Overlap Between Borderline and Schizotypal
Disorders
Richard J. Kavoussi
Borderline personality was split into two diagnotic
categories in DSM-III: borderline personality disorder
(BPD) and schizotypal personality disorder (SPD). There
remains a great deal of diagnostic overlap between
these two categories despite modifications in DSM-
III-R. This report discusses four possible hypotheses
for this overlap: (1) an independent, random associa-
tion; (2) a&factual overlap due to imperfections in the
S
INCE THE TIME of Bleuler, psychiatrists
have identified patients with attenuated
symptoms of schizophrenia-poverty of affect,
impaired interpersonal relatedness, and magi-
cal thinking.‘” Danish adoption studies sug-
gested that these “borderline schizophrenics”
had personality features that might represent a
phenotypic expression of a “schizophrenic
genotype.“’ Simultaneously, other investigators
identified a group of patients with unstable
affective symptoms and impulsivity who ap-
peared to lie “on the border” of classic affective
disorder.‘.” The identification of these two
groups of patients led to the development of
diagnostic criteria for two separate personality
disorders: schizotypal personality disorder (SPD)
and borderline personality disorder (BPD).”
Yet, although defined as separate diagnostic
categories, these personality disorders fre-
quently overlap. The degree of this overlap has
ranged from 7% to 58% in samples of border-
line and schizotypal patients previously re-
ported in the literature (Table 1). The extent of
overlap in these studies is, in part, a function of
the particular sample studied. Studies with
approximately equal numbers of SPD and BPD
in the sample show more overlap, while studies
with unequal samples have reported low over-
lap. Thus, it is imperative to take base rates into
account when evaluating studies of diagnostic
overlap.”
Some changes were made in DSM-III-R in an
attempt to reduce the degree of overlap. For
example, depersonalization and derealization
are no longer examples of unusual sensory
experiences for SPD and a new criterion-odd
behavior-was added to the criteria for SPD.
Still, even with these changes, the degree of
overlap is still significant’4-‘h and overlap be-
Comprehens/vefsychiatry, Vol. 33, No. 1 (January/February),
Personality
and Larry J. Siever
criteria sets; (3) a synergistic association of the two
personality disorders; and (4) a manifestation of dimen-
sional psychopathology. Empirical evidence for each
of the first three hypotheses is weak and contradic-
tory. Recent biologic and treatment studies appear to
most strongly support the use of dimensional models
of “borderline” and “schizotypal” personality traits.
Copyright 0 1992 by W.B. Saunders Company
tween these two disorders remains a concern for
DSM-III-R and the development of DSM-IV.
This substantial overlap has prompted ques-
tions regarding the validity of the current crite-
ria sets for these two personality disorders.” It
has also generated concern since accurate diag-
nosis of these disorders is important in determin-
ing response to treatment.
There are four plausible hypotheses that
might account for the overlap between schizo-
typal and borderline personality disorders. First,
the overlap may simply be an independent,
random association between the two personal-
ity disorders. Second, the overlap between BPD
and SPD may be an artifact of the nature of the
criteria sets used in DSM-III and DSM-III-R.
Third, there may be an inherent association or
“synergism” between these two disorders. Fi-
nally, these disorders may not exist as discrete
categorical entities, but rather as dimensional
manifestations of personality psychopathology.
Various empirical methods can be used to
test these hypotheses by studying differences
between three groups: “pure” BPD, “pure”
SPD, and “mixed” BPD-SPD. These methods
include phenomenological studies, family his-
tory and genetic studies, biologic marker stud-
ies, treatment response studies, and outcome
studies. In this report, we will present each
hypothesis and evaluate the empirical evidence
for each.
From the Department of PsychiatT, Medical College of
Pennsylvania, Philadelphia, PA; and the Department of Psychi-
atty, Mount Sinai Medical Center, New York, NY.
Address reprint requests to Richard J. Kavoussi, M.D.,
Department of Psychiatry, Medical College of Pennsylvania at
EPPI, 3200 Henry Ave, Philadelphia, PA 19129.
Copyright 0 I992 by WB. Saunders Company
OOlO-44OXl9213301-0006$03.0010
1992: pp 7-12 7
8 KAVOUSSI AND SIEVER

Table 1. Overlap of BPD and SPD Artifactual overlap also may result from im-
Study S B SB %SB precise definitions of criteria. This may be
Silk, 1990’6 0 31 8 20.5 especially true for BPD and SPD, since the
Vaglum. 1989 (DSM-III-R)15 6 41 7 13.0 criteria for these disorders had their origins in
Morey, 1988 (DSM-III-R)‘4 27 97 9 6.8 overlapping criteria sets.20For example, Gunder-
Widiger, 1987” 19 24 29 40.3
son’s criteria for BPD stress the importance of
McGlashan, 198724 10 81 18 16.5
George, 198625 4 24 18 39.1 psychotic-like symptoms while DSM-III does
Jacobsberg, 198627 19 6 16 39.0 not incorporate criteria for these symptoms.
F’fohl, 198640 6 23 6 17.1 Those who work with clinical samples argue for
Baron, 1985’* 16 17 20 37.7
the importance of including psychotic like expe-
Gunderson, 198321 8 6 13 48.1
Spitzer, 197912 145 170 436 58.0
riences in the diagnostic criteria for SPD since
this corresponds to current clinical diagnoses
Abbreviations: S, DSM-III schizotypal personality disorder; B,
DSM-III borderline personality disorder; SB, both schizotypal
and is thus useful to practicing clinicians in their
and borderline personality disorder. conceptualization of patients. On the other
hand, those who study genetic and biological
markers of SPD argue that schizotypal patients
RANDOM OVERLAP (as in the original conceptions of Rado and
The overlap between BPD and SPD may Meehl) should be defined less by psychotic
simply be an independent, random association experiences and more by social-interpersonal
between the two personality disorders. Then it dysfunction, impoverished affect, asociality, and
would be expected that the prevalence of over- somatization.”
lap would be equal to the product of the Imprecise criteria for axis II disorders may
prevalence of each personality disorder (% hinder the differentiation of psychotic-like per-
overlap = %SPD x %BPD). In most studies, sonality traits in BPD and SPD. Patients meet-
the overlap between SPD and BPD has been ing criteria for both SPD and BPD may repre-
higher than would be expected by chance associ- sent those borderlines with psychotic-like
ation alone (see Table 1). features as originally proposed by Gunderson.
The high degree of overlap in these samples However, psychotic-like symptoms in the border-
also may reflect the possibility that the overlap line patient may reflect different underlying
group is more ill than those with either SPD or psychopathology than psychotic-like symptoms
BPD alone and thus are more likely to seek in schizotypes, just as psychotic symptoms in
treatment in a clinical setting. Yet, even in bipolar patients do not necessarily reflect the
nonclinical samples, the degree of overlap is still same pathologic process as psychosis in schizo-
higher than would be expected from random phrenics.
overlap.‘” Thus, it is unlikely that this hypothesis There are several ways in which psychotic
alone is correct. symptoms in borderline patients can occur.2’,23
First, in some borderline patients, mood congru-
ARTIFACTUAL OVERLAP ent psychotic symptoms may reflect a coexisting
The overlap between BPD and SPD may be axis I affective disorder and not the underlying
an artifact of the nature of the criteria sets used psychopathology of this personality disorder.
in DSM-III and DSM-III-R. First, because Second, borderline patients may produce dra-
DSM-III uses a prototypic system of classifica- matic and bizarre psychotic symptoms to engage
tion, there is much heterogeneity among mem- caregivers or when faced with disruptions in
bers of each diagnostic category. For example, their chaotic interpersonal relations. Third, al-
there are 93 combinations of criteria that will tered cognitive-perceptual symptoms and para-
lead to a diagnosis of BPD. While the sensitivity noia in the borderline may be closely associated
of a particular diagnostic category is enhanced with intolerable, intense, and rapidly changing
when there is a broad range of combinations of affective states (guilt, anger, sadness, etc.). These
criteria sufficient to make a diagnosis, such a types of psychotic symptoms are different from
strategy reduces specificity, leading to increased the persistent psychotic-like symptoms (ideas of
overlap among diagnostic categories.” reference, paranoia, magical thinking) found in
BORDERLINE AND SCHIZOTYPAL OVERLAP
schizotypal patients. DSM-IV will need to ad-
dress these issues by defining more precisely the
nature of psychotic like experiences included in
the criteria sets.
There are other ways in which current criteria
for BPD and SPD may not adequately differen-
tiate affective-related traits from schizophrenia-
related traits. For example, both borderline and
schizotypal patients can exhibit social isolation
and social anxiety, although these are criteria
only for SPD. Yet, these symptoms may reflect
different underlying psychophysiologic pro-
cesses. The impairment in affective regulation
seen in BPD may lead to intense, stormy rela-
tionships resulting in social isolation. Impaired
cognitive-perceptual ability in the interpersonal
sphere in the schizotypal patient would lead to
chronic discomfort around others and a lack of
interpersonal contact. Future criteria for these
personality disorders must explicitly define these
traits to improve their nosologic utility.
If the overlap group in a particular study
consists of borderline patients with hysterical or
transient psychoses who are diagnosed as hav-
ing both BPD and SPD, then the overlap group
should resemble the pure BPD group on the
validating measures noted above. There is some
empirical support for this model. Several stud-
ies have found that patients in the mixed SPD-
BPD group have symptoms more like pure
borderline patients than pure schizotypal pa-
tients.‘4.‘5 The overlap group appears to resem-
ble the schizotypal group with respect to psy-
chotic-like SPD criteria (suspiciousness, magical
thinking), but is more like the borderline group
with respect to the absence of “negative” schizo-
typal symptoms (social isolation, inadequate
rapport).” These findings suggest that the diag-
nosis of SPD in the overlap group is in part
based on the presence of psychotic-like symp-
toms and may represent an artifact of the
criteria sets. Unfortunately, not all studies have
replicated these findings.“,”
Twin and family studies provide some sup-
port for the artifactual overlap hypothesis. In
the only twin study conducted to date,2y 33% of
monozygotic schizotypal probands and 4% of
dizygotic probands were concordant for SPD.
On the other hand, none of the monozygotic
probands and 29% of dizygotic borderline
probands were concordant for BPD. There
9
were no diagnoses of SPD or BPD in the twins
of mixed borderline-schizotypal probands. One
family study found an increased risk for SPD in
the relatives of pure SPD probands and no
increased risk of SPD in the relatives of the
mixed SPD-BPD sample.‘* Thus, it would ap-
pear that pure SPD has a clearer genetic compo-
nent than both BPD and the overlap group and
that the overlap group is a subset of BPD with
psychotic-like features.
One study looking at discharge status, treat-
ment variables, psychopathology, functional out-
come, and global outcome found that the mixed
group resembled the pure borderline group
more than the pure schizotypal group on most
indices of outcome.30 The only measures on
which the overlap group resembled the pure
SPD group were on lack of drug abuse and
problems in heterosexual relationships. An-
other study also found that while the mixed
group was as impaired as schizophrenics at
admission (and significantly lower functioning
than pure borderlines), at follow-up these pa-
tients were functioning as well as the pure
borderlines.“’ While these studies would appear
to support the artifactual hypothesis, another
study found that the mixed diagnosis patients
were more like the pure schizotypes in having a
poorer outcome than the pure borderlines.”
Biologic studies in these groups have not
supported the artifactual hypothesis. Amphet-
amine challenge tests performed on a sample of
borderline patients32 demonstrated that those
patients with pure BPD showed global improve-
ment in mood, while those patients with both
SPD and BPD had an increase in psychotic
symptoms and a decreased sense of well-being.
Smooth pursuit eye movements were abnormal
more often in patients with pure SPD, and the
overlap group than in a control group of other
personality disorders.33 These findings argue
against the artifactual hypothesis as the sole or
major cause of the overlap between these per-
sonality disorders.
SYNERGISTIC MODEL
A third explanation for the high degree of
SPD-BPD overlap is that there is an inherent
association or “synergism” between these two
disorders. In this model, etiologic factors for
each disorder are likely to act together to
10
produce distress and dysfunction as in hyperten-
sion and adult onset diabetes. These disorders
are associated with each other much more
commonly than chance alone would dictate,
sharing common etiologic factors (family his-
tory, diet, obesity) and outcome (increased risk
of arterial disease).
One method to investigate synergistic overlap
of SPD and BPD is to study the correlation
between the DSM-III item sets for each disor-
der independent of the degree of overlap. In the
original study by Spitzer et al.” although there
was 58% overlap between the two diagnoses,
there was only a .06 correlation between criteria
sets. More recent studies have found a some-
what higher correlation between SPD and BPD
criteria, ranging from .19 to .62,34-36suggesting
an inherent correlation between the two disor-
ders.
If the overlap group represents a synergistic
association between SPD and BPD, the mixed
group would have characteristics and symptoms
not observed in either diagnosis alone. Al-
though, as noted above, several family studies
favor the artifactual hypothesis, one study re-
ported higher rates of schizophrenia in the
relatives of patients with mixed BPD-SPD than
in pure SPD or BPD probands. Unfortunately,
there has been little other empirical evidence to
support this hypothesis.
DIMENSIONAL MODEL
Since the inception of the DSM-III personal-
ity disorders section, many nosologists have
argued that it is better to think of personality
disorders along dimensions of psychopathology
than as categorical entities.” In fact, in attempt-
ing to explain the overlap of BPD and SPD,
Spitzer and Endicott3’ noted that these disor-
ders may be better considered as independent
dimensions of personality that may coexist in
the same individual than as mutually exclusive
diagnoses. Phenomenological studies have sug-
gested that multidimensional scalings of person-
ality traits have more validity than categorical
diagnoses.3y-4’
There is increasing evidence that certain
dimensions of psychopathology in personality
disordered patients (e.g., affective instability,
cognitive-perceptual impairment, impulsivity)
may correspond more precisely than categorical
KAVOUSSI AND SIEVER
diagnoses to biological markers.42 Abnormali-
ties in central serotonergic functioning as mea-
sured by the prolactin response to the serotoner-
gic agonist fenfluramine have been associated
with disordered impulse control, irritability, and
aggressivity in patients with personality disor-
ders, regardless of categorical diagnosis.43 Mea-
sures of plasma and cerebral spinal fluid homo-
vanillic acid (HVA), which reflect central
dopaminergic functioning, have been found to
correlate with “positive” schizotypal symptoms
(e.g., magical thinking, ideas of reference), but
not with “negative” symptoms (e.g., social isola-
tion, odd speech, inadequate rapport).44,45
Treatment studies also support a dimensional
model. In a double-blind trial of haloperidol,
amitriptyline, and placebo, haloperidol was sig-
nificantly better than both amitriptyline and
placebo in reducing phobic anxiety, hostility,
paranoia, psychoticism, and obsessive symp-
toms.46No specific differences between diagnos-
tic groups were reported. In another double-
blind study comparing thiothixene with placebo,
drug effects were present, but were related
more to specific symptoms (such as illusions,
ideas of references, phobic anxiety, obsessions,
and somatization) than to measures of global
improvement across diagnoses.47 In a double-
blind, cross-over study comparing the effects of
various medications on the symptoms of border-
line personality, the monoamine oxidase inhibi-
tor tranylcypromine was most effective in im-
proving mood and impulse control, while
carbamzepine was most effective in the treat-
ment of behavioral dyscontro1.48 These results
suggest that treatment response in a given
patient depends more on specific dimensions of
symptoms, rather than on the categorical person-
ality diagnosis.
CONCLUSIONS
None of the above hypotheses fully account
for the overlap found between SPD and BPD as
defined by DSM-III and DSM-III-R. However,
the empirical evidence tends to support the
dimensional model of overlap. This model is
supported by biologic marker studies, treatment
response studies, and conflicting results of em-
pirical studies in categorical models. The associ-
ation of specific personality traits with specific
biological markers and specific treatment re-
BORDERLINE AND SCHIZOTYPAL OVERLAP 11

sponse suggests that personality pathology may
be best studied using dimensional models. Vari-
ous traits such as impulsivity, avoidance, affec-
tive lability, avoidance, and perceptual deficits
should be studied independently and correlated
with genetic vulnerability, phenomenologic man-
ifestations, biological features, and treatment
response.
This hypothesis of overlap does not necessar-
ily exclude the previous hypotheses discussed
since models of dimensional psychopathology
may coexist with categorical models. It is possi-
ble for an individual to have traits that occur
along a continuum with a syndromal disease
state. For example, myocardial oxygen demands
vary across individuals depending on congenital
factors, exercise, and life-style. When coronary
artery disease occurs, manifestations of this
disease will depend as much on preexisting
myocardial functioning as on the degree of
CAD and can range from no symptoms to
angina to myocardial infarction. Similarly, cate-
gorical psychiatric disorder will be influenced in
their expression by underlying traits that will
vary across individuals. Until more empirical
data are available, it would be prudent to use
both categorical and dimensional models to
improve our diagnostic ability with respect to
BPD and SPD.

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