Voice Hearing in Borderline Personality Disorder Across Perceptual, Subjective, and Neural Dimensions

Psychotic-Like Reasoning Styles in Patients With Borderline Personality Disorder? An Experimental Investigation of the Jumping to Conclusions Bias

INTRODUCTION

Patients with borderline personality disorder (BPD) commonly display psychotic symptoms such as hallucinations or delusional/paranoid ideas. We used the fish task to investigate cognitive biases (jumping to conclusions and overcorrection) implicated in the aetiology of psychotic symptoms in patients with BPD.

METHODS

Participants received consecutive pieces of information to determine which of two lakes a fisherman was catching fish from. Outcome measures were draws to decision and frequency of premature decisions after just one and after not more than two fish (jumping to conclusions), probability estimate at the time of the decision (decision threshold) and adjustment of the probability estimate after receiving disconfirmatory information (overcorrection). With data aggregated from multiple studies, a total of 170 patients with BPD and 72 healthy controls (parallelized by age, gender and education) participated.

RESULTS

The two groups showed similar draws to decision and frequencies of premature decisions. The decision threshold was also comparable across the groups. However, the patients with BPD showed overcorrection.

CONCLUSIONS

The experimental study found no evidence for a jumping to conclusions bias or a lower decision threshold in patients with BPD. The stronger adjustment of probability estimates (overcorrection) in patients with BPD is compatible with the unstable affect, self-image and interpersonal relationships observed in patients with BPD.

Recognition and management of auditory verbal hallucinations in borderline personality disorder

Background

Auditory verbal hallucinations (AVH) are experienced by 25% of all people diagnosed with a borderline personality disorder. Since the impact of these hallucinations is often substantial, we asked ourselves how often they are discussed in clinical practice, whether they are treated, and if so, how and to what effect.

Methods

We studied the clinical files of 130 people under treatment at a specialized outpatient clinic for people with personality disorders, and compared the data on the presence and treatment of AVH to those collected in four prior scientific studies by our group.

Results

Of the 130 participants to those earlier studies, 42 had reported on experiencing AVH ≥ once per week. In 31% of the cases this had been missed by the treating healthcare professionals. Of the people suffering from severe AVH, a concurrent schizophrenia spectrum disorder was diagnosed in only 10%. A minority of 41% had received targeted treatment for their AVH. Doses of antipsychotics had been relatively low compared to those recommended for psychotic disorders, and yet all patients treated had reported a decrease in the frequency or severity (or both) of their AVH. Unfortunately, 93% also reported side effects, which led 57% of the group to discontinue this type of treatment. Nonpharmacological treatments such as cognitive behavioral therapy had been offered only to a minority of the participants.

Conclusion

Even in specialized clinical settings it remains challenging to establish the possible presence of AVH in people with a borderline personality disorder. And yet this is worth the effort because of the impact that these hallucinations tend to have, and the positive effects of antipsychotic treatment here presented. Further research is needed to develop algorithms to optimize doses in individual patients, to develop treatment guidelines, and to explore the effects of nonpharmacological treatments.

Examining the relationships between cognition and auditory hallucinations: A systematic review

OBJECTIVE

Auditory hallucinations (hearing voices) have been associated with a range of altered cognitive functions, pertaining to signal detection, source-monitoring, memory, inhibition and language processes. Yet, empirical results are inconsistent. Despite this, several theoretical models of auditory hallucinations persist, alongside increasing emphasis on the utility of a multidimensional framework. Thus, clarification of current evidence across the broad scope of proposed mechanisms is warranted.

METHOD

A systematic search of the Web of Science, PubMed and Scopus databases was conducted. Records were screened to confirm the use of an objective behavioural cognitive task, and valid measurement of hallucinations specific to the auditory modality.

RESULTS

Auditory hallucinations were primarily associated with difficulties in perceptual decision-making (i.e. reduced sensitivity/accuracy for signal-noise discrimination; liberal responding to ambiguity), source-monitoring (i.e. self-other and temporal context confusion), working memory and language function (i.e. reduced verbal fluency). Mixed or limited support was observed for perceptual feature discrimination, imagery vividness/illusion susceptibility, source-monitoring for stimulus form and spatial context, recognition and recall memory, executive functions (e.g. attention, inhibition), emotion processing and language comprehension/hemispheric organisation.

CONCLUSIONS

Findings were considered within predictive coding and self-monitoring frameworks. Of concern was the portion of studies which - despite offering auditory-hallucination-specific aims and inferences - employed modality-general measures, and/or diagnostic-based contrasts with psychologically healthy individuals. This review highlights disparities within the literature between theoretical conceptualisations of auditory hallucinations and the body of rigorous empirical evidence supporting such inferences. Future cognitive investigations, beyond the schizophrenia-spectrum, which explicitly define and measure the timeframe and sensory modality of hallucinations, are recommended.

A phenomenological comparison of auditory hallucinations between borderline personality disorder and schizophrenia: A systematic review

OBJECTIVE

Borderline personality disorder (BPD) with auditory hallucinations (AHs) may inadvertently be misdiagnosed with a primary psychotic disorder, such as schizophrenia (SZ). This misidentification can lead to challenges in providing effective psychological treatment. This review therefore aims to identify the phenomenological characteristics of AHs in BPD in comparison to SZ, as well as psychological interventions that explicitly target AHs in BPD.

METHODS

A systematic review was conducted to summarise the existing evidence base regarding the phenomenological similarities and differences of AHs in BPD and SZ, along with the identification of psychological interventions for AHs in BPD.

RESULTS

Eighteen studies were eligible for inclusion. Compared to the SZ group, BPD clients were characterised by more persistent and repetitive AHs, significantly more voice-related distress and appraisals of omnipotence, and an earlier age of onset of AHs. The BPD group also reported more severe depression and anxiety, a higher incidence of childhood trauma, and more negative self-schema. Cognitive Behaviour Therapy Coping Strategy Enhancement (CBT-CSE) might be a promising intervention to reduce AH-related distress in BPD, although further studies are required to determine its effectiveness.

CONCLUSION

In order to prevent misdiagnosis of AHs in BPD, the DSM-5 may need to acknowledge the broader and more frequent occurrence of psychosis symptoms in BPD clients. Such clarification may enhance diagnostic practices and facilitate more timely access to treatment. There is also a need to develop and trial psychological interventions that explicitly target AHs in BPD.