Severe insomnia and perceptual disturbances in borderline personality disorder: Diagnostic challenges in the context of polypharmacy

Abstract

Introduction: Borderline Personality Disorder (BPD) is characterized by affective instability, impulsivity, disturbed self-image, and unstable interpersonal relationships, with high psychiatric comorbidity. Generalized Anxiety Disorder (GAD) commonly coexists with BPD and is associated with greater emotional dysregulation and suicidal ideation. In severe cases, GAD may present with atypical features such as profound insomnia and dissociative symptoms, complicating the differential diagnosis with mood and psychotic disorders. Case Report: Case of a 39-year-old woman with severe BPD, GAD, Alcohol Use Disorder in remission, and a history of complex trauma receiving multiple psychotropic medications. She presented to the Emergency Department with progressive insomnia for three months, progressing to near-total sleep deprivation for two weeks, accompanied by severe anxiety, emotional lability, pressured speech, hyporexia, visual hallucinations with preserved insight, dissociative symptoms, and a recent suicide attempt. On admission, she was alert and oriented, without elevated mood or delusions. The initial differential diagnosis included hypomania and medication-induced symptoms. During hospitalization, psychotropic treatment was optimized, including discontinuation of several medications and adjustment of antipsychotic therapy. Severe insomnia initially persisted in the absence of other affective symptoms, leading to exclusion of hypomania. Sleep subsequently normalized, and the perceptual disturbances were interpreted as manifestations of severe anxiety and BPD-related decompensation rather than a primary mood or psychotic disorder. This case highlights the diagnostic challenges of severe BPD and underscores the contribution of profound insomnia and polypharmacy to perceptual disturbances and emotional dysregulation.