Treating Schizophrenia and Borderline Personality Disorder Differently

Psychopathology may be represented as residing on a continuum, ranging from, at one end “psychotic” to at the other end, “normal”. “Personality disordered” and “neurotic” lie between the two. However, there are general differences in the psychological and relational experience of individuals with schizophrenia versus those with borderline personality disorder. 

Clearly, schizophrenia and borderline personality disorder should not be viewed from a compartmentalized and discrete either/or mentality. Given this continuum, however, these conditions are more or less differentiated form each other. In general, schizophrenics have more of a problem with a sense of self. They tend to be more dissociative and emotionally withdrawn than those persons with borderline personality disorder.

Most people with schizophrenia are psychologically assaulted by their internal experiences in the form of hallucinations. They lack perceived emotional and relational boundaries within their minds due to the onslaught of auditory hallucinations more or less commenting on their thoughts and behavior. 

This results in emotional distancing of themselves from real people and auditory hallucinations from which schizophrenics cannot escape. People with schizophrenia may be threatened and overwhelmed by painful emotional experience, causing resistance to emotional and relational engulfment in the material world.

People with borderline personality disorder can experience hallucinations intermittently. However, it is not generally as intrusive as that experienced by schizophrenics. While the emotional experience of people with borderline personality disorder is punitive, it is not as devastatingly painful. Even though people with borderline personality disorder are dramatic about their own emotional pain, schizophrenics simply shut down emotionally due to their psychological suffering. This results in limited emotional expression and a lack of motivation

Borderline personality disordered individuals value and devalue engulfment intermittently. This results from difficulties in early childhood relationships.  Essentially, children with borderline personality disorder most likely had care-givers who made them feel safe and unsafe intermittently. This results in the grown child seeking both engulfment and emotional distancing as a cyclic, dysfunctional pattern of behavior.

The differences in the general emotional and psychological experience of people with borderline personality disorder and those with schizophrenic imply differences in psychological treatment for these disorders.

People with borderline personality disorder should be treated with implacable good will by the psychotherapist, which may allow them to overcome their essential lack of trust.  The psychotherapist should be consistent in their positive treatment. Treatment should target dysfunctional, ingrained character traits that are longstanding in the individual’s relationship to the world. Such traits may include a sense of extreme distrust in others and an overwhelming need to depend on others. 

This does not mean that schizophrenics should not be treated with implacable good will.  However, schizophrenic people deal with isolation resulting from their emotional withdrawal and delusional thinking. Moreover, the stigma attached to having a psychotic disorder may inhibit them from discussing their hallucinations and delusions with their psychotherapist.

Schizophrenic patients’ isolation demands that the psychotherapist draws them out of their idiosyncratic view of the world. Their delusions must be challenged, and social involvement is important. Social interaction will help reduce dissociation resulting from traumatic experience of mental illness. Group and individual therapy is said to mitigate some, if not all, delusional ideas. The central aim in psychotherapy with schizophrenic people is to help them vent emotions that might otherwise remain dangerously dormant.

In terms of individuals with borderline personality disorder, diminished emotional expression is not an issue. The aim of psychotherapy is not to elicit emotion, but to regulate and stabilize it. Although such individuals express much dramatic emotion, including suicidal gestures and intent, they may not actually want to kill themselves.

Stigma related to borderline personality disorder may exceed that attached to schizophrenia. The possibility of the psychotherapist’s culpability in exacerbating the psychopathology of the borderline personality disordered individual should be scrutinized. While most psychotherapists who treat this disorder are ethical and responsible, the remaining few should carefully examine their own feelings and views of their clients. 

Overall, relating to the world in a healthy way is crucial to both people with schizophrenia and borderline personality disorder. Psychotherapy with both of these clients relies on building a relationship with them and talking to them. 

This means that psychotherapy for both those with schizophrenia and those with borderline personality disorder may be approached from a cognitive-relational perspective by the psychotherapist to good effect. As such, a cognitive-relational stance by a clinician is advocated as potentially helpful and perhaps somewhat curative to individuals with schizophrenia and borderline personality disorder.

Image via Wave Break Media / Shutterstock.

Ann Reitan, PsyD

Ann Reitan, PsyD, is a clinical psychologist and well published essayist of fiction and creative nonfiction. She holds a Bachelor of Arts in Psychology from University of Washington, Master of Arts in Psychology from Pepperdine University, and Doctorate of Clinical Psychology from Alliant International University. Her post-doctoral research at Washington University in St. Louis, MO, involved personality theory, idiodynamics and creativity in literature. She recently published Illuminating Schizophrenia: Insights into the Uncommon Mind.
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