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Borderline personality disorder (BPD) is a severe psychiatric condition marked by disturbances in self-image, affect regulation, and interpersonal functioning. Up to 54% of individuals with BPD experience psychotic symptoms, particularly auditory verbal hallucinations (AVH). While AVH's neural correlates have been studied in schizophrenia (SZ), their structural basis in BPD remains poorly understood within a transdiagnostic framework.

This cross-sectional study used voxel-based morphometry (VBM) on MRI data to assess gray matter volume (GMV) in BPD patients with AVH (n = 20), without AVH (n = 26), and healthy controls (HC; n = 30). The Psychotic Symptom Rating Scale (PSYRATS) assessed AVH severity. Analyses included factorial group models, small-volume correction for regions of interest, and regression analyses.

Compared to HC, BPD patients exhibited GMV reductions in primary motor, frontal, parietal, cingulate, and cerebellar cortices. BPD with AVH showed additional reductions in primary motor, frontal, parietal and occipital cortices relative to those without AVH and HC. In BPD with AVH, PSYRATS total scores negatively correlated with GMV in temporal, parietal, cingulate, primary motor, and cerebellar regions.

These findings reveal structural correlates of AVH in BPD, implicating sensorimotor, executive, and affective networks. The overlap with SZ-associated cortical patterns suggests transdiagnostic neural mechanisms and shared pathophysiological substrates of AVH.