treatment options that can support young people to live normal and fulfilling lives. 

Understanding Paranoia and BPD

Experiences of paranoia are a core feature of borderline personality disorder. Indeed, transient, stress-related paranoid ideation is one of the 9 DSM-V criteria for a BPD diagnosis.

But while the presence of paranoia in BPD is well established, experts’ opinions are changing about the way that paranoia is usually experienced.

Quasi-Psychotic Experiences

In the past, most researchers thought that experiences of paranoia among people with BPD were usually a kind of “quasi-psychotic” experience. Research on quasi-psychotic experiences often centred around nondelusional paranoia. Nondelusional paranoia involves interpersonal distrust and a belief that others have harmful intentions, but without holding onto conceptions of reality and events that are clearly different from other people’s.

Some studies have found that almost everyone with BPD experiences some form of quasi-psychotic experience. They’re also more common in BPD than other personality disorders. In one longitudinal study, 86.6% of people with BPD had episodes of nondelusional paranoia, compared to 43.1% of those with other personality disorders.

Research shows that while paranoia is present in other personality disorders, it’s especially connected to a risk for BPD. Some studies have found that it’s more common in BPD than persistent depressive disorder and even schizophrenia.

Persistence and Transience

In the DSM-V criteria for BPD, paranoia is described as transient and stress-related. However, research suggests that many people with BPD experience persistent paranoia over a long period of time.

In one study, episodes of paranoid delusion lasted between one and twelve weeks. Other researchers have concluded that experiences of hallucinations and delusions among those with BPD are ‘moderately stable.’ These experiences can persist intermittently or even persistently for many years.

On the other hand, when individuals are in treatment, their experiences of delusions can decrease over time. This might be connected to their recovery from BPD. Since delusions are often stronger and more frequent when someone is experiencing difficult emotions or low self-esteem, improvements in these symptoms may also lead to fewer delusions.

Paranoia and Delusions as Psychotic Experiences

While BPD delusions were previously assumed to be mostly quasi-psychotic experiences, experts now think that they’re often more similar to the psychotic experiences of people with schizophrenia and other psychotic disorders. For example, delusion conviction (the belief that delusions are real) appears to be similar for people with schizophrenia and BPD. 

Other research has found that people with BPD tend to experience more obvious than subtle forms of paranoia and sometimes severe paranoia.

Are BPD Delusions Distressing?

BPD delusions are often distressing for young people and adults. However, some research suggests that this distress is moderate and may not, in itself, cause significant disruption to their daily life.

Delusions among people with BPD seem to be less distressing than those experienced by people with schizophrenia, and those with BPD are less likely to be preoccupied by their delusions. People with schizophrenia also tended to experience delusions associated with persecution and loss of control more often.

Some researchers suggest that BPD delusions usually sit somewhere in the middle of a psychotic continuum between the experiences of healthy individuals and those for whom experiences of psychosis seriously disrupt their daily lives and require clinical care.

Suspicion and Lack of Trust

As well as experiencing paranoia, young people with BPD are often untrustworthy of others. People with BPD tend to have more negative opinions about other people than the general population, and cluster-C personality disorders (personality disorders like avoidant personality disorder that cause long-term feelings of insecurity and anxiety).

Mistrust of others among those with BPD may be largely rooted in early childhood adversity and trauma. Young people with BPD have often experienced some form of childhood trauma, such as abuse or neglect, or have had parents or caregivers who have been unable to meet their needs. This can have long-lasting effects on the way that young people relate to others, assuming neglect or mistreatment rather than support and care.

These childhood experiences can also cause people with BPD to be especially sensitive to rejection. Insecure relationships with caregivers are associated with a fear of abandonment – and rejection – by others. This may lead to increased expectations and perceptions of rejection and stronger emotional responses. 

In turn, expectations and overreactions to rejection may cause people with BPD to be less trusting of others. Studies have found that sensitivity to rejection (specifically, feelings of anger and anxiety) partly explains the relationship between BPD features and untrustingness.

What Happens When We Don’t Have Epistemic Trust?

When someone has epistemic trust, they believe that the information they learn from social interactions is trustworthy and relevant to their own experiences. Epistemic trust allows people to develop social and cultural skills that support effective and fulfilling social relationships. 

Epistemic mistrust, on the other hand, can cause interpersonal difficulties. For example, someone with epistemic mistrust may not learn after a positive experience with someone that people can be trustworthy but hold onto previous ideas of the general untrustworthiness of others. 

Experts think that people with BPD often have epidemic mistrust. This means that someone who has developed negative perceptions of others from their childhood experiences may find it hard to change these ideas despite having social experiences that contradict them. This can sustain feelings of paranoia and suspicion among people with BPD.

BPD in Young People: Treatment and Recovery

Paranoia, suspicion, and mistrust among young people with BPD can cause distress and act as a barrier to fulfilling relationships with others. However, with treatment and support, young people can challenge their perceptions of others and develop feelings of trust. They can also receive treatment to reduce paranoid delusions and other quasi-psychotic or psychotic symptoms.

When developing a treatment plan for a young person with BPD, it’s important to acknowledge that they may be experiencing psychotic symptoms and not only non-delusional paranoia. These symptoms shouldn’t be disregarded or assumed to be transient. Instead, treatment providers should develop a treatment plan to help manage and reduce symptoms and distress, such as psycho-education, therapy, and medication.

To address general mistrust of others and epistemic mistrust, treatment programs may include dialectical behavioural therapy and interpersonal therapy. These modalities work with young people to identify harmful attitudes and behavioural patterns and replace them with more positive ones. They teach a variety of skills, including trust in relationships and boundaries.

In general, treatment for BPD involves more than just psychological support. Instead, a team of professionals work together to support a young person to manage day-to-day life. This might include psychologists, psychiatrists, occupational therapists, and social workers.

The Wave Clinic: Transformative Recovery for Young People

The Wave Clinic offers specialist mental health support for children, teenagers, and young adults. Our programs aim to make a difference in the lives of young people, combining exceptional clinical care with education, enriching experiences, and social responsibility. We work with young people to discover new life paths, reconnect with themselves, and grow in self-confidence.

From our residential and outpatient centres in Kuala Lumpur, Malaysia, we provide a diverse range of specialist modalities, delivered by experts in teenage and adolescent psychiatry. We specialise in eating disorders, borderline personality disorder, and trauma-focused approaches. We work with sensitivity in everything we do and consider neurodiversity throughout our programs.

If you’re interested in finding out more about our programs, get in touch today. We’re here to help.

Fiona - The Wave Clinic

Fiona Yassin is the founder and clinical director at The Wave Clinic. She is a U.K. and International registered Psychotherapist and Accredited Clinical Supervisor (U.K. and UNCG).

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