We Need to Stop Excluding Paranoid Ideation in Discussions About Borderline Personality Disorder

I thought someone was watching me through my window. I closed my blinds, turned my lights off and locked my bedroom door. I dragged my laundry basket in front of my door to barricade it as if that would suffice. I then thought I needed to decipher a numerical code and began texting some random numbers to my friends, frantically awaiting a response from them. My hands did not seem to belong to me, and neither did my body. I cried myself to sleep and spent the night on the floor.

I awakened hours later, emotionally depleted, worried and confused, wondering why and how the paranoid mirage emerged. I saw the texts to my friends and the puzzled responses, but I maintained only a vague memory. I was 15 years old. If only I could identify the trigger and learn what to do next time.

One of my worst symptoms of borderline personality disorder (BPD) is transient, stress-related paranoid ideation. This is one symptom evaluated when making a diagnosis of BPD. It also seems to be rarely talked about, and there is a lack of research in the area, even though it discernibly links to the other symptoms. In one comprehensive study, 87% of people with BPD experienced the symptom of paranoid ideation.

Paranoid ideation describes thoughts of being conspired against, persecuted and suspicion towards the motives of others.

First, there are a few features with BPD and paranoid ideation.

1. The paranoid ideation is transient (relatively short-lived, such as minutes or hours) and occurs under the context of stress. The stressor is often interpersonal but may not be. This symptom characteristically occurs weekly but at least every month.

2. This symptom tends to regress quickly when the stress subsides, especially when someone with BPD is in a social context where they feel supported, nurtured and attended to. The transiency and reversion help set BPD apart from psychosis or delusions, which are false and fixed beliefs.

3. Even if we realize to an extent that our paranoid ideation is not a concrete fact, we doubt the reality strong enough and are so anxious that it leads to problems such as acting on it (e.g., confronting the source of the paranoia), extreme reactions or preoccupations.

4. Although often incorrectly used interchangeably, paranoid ideation differs from anxiety. Paranoid ideation is a type of anxious thought, and while it may make someone feel anxious, someone who is anxious is not necessarily struggling with paranoid ideation.

5. Paranoid ideation is not exclusive to BPD and may have different presentations, triggers and contexts depending on the condition (e.g., schizophrenia, post-traumatic stress disorder).

Someone with BPD who experiences paranoid ideation may think:

• Their partner is abandoning them or cheating them.
• Someone can read their mind.
• Someone is acting with malicious intent to make life difficult.
• Someone is taking advantage of them.
• Someone is “watching them.”
• There is a plot to hurt, abandon or reject them.
• There are hidden threats in someone’s tone, glances, body language and speech.

Abandonment fears, or more accurately, extreme reactions to and preoccupations with abandonment (and rejection), is another primary symptom of BPD that is stressful and often links with paranoid ideation. Mundane events, such as brief separations at work or school, perceived slights or misunderstandings may trigger extreme reactions, frantic efforts to avoid abandonment or paranoia.

For example, paranoid ideation may present itself when we are home alone and feel abandoned. We may experience the overwhelming feeling that we are being watched. As summed up by Dr. Gunderson: The idea that someone is watching them actually is a psychological way of not being alone. They’d rather have someone watching them than being alone. They can also have a sort of hallucinogenic-type phenomena. These are people who may have trouble going to sleep at night because they’re alone and they may hear voices under those circumstances.

A sudden wave of relief fell over me when I learned why these symptoms may happen in contexts when I feel abandoned. I became less afraid and more aware of it instead. I knew there was a connection between the abandonment reactions and paranoid ideation, but I never linked them that way before.

Other times, something mundane, such as someone accidentally stepping on my toe or brushing against me, may consume my thoughts for a whole day as I begin to slip away from reality and think they plotted over the course of time to hurt me. I may avoid the person and feel unsafe, which interferes with relationships. I may recognize that is not realistic, but it feels like two different people in my head arguing, both of whom sometimes have equal consideration. I vividly recall yet another instance when I thought my friends generated a secret email chain about me to plot about terminating my college enrollment. I cried for a few hours, fell asleep and no longer held this thought the next day. This sudden paranoid ideation toward people we trust is characteristic of BPD and relates to another main symptom of BPD called idealization and devaluation.

In my mind, most of my paranoid ideations are linked to abandonment or rejection in some way, no matter how mundane or unrelated they seem. The feeling that someone hurt me or plotted against me is the ultimate rejection.

Paranoid ideation in BPD may also relate to suicidality. During a period when I was alone and accumulated stress, I became paranoid that I was under the control of something else. While I did not wholly believe it, there seemed to be a chip implanted in my head with a voice telling me to take my life on repeat. This is the best way I can describe it, given that they did not seem to be “full” hallucinations, but they certainly were not my typical thoughts either. I cried and began to argue out loud with the voices before I recognized this red flag in a fleeting moment of clarity. I admitted myself to the hospital and regressed completely a couple of hours later.

My thoughts can easily become jumbled, disconnected and can race under minor stress. It can be apparent in my difficulty forming a simple, coherent sentence.

Even more, physical vulnerabilities (e.g., poor sleep and hunger) may increase susceptibility to emotion dysregulation and stress, increasing paranoid ideation.

Evidently, paranoid ideation in BPD relates to factors of increased stress and links to other BPD symptoms. Yet, discussions surrounding BPD often exclude it, in addition to other broader stress-induced BPD features that may relate to paranoid occurrences: transient hallucinations, ideas of reference — which is the belief that random occurrences or coincidences are directly related to the person (e.g., believing a message on TV or the radio is specifically directed at them) — and dissociation, like when I did not feel as if my body belonged to me.

Indeed, I have found understanding paranoid ideation and the links to my other symptoms and physical vulnerabilities to be a significant part in managing my symptoms. Before I was diagnosed with BPD, this symptom was not evaluated or identified in my treatment. Thus, it continued to worsen. Most of the time, my previous therapists did not pay much thought to it and seemed ill-equipped if I tried to mention it in the way that I knew how at the time.

Stigma is one reason this symptom may be overlooked beyond discussions of depression and anxiety. Additionally, paranoid ideation tends to be more often discussed in contexts of psychotic conditions like schizophrenia. However, others need to understand paranoid ideation is a main BPD symptom that has more to do with deep-rooted anxiety and fears of abandonment than it does with being dangerous.

Sometimes, but not always, it relates to early experiences of abandonment or neglect. Other times, we have extreme interpersonal sensitivities and emotion dysregulation that present this way. Simply, we want to manage our emotions, be loved and feel heard. We need help, but until accessible care, research dissemination and stigma improve, we may be unable to receive it.

It took years of practice, identifying my triggers and self-awareness skills to recognize this symptom, and I can still struggle. The discussion surrounding BPD must take a more holistic perspective.