A study of psychotic symptoms in borderline personality disorder

Borderline personality disorder vs. schizophrenia spectrum disorders in young people recruited within an "Early Intervention in Psychosis" service: clinical and outcome comparisons

Borderline Personality Disorder (BPD) is under-recognized in First-Episode Psychosis (FEP) and its psychotic manifestations are difficult to differentiate from Schizophrenia Spectrum Disorders (SSD). The aim of this investigation was to compare clinical, sociodemographic, and outcome characteristics between FEP patients with BPD vs. FEP subjects with SSD both at baseline and across a 2-year follow-up period. Participants completed the Health of the Nation Outcome Scale (HoNOS), the Positive And Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF) scale both at entry and every 12 months during the follow-up. A mixed-design ANOVA model was conducted to investigate the temporal stability of clinical scores within and between the two subgroups. Among 356 FEP participants, 49 had a BPD diagnosis. Compared to FEP/SSD (n = 307), FEP/BPD patients showed higher prevalence of employment, current substance use, and past attempted suicide. They had a lower equivalent dose of antipsychotic medication at entry and lower levels of negative symptoms. Finally, they had a higher 2-year drop-out rate and a significant improvement in psychopathological scores limited to the first year of treatment. BPD as categorical entity represents a FEP subgroup with specific clinical challenges. Appropriate treatment guidelines for this FEP subgroup are thus needed.

Contrasting characteristics of psychosis in outpatients with borderline personality disorder or schizophrenia at a tertiary care institution

Summary and objectives

Borderline personality disorder (BPD) and schizophrenia can present with psychotic symptoms, such as delusions and hallucinations. This study, conducted at a tertiary care center, compared the characteristics of psychotic symptoms in patients diagnosed with BPD and patients diagnosed with schizophrenia, as well as the prevalence of self-harm, suicide attempts, and hospitalizations within these groups.

Method

In this comparative study, 50 individuals diagnosed with BPD and 50 with Schizophrenia, aged between 18 and 45 years, were assessed for intensity of psychotic symptoms with the Psychotic Symptom Assessment Scale (PSYRATS) and the Cardiff Abnormal Perceptions Scale (CAPS). Data were analyzed with IBM SPSS v25.0.

Results

On the PSYRATS, the schizophrenia group scored higher in auditory hallucinations and in the number of voices, while in the BPD group the auditory hallucinations score was correlated with the number of suicide attempts (P=0.025). On the CAPS, the BPD group showed higher scores on positive abnormal perceptions in all dimensions compared to the schizophrenia group (P=0.002).

Conclusions

Our study suggests that patients with BPD experienced a more intense burden of psychotic-like experiences compared to those with Schizophrenia, with a greater frequency, interference, and distress reported. Although patients with Schizophrenia had higher scores on the PSYRATS, the BPD group's scores were also notable, and a correlation was identified between auditory hallucinations and suicide attempts in the BPD group.

Personality disorders and schizophrenia spectrum disorders in the Italian forensic psychiatric population: clinical features, pattern of violence and treatment

Starting in 2015, the Residencies for Execution of Security Measures (REMS) became the place of treatment and care for dangerous offenders who were acquitted due to a mental disorder in Italy. Schizophrenia spectrum disorders (SSD) and personality disorders (PD) are the most common psychiatric disorders among REMS patients. This study aimed to identify and describe potential clinical, therapeutic, and criminal-related differences in REMS patients with SSD and PD. A sample of 528 REMS patients extracted from a previous observational retrospective study underwent secondary analysis. The group of PD patients (n = 150) comprised more females (p < 0.001) and had a higher frequency of substance abuse (p < 0.001) than the SSD group (n = 378). The SSD group was more frequently admitted to the REMS due to homicide/attempted homicide (p < 0.001). Among SSD patients, we found a higher recognition of criminal irresponsibility (p < 0.001). Patients with PD were more likely to engage in violent behavior in the REMS than their SSD counterparts (p < 0.001). Patients with SSD were more likely to receive antipsychotic polypharmacy (p < 0.05) and a higher dose of antipsychotics (p < 0.001). These initial results provide empirical evidence to support the need for personalized forensic treatment paths.

Content-based clustering of hallucinations across sensory modalities in a large online survey

Hallucinations can have rather heterogeneous aetiology and presentation. This inspired the concept of different subtypes based on symptom profiles, especially in the field of auditory hallucinations. As many people experience hallucinations in more than one sensory modality, it seems important to investigate potential hallucination subtypes across different sensory modalities. We assessed the content of hallucinations as part of a large survey among the general Dutch population (n = 10,448) using the Questionnaire for Psychotic Experiences. Based on their descriptions, thematic categories were created in a data-driven cluster analysis. 2594 participants who experienced hallucinations over the past week that contained at least 2 different thematic categories were selected. Clustering of their hallucination content was performed with the HDBSCAN method. We identified 4 clusters, i.e., subtypes, which can be typified as 1. hallucinations of foul odors, 2. complex visual scenes, 3. a vast variety of rather common hallucinations possibly related to heightened alertness, and 4. possibly bereavement hallucinations. The bereavement subtype showed an increase in emotional loneliness and the presence of delusions. Our findings suggest that the content of hallucinations can be informative, especially when investigated across sensory modalities. Such subtypes may help to better understand their underlying mechanisms.

Psychopathology and psychosocial functioning among young people with first-episode psychosis and/or first-presentation borderline personality disorder

BACKGROUND

One in five young people with first-episode psychosis (FEP) also presents with borderline personality disorder (BPD) features. Among people diagnosed with BPD, auditory verbal hallucinations occur in 29-50 % and delusions in 10-100 %. Co-occurrence of psychotic symptoms and BPD is associated with greater clinical severity and greater difficulty accessing evidence based FEP care. This study aimed to investigate psychotic symptoms and psychosocial functioning among young people presenting to an early intervention mental health service.

METHOD

According to the presence or absence of either FEP or BPD, 141 participants, aged 15-25 years, were assigned to one of four groups: FEP, BPD, combined FEP + BPD, or clinical comparison (CC) participants with neither FEP nor BPD. Participants completed semi-structured diagnostic interviews and interviewer and self-report measures of psychopathology and psychosocial functioning.

RESULTS

The FEP + BPD group had significantly more severe psychopathology and poorer psychosocial functioning than the FEP group on every measure, apart from intensity of hallucinations. Comparing the FEP or BPD groups, the BPD group had greater psychopathology, apart from intensity of psychotic symptoms, which was significantly greater in the FEP group. These two groups did not significantly differ in their overall psychosocial functioning. Compared with CC young people, both the FEP + BPD and BPD groups differed significantly on every measure, with medium to large effect sizes.

CONCLUSIONS

Young people with co-occurring FEP and BPD experience more severe difficulties than young people with either diagnosis alone. This combination of psychosis and severe personality pathology has been longitudinally associated with poorer outcomes among adults and requires specific clinical attention.

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.

Borderline personality features among individuals at clinical high risk for psychosis (CHR-P): A brief report

AIM

This exploratory study reports on borderline symptomatology within a sample of individuals at clinical high risk for psychosis (CHR-P) through a validated, self-report instrument, the short version of the Borderline Symptom List (BSL-23).

METHODS

The sample consisted of 44 help-seeking CHR-P youth (ages 14-29 years) who completed an initial evaluation at a specialized clinic for psychosis-risk.

RESULTS

The mean BSL-23 score was 1.5 (SD = 1.0, range 0.1-4.0). Higher scores were strongly associated with greater reported depressive symptoms (r = 0.84, p < 0.001). Additionally, borderline symptoms associated with attenuated positive symptoms (r = 0.32, p = 0.034) and social anxiety (r = 0.34, p = 0.027). Borderline symptomatology was not associated with role or social functioning.

CONCLUSIONS

This study is one of the first examinations of borderline symptomatology within a CHR-P sample through a validated self-report measure. Future research replicating these results is required to determine their robustness.

Can you trust this source? Advice taking in borderline personality disorder

Research suggests that patients with borderline personality disorder (BPD) share a range of cognitive biases with patients with psychosis. As the disorder often manifests in dysfunctional social interactions, we assumed associated reasoning styles would be exaggerated in a social setting. For the present study, we applied the Judge-Advisor System by asking participants to provide initial estimates of a person's age and presumed hostility based on a portrait photo. Afterwards, we presented additional cues/advice in the form of responses by anonymous previous respondents. Participants could revise their estimate, seek additional advice, or make a decision. Contrary to our preregistered hypothesis, patients with BPD (n = 38) performed similarly to healthy controls (n = 30). Patients sought the same number of pieces of advice, were equally confident, and used advice in similar ways to revise their estimates. Thus, patients with BPD did trust advice. However, patients gave higher hostility ratings to the portrayed persons. In conclusion, patients with BPD showed no cognitive biases in seeking, evaluating, and integrating socially provided information. While the study implies emotional rather than cognitive biases in the disorder, cognitive biases may still prove to be useful treatment targets in order to encourage delaying and reflecting on extreme emotional responses in social interactions.

Using Smartphones to Identify Momentary Characteristics of Persecutory Ideation Associated With Functional Disability

Objectives

Though often a feature of schizophrenia-spectrum disorders, persecutory ideation (PI) is also common in other psychiatric disorders as well as among individuals who are otherwise healthy. Emerging technologies allow for a more thorough understanding of the momentary phenomenological characteristics that determine whether PI leads to significant distress and dysfunction. This study aims to identify the momentary phenomenological features of PI associated with distress, dysfunction, and need for clinical care.

Methods

A total of 231 individuals with at least moderate PI from 43 US states participated in a study involving 30 days of data collection using a smartphone data collection system combining ecological momentary assessment and passive sensors, wherein they reported on occurrence of PI as well as related appraisals, responses, and cooccurring states. Most (N = 120, 51.9%) participants reported never having received treatment for their PI, while 50 participants had received inpatient treatment (21.6%), and 60 (26.4%) had received outpatient care only.

Results

Individuals with greater functional disability did not differ in PI frequency but were more likely at the moment to describe threats as important to them, to ruminate about those threats, to experience distress related to them, and to change their behavior in response. Groups based on treatment-seeking patterns largely did not differ in baseline measures or momentary phenomenology of PI as assessed by self-report or passive sensors.

Conclusions

Smartphone data collection allows for granular assessment of PI-related phenomena. Functional disability is associated with differences in appraisals of and responses to PI at the moment.

Co-occurring first-episode psychosis and borderline personality pathology in an early intervention for psychosis cohort

INTRODUCTION

Borderline personality disorder (BPD) is common among people diagnosed with first episode of psychosis (FEP), but is often under-recognized and under-researched. This study aimed to determine: (i) the prevalence of borderline personality pathology (subthreshold features and categorical disorder) in a FEP cohort (termed FEP + BPP); (ii) demographic and clinical factors associated with FEP + BPP; (iii) the symptomatic and functional outcomes.

METHODS

This study was conducted within the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen over the 30-month period between 2014 and 2016. BPP was evaluated by using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire BPD criteria.

RESULTS

In a cohort of 457 young people with a FEP (mean age 19.5 years, 56% male), 18.4% had borderline personality pathology (BPP). Compared with FEP alone, young people with FEP + BPP were more likely to be female, younger, Australian-born. In addition, young people with FEP + BPP were more likely to be diagnosed with Psychosis NOS, present with more severe hallucinations, and have alcohol abuse. Young people with FEP + BPP had more relationship difficulties at presentation and they were more likely to suffer of depression and to engage in self-harm throughout the follow-up. In relation to outcome, FEP + BPP was not associated with different rates of remission or relapse, however they were less likely to be admitted to hospital at presentation or involuntarily during their episode of care.

CONCLUSION

BPP is a common occurrence in psychotic disorders and is associated with more severe hallucinations and depression with higher risks of self-harm. Specific interventions need to be developed.

Comparison of the Phenomenology of Hallucination and Delusion Characteristics in People Diagnosed With Borderline Personality Disorder and Schizophrenia

Hallucinations and delusions in borderline personality disorder (BPD) are understudied. The authors explore the phenomenology of multisensory hallucinations and delusions in individuals with BPD and compare them to those in individuals with schizophrenia spectrum disorders (SSD). Clinical psychopathology was also explored. Eighty-nine adults participated and were categorized into four groups: BPD with voices, BPD without voices, SSD with high BPD traits, and SSD with low BPD traits. Among individuals with BPD, 81% reported visual and tactile hallucinations, 75% reported olfactory hallucinations, and 94% experienced delusions. When comparing BPD with and without voices, there were no significant differences in nonpsychotic psychopathology. Slight differences were found when hallucinations in BPD were compared with hallucinations in SSD, but overall the experiences were similar across diagnoses. The BPD group also reported significantly higher rates of paranoia/suspiciousness and delusions of guilt than the SSD group. Multisensory hallucinations and delusions occur in BPD and should be explored when treating people with BPD.

Characteristics and stability of hallucinations and delusions in patients with borderline personality disorder

BACKGROUND

Psychotic features have been part of the description of the borderline personality disorder (BPD) ever since the concept "borderline" was introduced. However, there is still much to learn about the presence and characteristics of delusions and about the stability of both hallucinations and delusions in patients with BPD.

METHODS

A follow-up study was conducted in 326 BPD outpatients (median time between baseline and follow-up = 3.16 years). Data were collected via telephone (n = 267) and face-to-face interviews (n = 60) including the Comprehensive Assessment of Symptoms and History interview, Positive And Negative Syndrome Scale and the Psychotic Symptom Rating Scale.

RESULTS

The point prevalence of delusions was 26%, with a median strong delusion conviction. For the group as a whole, the presence and severity of both hallucinations and delusions was found to be stable at follow-up. Participants with persistent hallucinations experienced more comorbid psychiatric disorders, and they differed from those with intermittent or sporadic hallucinations with their hallucinations being characterized by a higher frequency, causing a higher intensity of distress and more disruption in daytime or social activities.

CONCLUSIONS

Delusions in patients with BPD occur frequently and cause distress. Contrary to tenacious beliefs, hallucinations and delusions in participants with BPD are often present in an intermittent or persistent pattern. Persistent hallucinations can be severe, causing disruption of life. Overall, we advise to refrain from terms such as "pseudo", or assume transience when encountering psychotic phenomena in patients with BPD, but rather to carefully assess these experiences and initiate a tailor-made treatment plan.

Hallucinations and Other Psychotic Symptoms in Patients with Borderline Personality Disorder

BACKGROUND

Psychotic symptoms in BPD are not uncommon, and they are diverse and phenomenologically similar to those in schizophrenia spectrum disorders. Despite their prevalence in BPD patients, knowledge about the characteristics and severity of hallucinations is limited, especially in modalities other than auditory.

AIM

This review summarises the causes, phenomenology, severity, and treatment options of hallucinations and other psychotic symptoms in BPD.

METHODS

The PubMed database was used with the following key terms: "borderline personality disorder" and 'hallucinations' and "psychotic symptoms". Articles were selected between January 1990 and May 2021. The primary keyword search yielded a total of 545 papers, of which 102 articles met the inclusion criteria and were fully screened. Papers from the primary source reference lists were also screened, assessed for eligibility, and then added to the primary documents where appropriate (n = 143). After the relevance assessment, 102 papers were included in the review. We included adult and adolescent studies to gather more recent reviews on this topic.

RESULTS

Hallucinations are significantly prevalent in BPD, mainly auditory, similar to schizophrenia spectrum disorders. The relationship between hallucinations and depression, anxiety, suicidality, schizotypy, and loneliness in BPD has been discovered but requires more research. Studies for treatment options for hallucinations in BPD are lacking.

CONCLUSION

Recognition of psychotic symptoms in patients with BPD as distinguished psychopathological phenomena instead of diminishing and overlooking them is essential in the clinical assessment and can be useful in predicting complications during treatment. More focused research in this area is needed.

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

BACKGROUND

Auditory verbal hallucinations (AVH) commonly occur in the context of borderline personality disorder (BPD) yet remain poorly understood. AVH are often perceived by patients with BPD as originating from inside the head and hence viewed clinically as "pseudohallucinations," but they nevertheless have a detrimental impact on well-being.

METHODS

The current study characterized perceptual, subjective, and neural expressions of AVH by using an auditory detection task, experience sampling and questionnaires, and functional neuroimaging, respectively.

RESULTS

Perceptually, reported AVH correlated with a bias for reporting the presence of a voice in white noise. Subjectively, questionnaire measures indicated that AVH were significantly distressing and persecutory. In addition, AVH intensity, but not perceived origin (i.e., inside vs outside the head), was associated with greater concurrent anxiety. Neurally, fMRI of BPD participants demonstrated that, relative to imagining or listening to voices, periods of reported AVH induced greater blood oxygenation level-dependent activity in anterior cingulate and bilateral temporal cortices (regional substrates for language processing). AVH symptom severity was associated with weaker functional connectivity between anterior cingulate and bilateral insular cortices.

CONCLUSION

In summary, our results indicate that AVH in participants with BPD are (1) underpinned by aberrant perceptual-cognitive mechanisms for signal detection, (2) experienced subjectively as persecutory and distressing, and (3) associated with distinct patterns of neural activity that inform proximal mechanistic understanding. Our findings are like analogous observations in patients with schizophrenia and validate the clinical significance of the AVH experience in BPD, often dismissed as "pseudohallucinations." These highlight a need to reconsider this experience as a treatment priority.

Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment

Despite substantial efforts aimed at the detection and intervention for early symptoms of mental illness, there is relatively limited research on the clinical overlap between borderline personality disorder (BPD) and early psychosis, for example, clinical high risk (CHR) for psychosis, in young people. We present a narrative review of the clinical overlap between BPD and psychosis spectrum symptoms. Both conditions have unstable temporal course, and both are marked by functional impairment, increased suicide risk, and higher rates of psychiatric inpatient services. We then review evidence-based treatments for psychosis and BPD, emphasizing treatments for early presentations of these symptoms and initial research considering treatments for the overlap. Psychotherapies with the strongest empirical support include cognitive behavioral models, with BPD showing limited response to adjunctive pharmacotherapy. We end by discussing specific recommendations for future research, including longitudinal studies to determine the predictors of the course of illness and the development of treatments to target comorbid BPD and CHR symptoms.

Brief coping strategy enhancement for the treatment of distressing voices in the context of borderline personality disorder: A comparison with outcomes in the context of psychosis

BACKGROUND

Voice hearing in the context of Borderline Personality Disorder (BPD) has traditionally been regarded as transient and an experience that lacks legitimacy. Consequently, there are no evidence-based treatments for the voices reported by BPD patients. Contrary to the traditional view, there is a growing literature suggesting that voice hearing in the context of BPD can be an enduring and distressing experience which shares similarities with voice hearing in the context of psychosis. Given these similarities, the aim of this study was to explore whether brief Coping Strategy Enhancement developed in the context of psychosis can be used to treat distressing voice hearing in the context of BPD.

METHOD

This was a service evaluation carried out in a specialist NHS service delivering psychological therapies for distressing voices. Patients with either a BPD (n = 46) or a psychosis diagnosis (n = 125) received four sessions of Coping Strategy Enhancement (CSE). The primary outcome was voice-related distress. The pre-post outcomes for BPD patients were explored and compared with those achieved by the psychosis patients.

RESULTS

Both the BPD and psychosis groups experienced a significant reduction in voice-related distress after CSE compared with baseline. The interaction between diagnosis group and time was small and statistically non-significant.

CONCLUSION

These findings suggest a brief CSE intervention developed in the context of psychosis can be an effective starting point in the treatment of distressing voice hearing in the context of BPD. Such interventions have the potential to be integrated into broader BPD treatment programmes for those who hear voices.

Psychiatric and legal considerations in cases of Fetal Abduction by Maternal Evisceration

Fifteen cases of Fetal Abduction by Maternal Evisceration (FAMAE) reported to the National Center for Missing and Exploited Children during 1987-2011 outline the findings from a review of the forensic psychiatric considerations and legal course of each of the cases. Most offenders confessed to law enforcement within a short time of being placed under arrest in statements reflecting a continued effort to manage impressions and minimize culpability. Psychiatric assessment is invariably central to the legal disposition of FAMAE cases, as the defendant's goal is to diminish the perception of culpability/criminal responsibility and mitigate sentencing. Of those sentenced in the United States, nine defendants received life without parole, two received the death penalty (one executed), and one received a minimum of 30 years. Two abductors committed suicide and were not sentenced. Proffered diagnoses at trial included psychogenic amnesia, pseudocyesis, dissociative disorder, and delusional disorder; however, these rarely stood up to court scrutiny. Psychiatric experts showed the greatest variance in diagnosis over what to call the feigned pregnancy. In addition to delusional disorder and dissociative disorder, pseudocyesis, factitious disorder/pregnancy, pseudopregnancy, schizophrenia, and PTSD were among the various diagnoses proposed. A differential diagnosis for many FAMAE offenders may also include borderline personality disorder. Future research accounting for those women claiming false pregnancy who do not become homicidal will clarify whether FAMAE is the extreme endpoint of a fertility identity disorder.

Exploring Identity Disturbance and Psychotic Spectrum Symptoms as Predictors of Borderline and Schizotypal Personality Disorders

INTRODUCTION

Borderline personality disorder (BPD) and schizotypal personality disorder (SPD) were introduced in DSM-III and retained in DSM-5 Section II. They often co-occur and some aspects of the clinical differentiation between the 2 diagnoses remain unclear (e.g., psychotic-like features and identity disturbance).

METHODS

The present study explored if self-reported identity disturbance and psychosis proneness could discriminate between the BPD and SPD DSM-5 diagnoses. All patients were interviewed with the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders, and administered the Inventory of Personality Organization, Self-Concept and Identity Measure, Schizotypal Personality Questionnaire, Perceptual Aberration Scale, and the Magical Ideation Scale.

RESULTS

A total of 105 patients were initially assessed, 26 were excluded, and the final sample (N = 79) was composed of 34 BPD patients, 25 SPD patients, and 20 patients with co-occurring SPD and BPD. The BPD group (n = 34) was first compared with the pure SPD group (n = 25), and secondly with the total group of patients diagnosed with SPD (n = 25 + 20). Logistic regression analyses indicated that primitive defenses and disorganization best differentiated the BPD and the pure SPD group, while primitive defenses and interpersonal factor along with perceptual aberrations best differentiated the BPD and the total SPD group.

CONCLUSION

Identity disturbance did not predict the diagnostic groups, but BPD patients were characterized by primitive defenses, which are closely related to identity disturbance. Pure SPD was characterized by oddness/eccentricity, while the lack of specificity for cognitive-perceptual symptoms suggests that the positive symptoms do not differentiate BPD from SPD.

A Phenomenological Exploration of the Voices Reported by Borderline Personality and Schizophrenia Patients

INTRODUCTION

Over time, there have been different views regarding the verbal auditory hallucinations (VAHs) reported by borderline personality disorder (BPD) and schizophrenia patients. More recently, their similarity has been emphasized, a view that undoubtedly has significant implications in terms of differential diagnosis and management. To explore this important issue, we undertook a detailed phenomenological assessment of persistent VAH reported by BPD and schizophrenia DSM-IV participants.

METHODS

The Psychotic Symptoms Rating Scale (PSYRATS), the Revised Beliefs About Voices Questionnaire (BAVQ-R), the Multidimensional Scale for Hallucinations (MSH), and a detailed clinical interview were administered to 11 BPD and 10 schizophrenia DSM-IV participants.

RESULTS

The VAHs of both groups were similar regarding intensity, reported as located inside or outside the head, and frequency in which they were described as a third-person phenomenon. However, the patients' stance towards their VAH was clearly different. Whilst BPD patients identified them in a clear way in terms of gender and age and disliked them, schizophrenia patients identified them more vaguely, reported them both as more disruptive but at the same time engaged with them more positively; schizophrenia patients also integrated their VAH more into delusions.

DISCUSSION

Whilst reporting similar intensity of their VAH, the 2 groups' stance towards them were strikingly different in that BPD participants regarded them as identifiable and unequivocally unpleasant whilst schizophrenia participants regarded them in a rather vague and ambiguous manner. Methodologically, this preliminary study suggests that in-depth phenomenological assessment can help to elucidate the differential diagnosis of VAH in these, possibly other, clinical groups. Further research is warranted to establish whether these preliminary findings are replicated on a bigger clinical sample.

Evidence for default mode network dysfunction in borderline personality disorder

BACKGROUND

Although executive and other cognitive deficits have been found in patients with borderline personality disorder (BPD), whether these have brain functional correlates has been little studied. This study aimed to examine patterns of task-related activation and de-activation during the performance of a working memory task in patients with the disorder.

METHODS

Sixty-seven DSM-IV BPD patients and 67 healthy controls underwent fMRI during the performance of the n-back task. Linear models were used to obtain maps of within-group activations and areas of differential activation between the groups.

RESULTS

On corrected whole-brain analysis, there were no activation differences between the BPD patients and the healthy controls during the main 2-back v. baseline contrast, but reduced activation was seen in the precentral cortex bilaterally and the left inferior parietal cortex in the 2-back v. 1-back contrast. The patients showed failure of de-activation affecting the medial frontal cortex and the precuneus, plus in other areas. The changes did not appear to be attributable to previous history of depression, which was present in nearly half the sample.

CONCLUSIONS

In this study, there was some, though limited, evidence for lateral frontal hypoactivation in BPD during the performance of an executive task. BPD also appears to be associated with failure of de-activation in key regions of the default mode network.

Diagnosis and Treatment of Borderline Personality Disorder in Young People

PURPOSE OF REVIEW

We review recent research concerning the diagnosis and treatment of borderline personality disorder (BPD) in young people. We examine evidence for the need to define an appropriate age for detection, and the suitability of current classification methods and treatment.

RECENT FINDINGS

Evidence supports early detection and intervention for subsyndromal borderline pathology or categorical BPD across an extended developmental period. A range of structured treatments are effective for BPD in young people, although the role of treatment components in successful outcomes is unclear. Substantial evidence suggests that a stronger focus on functional outcomes, especially social and vocational outcomes, is warranted. Effective treatments for BPD are rarely available internationally. There is a need to assess whether less complex interventions might be developed that are scalable across health systems. A clinical staging model should be considered, addressing clinical distress and co-occurring psychopathology, as well as diagnosis.

Borderline personality disorder: part 1 – assessment and diagnosis

General adult psychiatrists are largely responsible for the care of patients with personality disorders in community and in-patient settings, and this can be associated with diagnostic and management challenges. In the first of two articles focusing specifically on borderline personality disorder (BPD), we summarise the core clinical features of the disorder and discuss appropriate diagnostic practice.

Testing the Interpersonal-Cognitive Model of Auditory Verbal Hallucinations in Youths with Either Early-Stage Borderline Personality Disorder or First-Episode Schizophrenia Spectrum Disorder

This is the first study to explore interpersonal schemata in outpatient youths (age 15-25 years) with early-stage borderline personality disorder (BPD) and auditory verbal hallucinations (AVH). It also aimed to replicate, in a transdiagnostic youth sample, the finding from studies of adults with AVH that negative beliefs about the self and others lead to negative appraisals of voices, which in turn elicits depression. The following 3 groups were compared: youth with BPD+AVH (n = 23), youth with schizophrenia spectrum disorder (SZ) with AVH (SZ+AVH, n = 20), and youths with BPD who did not experience AVH (BPD no AVH, n = 23). The BPD+AVH group reported more negative and fewer positive self schemata than the SZ+AVH group. They also saw themselves as being more socially inferior to others than did the SZ+AVH group, but they did not differ in appraisals of self or others, compared with the BPD no AVH group. In youths with AVH (BPD+AVH, SZ+AVH combined), the indirect effect of beliefs about self or others, via negative appraisals of voices on depression, was not significant. Instead, a significant indirect effect of negative appraisals of voices on depression, via negative beliefs about self, was found. The experience of AVH during adolescence and young adulthood, when the identity is still being formed, might have a more profound effect on the developing self than during later adulthood, when the self is more stable and resilient. Negative self-appraisals might constitute a treatment target for early intervention for youths with distressing voices, including those with BPD.

Avoiding Misdiagnosis When Auditory Verbal Hallucinations Are Present in Borderline Personality Disorder

Misdiagnosis is common for patients with a primary diagnosis of borderline personality disorder (BPD) who experience auditory verbal hallucinations (AVHs). AVHs in BPD are associated with severe BPD and high levels of suicidality. Wrongly treating these patients as though they are suffering from schizophrenia or other primary psychotic disorder and not treating BPD can cause significant iatrogenic damage. We outline a specific pattern of symptoms and phenomenology that will assist diagnostic accuracy in these cases. A focused review identified the following characteristic pattern: AVHs in BPD cannot be distinguished phenomenologically from AVH in schizophrenia, often meet the criteria for First-Rank Symptoms (FRSs), are highly stress related, and are strongly associated with dissociative experiences and childhood trauma. Formal thought disorder is uncommon, negative symptoms are usually absent, bizarre delusions are absent, affect remains reactive, and sociability is usually retained. Diagnostic accuracy can be improved by examining the overall clinical presentation and is essential to improving the prognosis for these patients.

Aripiprazole compared with placebo for auditory verbal hallucinations in youth with borderline personality disorder: Protocol for the VERBATIM randomized controlled trial

AIM

Up to half of patients with borderline personality disorder report auditory verbal hallucinations that are phenomenologically indistinguishable from those in schizophrenia, occur early in the course of the disorder, and are enduring, distressing and disabling. In clinical practice, this symptom is widely assumed to be unresponsive to treatment with antipsychotic medication and early intervention is rarely offered. The Verbal Experiences Response in Borderline personality disorder to Aripiprazole TrIal Medication (VERBATIM) study aims to be the first controlled trial to investigate the effectiveness of conventional pharmacotherapy for this symptom in this patient group.

METHOD

VERBATIM is a 12-week, triple-blind, single-centre, parallel groups randomised controlled trial, with a 27-week follow-up period. Participants between the ages of 15 and 25 years receive either aripiprazole or placebo daily, commencing at 2 mg and increasing to 10 mg by day 15. Further dose escalations (up to 30 mg) may occur, as clinically indicated. This trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry ACTRN12616001192471 on 30/08/2016.

RESULTS

The primary outcome is severity of auditory verbal hallucinations assessed using the Psychotic Symptom Rating Scale. Secondary outcomes include the severity of general psychopathology, borderline personality pathology, social and occupational functioning and change in brain resting state connectivity. The primary endpoint is week 12 and secondary endpoint is week 39.

CONCLUSION

The results will inform treatment decisions for individuals with borderline personality disorder who present with auditory verbal hallucinations.

Sensory processing deficiencies in patients with borderline personality disorder who experience auditory verbal hallucinations

Auditory verbal hallucinations (AVH) are common in patients with borderline personality disorder (BPD). We examined two candidate mechanisms of AVH in patients with BPD, suggested to underlie sensory processing systems that contribute to psychotic symptoms in patients with schizophrenia; sensory gating (P50 ratio and P50 difference) and change detection (mismatch negativity; MMN). Via electroencephalographic recordings P50 amplitude, P50 ratio, P50 difference and MMN amplitude were compared between 23 borderline patients with and 25 without AVH, and 26 healthy controls. Borderline patients with AVH had a significantly lower P50 difference compared with healthy controls, whereas no difference was found between borderline patients without AVH and healthy controls. The groups did not differ on MMN amplitude. The impaired sensory gating in patients with borderline personality disorder who experience AVH implies that P50 sensory gating deficiencies may underlie psychotic vulnerability in this specific patient group. Patients with borderline personality disorder with or without AVH did not have problems with auditory change detection. This may explain why they are spared from the poor outcome associated with negative symptoms and symptoms of disorganization in patients with chronic schizophrenia.

Exploratory comparison of auditory verbal hallucinations and other psychotic symptoms among youth with borderline personality disorder or schizophrenia spectrum disorder

OBJECTIVE

This study explored phenomenological aspects of auditory verbal hallucinations (AVH) and other psychotic symptoms among youth with borderline personality disorder (BPD).

METHODS

Sixty-eight outpatients, aged 15 to 25 years, were categorized into three groups according to their primary Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis and AVH symptom profile; BPD + AVH (n = 23), schizophrenia spectrum disorder (SZ) + AVH (n = 22) and BPD with no AVH (n = 23).

RESULTS

No differences in AVH were found between BPD + AVH and SZ + AVH. Compared with SZ + AVH, BPD + AVH scored lower on delusions and difficulty in abstract thinking and higher on hostility. BPD + AVH reported more severe self-harm, paranoid ideation, dissociation, anxiety and stress than BPD no AVH.

CONCLUSIONS

This study replicates, in a sample of youth, the finding from studies of adults that AVH in BPD are indistinguishable from those in SZ, when assessed with the Psychotic Symptom Rating Scales (PSYRATS). Clinicians should specifically enquire about AVH among youth with BPD. When present, AVH appear to be an indicator of a more severe form of BPD.

Psychotic symptoms in adolescents with borderline personality disorder features

Psychotic symptoms have been found to be relatively common among adults with borderline personality disorder (BPD), and to be a marker of BPD severity, but are not recognised in daily clinical practice in these patients. This study is the first to examine the prevalence of psychotic symptoms in 15-18-year olds with BPD features. It was hypothesised that adolescents with full-threshold BPD would have significantly more psychotic symptoms than adolescents with sub-threshold BPD features, and that both these groups would have significantly more psychotic symptoms than adolescents with no BPD features. A total of 171 psychiatric outpatients, aged 15-18 years, were assessed using a structured interview for DSM-IV personality disorder and categorised into three groups: no BPD features (n = 48), sub-threshold BPD features (n = 80), and full-threshold BPD (n = 43). The groups were compared on measures of psychopathology and functioning (e.g. Youth Self Report, Symptom Check List-90-R, SOFAS). Adolescents with full-threshold BPD reported more psychotic symptoms than the sub-threshold BPD group (p < .001), and both these groups reported more psychotic symptoms than those with no BPD features (p < .001). Adolescents with full-threshold BPD reported more confusion (p < .01), paranoia (p < .001), visual hallucinations (p < .001) and strange thoughts (p < .01), than the other two groups. Psychotic symptoms predicted group membership, determined by BPD severity, after adjusting for other psychopathology and functional impairment (p < .01). Assessment of unusual perceptual experiences, paranoia or odd thoughts is highly clinically relevant in adolescents with BPD features, as these symptoms are associated with a more severe clinical presentation of BPD.

Hallucinations in patients with borderline personality disorder: characteristics, severity, and relationship with schizotypy and loneliness

OBJECTIVE

In patients with borderline personality disorder (BPD), data are lacking on characteristics and severity of hallucinations in modalities other than the auditory (verbal) type. The same applies to relationships between hallucinations and the severity of depression, anxiety, schizotypy, and loneliness.

METHODS

In 60 female patients with BPD (37 also with hallucinations), this cross-sectional study explored characteristics and severity of (i) hallucinations and (ii) schizotypal features, (iii) severity of depression and anxiety, and (iv) loneliness, and the relationships between hallucinations and the other characteristics.

RESULTS

In patients with hallucinations, 80% experienced hallucinations in more than one modality; in the different modalities, the characteristics of the hallucinations were similar. The criteria for loneliness were fulfilled in 81% and 48% of patients with and without hallucinations. Compared to patients with BPD without hallucinations, the presence of hallucinations was associated with higher scores for depression, anxiety, loneliness, and schizotypy. Furthermore, the severity of hallucinations showed a positive correlation with the severity of loneliness and schizotypy.

CONCLUSION

Patients with BPD experienced hallucinations with characteristics similar to the more frequently studied auditory (verbal) hallucinations. Higher scores for schizotypy and loneliness indicate that patients with hallucinations had more characteristics of cluster A personality disorders.

Paranoia and risk of personality disorder in the general population

BACKGROUND

We hypothesized that paranoia is associated with personality disorder (PD) in the general population.

METHOD

This was a population-based cross-sectional survey carried out in Andalusia (Spain) using a representative sample of 4 507 participants. Paranoia was measured using the Green Paranoid Thought Scale, and risk of having a PD was screened using the Standardized Assessment of Personality Abbreviated Scale whilst borderline personality disorder (BPD) was measured with the CEPER-III Exploratory Interview of Personality disorder. Adjusted Pearsons' correlations between paranoia and PD or BPD were calculated.

RESULTS

Paranoia was associated with the risk of having PD and, more robustly, with BPD. Both associations held true for both personality outcomes (PD and BPD) when tested for two Green Paranoid Thought Scale paranoia subtypes (persecutory and reference) after accounting for the effects of age, sex and child abuse.

CONCLUSIONS

Paranoia seems to either augment the risk for, or be part of, PD/BPD. © 2019 John Wiley & Sons, Ltd.

Preliminary Evidence for the Cognitive Model of Auditory Verbal Hallucinations in Youth With Borderline Personality Disorder

Objectives: This is the first study to explore cognitive, emotional, and behavioral responses to voices in youth with borderline personality disorder (BPD) compared with those with schizophrenia spectrum disorder (SZ), and to examine if negative appraisals of voices predict depression and anxiety across the groups. Methods: The sample comprised 43 outpatients, aged 15-25 years, who reported auditory verbal hallucinations (AVH) and were diagnosed with either Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) BPD or SZ. Data were collected using the Psychotic Symptom Rating Scales, the revised Beliefs About Voices Questionnaire, the Voice Rank Scale, and the Depression Anxiety Stress Scale. Results: Youth with BPD did not differ from youth with SZ in beliefs about the benevolence or malevolence of voices. Youth with BPD appraised their voices as more omnipotent and of higher social rank in relation to themselves, compared with youth with SZ. In both diagnostic groups, beliefs about malevolence and omnipotence of voices were correlated with more resistance toward voices, and beliefs about benevolence with more engagement with voices. In addition, perceiving the voices as being of higher social rank than oneself and negative voice content were both independent predictors of depression, irrespective of diagnostic group. In contrast, negative appraisals of voices did not predict anxiety after adjusting for negative voice content. Conclusions: This study replicated the link between negative appraisals of voices and depression that has been found in adults with SZ in a mixed diagnostic youth sample. It, thus, provides preliminary evidence that the cognitive model of AVH can be applied to understanding and treating voices in youth with BPD.

Psychotic symptoms in borderline personality disorder: an update

PURPOSE OF REVIEW

The purpose of this article is to review the most recent literature on psychotic symptoms in borderline personality disorder (BPD).

RECENT FINDINGS

Both auditory hallucinations and delusional ideation (especially paranoid delusions) are relatively common in individuals with BPD. It is still difficult to distinguish these and related phenomena in BPD from the corresponding experiences in psychotic disorders and schizophrenia, despite numerous attempts to do so. The terminology introduced to help with this effort has not been particularly useful. The presence of auditory hallucinations may affect the course of BPD negatively. Psychotic symptoms in BPD seem to be significantly related to the context (usually stressful events) and appear or intensify in response to situational crisis. The role of certain co-occurring disorders in increasing the risk of psychotic symptoms in BPD remains uncertain.

SUMMARY

Psychotic symptoms in BPD continue to be poorly understood. Further research should try to ascertain the relationships between hallucinations and delusions on one hand and the processing of trauma, emotion regulation, distress tolerance and interpersonal sensitivity on the other. Ultimately, such endeavor will contribute to developing more effective treatments for BPD.

The mediating role of borderline personality features in the relationship between childhood trauma and psychotic-like experiences in a sample of help-seeking non-psychotic adolescents and young adults

Objective:

Psychotic-like experiences (PLEs) often occur across different non-psychotic disorders in adolescent and young adult population and are related to early trauma. However, the mechanisms of how exposure to early trauma shapes the risk of PLEs are unclear. In our study, we investigated whether borderline personality features and further non-psychotic symptoms, i.e. factors related to both PLEs and childhood trauma, may mediate the relationship between childhood trauma and PLEs.

Methods:

Two hundred inpatients aged 16–21 years who were treated due to non-psychotic disorders were included. PLEs were assessed with the Prodromal Questionnaire (PQ-16). Childhood Trauma was assessed with the Adverse Childhood Experience Questionnaire (ACE). Borderline personality features were assessed by using the Borderline-Symptom Checklist (BSL-23). Presence and frequency of depressive symptoms and anxiety were assessed by Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Questionnaire (GAD-7).

Table 1

Results:

A significant relationship between childhood trauma (ACE total score) and PLEs was found (ß = 0.30, 95% CI 0.247--0.659). In particular, emotional neglect (r = 0.298, p < 0.001) and sexual abuse (r = 0.264, p < 0.001) were significantly associated with PLEs. Borderline personality features fully mediated the relationship of childhood trauma and PLEs (ß = 0.12, 95% CI: -0.019--0.370). Anxiety and Depression showed a significant, but partial mediation of the relationship.

Conclusion:

Borderline personality features seem to be an important mediator of the relationship between childhood trauma and PLEs in adolescent patients with different non-psychotic psychiatric disorders. Theoretical and clinical implications are discussed.

Does co-occurring borderline personality disorder influence acute phase treatment for first-episode psychosis?

BACKGROUND

This aims of this study were: (1) to determine the prevalence of co-occurring borderline personality disorder (BPD) in a first-episode psychosis (FEP) sample; (2) to determine differences between patients with and without BPD on demographics, comorbidities and clinical risks and other variables; and (3) to examine whether BPD comorbidity influenced treatment received by patients for FEP during their first 3 months after service entry to a specialist early psychosis service.

METHODS

A file audit was conducted for 100 consecutive admissions to an early psychosis service. Patients with a clinician-rated co-occurring diagnosis of BPD were compared with patients without clinician-rated BPD on a range of variables.

RESULTS

Twenty-two percent of the FEP sample was diagnosed with co-occurring BPD by clinician ratings. The FEP group with co-occurring BPD was found to be younger, more likely to have other comorbidities, and were at higher risk of suicide and violent behaviour. Group differences were found in treatment received for FEP, whereby patients with co-occurring BPD had poorer access to standard treatment, including guideline concordant antipsychotic medication prescription.

CONCLUSION

Young people with co-occurring clinician-rated BPD and FEP experienced greater difficulty accessing standard care for FEP and received relatively different treatment, including different pharmacotherapy, compared with those FEP patients without BPD. There is a need to develop new clinical guidelines and effective treatments for this specific subgroup with early psychosis and co-occurring BPD that take into account interpersonal and "premorbid" aspects of their presenting problems.

Psychotic-Like Symptoms and the Temporal Lobe in Trauma-Related Disorders: Diagnosis, Treatment, and Assessment of Potential Malingering

Objective

To overview the phenomenology, etiology, assessment, and treatment of psychotic-like symptoms in trauma-related disorders focusing on the proposed role of temporal lobe dysfunction.

Method

We describe the literature pertaining to (i) psychotic-like symptoms and temporal lobe dysfunction in trauma-related disorders and (ii) psychological testing profiles in trauma-related disorders. We define trauma-related disorders as borderline personality disorder, post-traumatic stress disorder, and the dissociative disorders. Our search terms were dissociative disorders, temporal lobe, trauma, post-traumatic stress disorder, borderline personality disorder, psychosis, and malingering.

Results

Trauma-related psychotic-like symptoms are common and can differ in phenomenology from primary psychotic symptoms. Hallucinations consist of auditory and nonauditory content that may or may not relate to traumatic content. Child voices are highly suggestive of complex dissociative disorders. Critically, not only do these symptoms resemble those seen in temporal lobe epilepsy, but the temporal lobe is implicated in trauma-related disorders, thus providing a plausible neurobiological explanation. Despite such evidence, these symptoms are frequently considered atypical and misdiagnosed. Indeed, common structured psychological assessment tools categorize these symptoms as possible indicators of invalid testing profiles.

Conclusion

Psychotic-like symptoms are common in trauma-related disorders, may be related to temporal lobe dysfunction, and are frequently misinterpreted. This may lead to ineffective treatment and inappropriate determinations of malingering in the forensic system.

Personality Pathology and Schizophrenia

The interaction of personality pathology and schizophrenia has conceptually been a topic of considerable interest in psychiatry. Recent advances in taxonomy and assessment of relevance to the clinician and researcher is presented. Cluster A and avoidant personality disorders are regarded as risk factors or antecedents for the development of schizophrenia. Some features of borderline personality disorder may resemble schizophrenia. With both a hierarchical structure and symptom-focused classification systems, personality pathology and personality disorder comorbidities can be overlooked. They can remain untreated because they are seen as part of the psychotic syndrome or superseded. A case formulation of a patient with schizophrenia is likely enriched by considering both these facets and may highlight comorbid personality disorder that warrants independent treatment.

Individuals with Borderline Personality Disorder manifest cognitive biases implicated in psychosis

Individuals with Borderline Personality Disorder (BPD) frequently manifest psychotic symptoms. Certain cognitive biases have been implicated in the genesis and maintenance of psychotic symptoms. The present study aimed at exploring whether individuals with BPD manifest these cognitive biases. Twenty-eight individuals with BPD and 28 healthy participants were assessed on four sub-domains of the Davos Assessment of Cognitive Biases Scale, viz. jumping to conclusions, belief inflexibility, attention for threat and external attribution. The BPD group had significantly higher scores on all the four cognitive biases in comparison to the healthy controls. Thus, the findings of the present study indicate that individuals with BPD manifest cognitive biases implicated in psychosis more prominently than healthy individuals. These findings can be used to improve the existing psychotherapeutic techniques for BPD.

Abnormalities in gray matter volume in patients with borderline personality disorder and their relation to lifetime depression: A VBM study

Background

Structural imaging studies of borderline personality disorder (BPD) have found regions of reduced cortical volume, but these have varied considerably across studies. Reduced hippocampus and amygdala volume have also been a regular finding in studies using conventional volumetric measurement. How far comorbid major depression, which is common in BPD and can also affect in brain structure, influences the findings is not clear.

Methods

Seventy-six women with BPD and 76 matched controls were examined using whole-brain voxel-based morphometry (VBM). The hippocampus and amygdala were also measured, using both conventional volume measurement and VBM within a mask restricted to these two subcortical structures. Lifetime history of major depression was assessed using structured psychiatric interview.

Results

At a threshold of p = 0.05 corrected, the BPD patients showed clusters of volume reduction in the dorsolateral prefrontal cortex bilaterally and in the pregenual/subgenual medial frontal cortex. There was no evidence of volume reductions in the hippocampus or amygdala, either on conventional volumetry or using VBM masked to these regions. Instead there was evidence of right-sided enlargement of these structures. No significant structural differences were found between patients with and without lifetime major depression.

Conclusions

According to this study, BPD is characterized by a restricted pattern of cortical volume reduction involving the dorsolateral frontal cortex and the medial frontal cortex, both areas of potential relevance for the clinical features of the disorder. Previous findings concerning reduced hippocampus and amygdala volume in the disorder are not supported. Brain structural findings in BPD do not appear to be explainable on the basis of history of associated lifetime major depression.

Substance-induced psychotic symptoms in Borderline Personality Disorder among substance use disorder samples in Spain

Substance-induced psychosis (SIP) is frequent in substance use disorder patients. However, little is known about the presence of SIP in Borderline Personality Disorder (BPD) and what the risk factors for the development of SIP in this population would be. A sample of 91 BPD drug-dependent patients attending an outpatient substance use disorder unit was evaluated. Comorbidity with Axis I and II was assessed using SCID-I and SCID-II. Psychoactive drug related variables were registered as well as the presence of the ninth criterion of DSM-IV-TR as a code of psychotic symptoms. A total of 50.5% of the sample were women. The most prevalent drug consumed was cocaine (67%) followed by cannabis (47.3%) and then alcohol (39.6%). A total of 62.8% people with BPD registered substance-induced psychosis symptoms in their lifetime. Notably, this study found these symptoms were not associated with the presence of psychotic symptoms registered in ninth criterion. Cocaine and cannabis consumption are associated with the presence of SIP in SUD-BPD patients. No other clinical variables were related in this sample. Further research studies are needed to find other risk factors for SIP in this patient group.

Comorbid Diagnosis of Psychotic Disorders in Borderline Personality Disorder: Prevalence and Influence on Outcome

BACKGROUND

A diagnosis of psychotic disorder is traditionally considered incompatible with borderline personality disorder (BPD), even though patients sometimes fulfill the diagnostic criteria for both disorders. How often this happens is barely known, as is the influence of comorbid psychotic disorders on the outcome of BPD. Since studies on isolated auditory verbal hallucinations in patients with BPD indicate that these perceptual symptoms have severe consequences and are associated with suicidal behavior and hospitalization, patients with comorbid psychotic disorders are unlikely to fare better.

OBJECTIVE

To examine the point prevalence of psychotic disorders in patients with BPD, their association with the outcome of BPD, and their predictive value for outcome.

METHODS

In a cross-sectional design, 84 female outpatients diagnosed with BPD were interviewed with the aid of the MINI-International Neuropsychiatric Interview to establish the point prevalence of comorbid psychotic and other comorbid disorders. After termination of their treatment at a specialized outpatient clinic, the type of referral was considered to be a "good" outcome when they were referred to their general practitioner or to basic psychiatric care for noncomplex patients, and a "poor" outcome when referred to a specialized psychiatric department or to a psychiatric district team for patients with severe psychiatric disorders.

RESULTS

Psychotic disorders were present in 38% of the patients with BPD. With a prevalence of 20%, psychotic disorder not otherwise specified (NOS) was the most common subtype; the least common types were schizophrenia (2%), substance-induced psychotic disorder (2%), and brief psychotic disorder (1%). Among six types of comorbid disorders, only psychotic disorders were associated with a poor outcome; they were also predictors for a poor outcome, along with comorbid mood disorders, eating disorders, and somatoform disorders, as well as the severity of BPD, and, counterintuitively, more years of education.

CONCLUSION

Psychotic disorders, notably of the psychotic disorder NOS subtype, are common among patients with BPD, and their presence is associated with a poor outcome. This implies that adequate diagnosis and treatment of both disorders is warranted in this subgroup with a dual diagnosis.

Auditory Verbal Hallucinations in Borderline Personality Disorder and the Efficacy of Antipsychotics: A Systematic Review

Background: Auditory verbal hallucinations (AVH) are experienced more frequently by patients with borderline personality disorder (BPD) than previously assumed. However, consensus is lacking on how to treat them. Objective: To provide a systematic review of studies reporting on AVH in patients with BPD, with a focus on the efficacy of treatment of psychotic symptoms. Methods: For this review a systematic search was made in the PubMed and Ovid databases, and mean weighted prevalence rates, adjusted for sample size, were computed. Results: The search yielded 36 studies describing a total of 1,263 patients. Auditory hallucinations (including AVH) were reported in 27% of hospitalized BPD patients; AVH were reported in 25% of all patients and in 24% of outpatients. Of the hallucinating patients, 78% experienced AVH at least once per day, for a duration of several days to many years. On the whole, patients with BPD regarded their voices as malevolent and omnipotent in nature. Compared to patients with schizophrenia, the phenomenological characteristics of AVH were similar and the ensuing distress was equal or even higher, whereas scores for other positive symptoms were lower. The presence of AVH in BPD was associated with an increase of suicide plans and attempts, and more frequent hospitalization. Moreover, AVH in the context of BPD were associated with higher prevalence rates for post-traumatic stress disorder and emotional abuse. The efficacy of antipsychotics was investigated in 21 studies. Based on these studies, we conclude that both typical and atypical antipsychotics tend to have positive effects on AVH experienced in the context of BPD. The efficacy of cognitive-behavioral therapy and non-invasive brain stimulation has not yet been systematically assessed. Conclusions: These findings indicate that AVH experienced in the context of BPD are in need of proper diagnosis and treatment, and that antipsychotics tend to be beneficial in treating these (and other psychotic) symptoms.There is an urgent need for studies assessing the efficacy of cognitive-behavioral therapy and non-invasive brain stimulation in this underdiagnosed and undertreated group.

Hallucinations in borderline personality disorder: Prevalence, characteristics and associations with comorbid symptoms and disorders

To establish the point prevalence of hallucinations in borderline personality disorder (BPD), telephone interviews were conducted with 324 outpatients diagnosed with BPD. Then a subgroup (n = 98) was interviewed in person to investigate the co-occurrence of these phenomena with other psychotic symptoms, comorbid psychiatric disorders, prior childhood adversities, and adult life stressors. For hallucinations in general a point prevalence of 43% was found, with rates for hallucinations in separate sensory modalities ranging from 8–21%. Auditory verbal hallucinations consisted mostly of verbal abuse and were generally experienced as distressing. A significant association was found between the severity of hallucinations on the one hand, and delusions and unusual thought content on the other; this association was absent for negative symptoms and disorganization. The presence of hallucinations also correlated with the number of comorbid psychiatric disorders, and with posttraumatic stress disorder (PTSD) specifically. Childhood emotional abuse and adult life stressors were also associated with hallucinations. The latter three associations suggest that patients with BPD might have an etiological mechanism in common with other patient/nonpatient groups who experience hallucinations. Based on these findings, we advise to treat PTSD and hallucinations when found to be present in patients with BPD.

[Psychiatry of the future: multidimensionality of the problems of modern psychiatry and development of classification systems]

The success and achievements in the area of neurosciences due to the development of neuroimaging, neurochemical and genome studies provide tasks for psychiatry determined by the necessity to develop new classifications of mental diseases, primarily ICD-11, specify clinical diagnostic criteria and rethink the essence of some mental disorders. In spite of the multiple direction of scientific opinions on the discussed issues, the development of modern psychiatry is characterized by intensive search of biological background of psychiatric disorders and elaboration of effective approaches to the diagnosis and treatment of mental diseases, including medical rehabilitation of patients.

Transdiagnostic Extension of Delusions: Schizophrenia and Beyond

Delusion is central to the conceptualization, definition, and identification of schizophrenia. However, in current classifications, the presence of delusions is neither necessary nor sufficient for the diagnosis of schizophrenia, nor is it sufficient to exclude the diagnosis of some other psychiatric conditions. Partly as a consequence of these classification rules, it is possible for delusions to exist transdiagnostically. In this article, we evaluate the extent to which this happens, and in what ways the characteristics of delusions vary according to diagnostic context. We were able to examine their presence and form in delusional disorder, affective disorder, obsessive-compulsive disorder, borderline personality disorder, and dementia, in all of which they have an appreciable presence. There is some evidence that the mechanisms of delusion formation are, at least to an extent, shared across these disorders. This transdiagnostic extension of delusions is an argument for targeting them therapeutically in their own right. However there is a dearth of research to enable the rational transdiagnostic deployment of either pharmacological or psychological treatments.

Suicidality and hospitalisation in patients with borderline personality disorder who experience auditory verbal hallucinations

BACKGROUND

In patients with borderline personality disorder (BPD), about 22-50% experience auditory verbal hallucinations (AVH). However, the impact of these hallucinations on suicidal ideation, suicide attempts, crisis-service interventions, and hospital admissions is unknown.

METHODS

In a cross-sectional design, data were collected with the Psychotic Symptom Rating Scales (PSYRATS) and the MINI International Neuropsychiatric Interview Plus, as well as from the medical records of a convenience sample of outpatients fulfilling the DSM-IV criteria for BPD.

RESULTS

Of the 89 included patients, 27 experienced AVH. In the latter group, the presence of AVH was associated with a significantly higher incidence of suicidal plans and attempts in the month prior to study participation, more hospitalisations, and a shorter interval until hospitalisation. All subscales of the PSYRATS correlated positively with suicide plans, while the phenomenological and emotional subscales also correlated positively with suicide attempts. Moreover, higher scores on the emotional subscale were associated with more hospital admissions.

CONCLUSIONS

AVH experienced by patients with BPD might constitute a risk factor for suicide plans and attempts, and hospitalisation. This finding emphasises that this population requires adequate clinical attention, as well as effective treatment for AVH.

Varieties of Voice-Hearing: Psychics and the Psychosis Continuum

Hearing voices that are not present is a prominent symptom of serious mental illness. However, these experiences may be common in the non-help-seeking population, leading some to propose the existence of a continuum of psychosis from health to disease. Thus far, research on this continuum has focused on what is impaired in help-seeking groups. Here we focus on protective factors in non-help-seeking voice-hearers. We introduce a new study population: clairaudient psychics who receive daily auditory messages. We conducted phenomenological interviews with these subjects, as well as with patients diagnosed with a psychotic disorder who hear voices, people with a diagnosis of a psychotic disorder who do not hear voices, and matched control subjects (without voices or a diagnosis). We found the hallucinatory experiences of psychic voice-hearers to be very similar to those of patients who were diagnosed. We employed techniques from forensic psychiatry to conclude that the psychics were not malingering. Critically, we found that this sample of non-help-seeking voice hearers were able to control the onset and offset of their voices, that they were less distressed by their voice-hearing experiences and that, the first time they admitted to voice-hearing, the reception by others was much more likely to be positive. Patients had much more negative voice-hearing experiences, were more likely to receive a negative reaction when sharing their voices with others for the first time, and this was subsequently more disruptive to their social relationships. We predict that this sub-population of healthy voice-hearers may have much to teach us about the neurobiology, cognitive psychology and ultimately the treatment of voices that are distressing.