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

The Subjective Experience of the Punitive Parent Mode in Individuals With Borderline Personality Disorder Following Schema Therapy: A Qualitative Study

Borderline personality disorder (BPD) is often characterized by self-critical and punitive thoughts, emotions, beliefs and behaviours, conceptualized in schema therapy (ST) as the punitive parent mode (PPM). This mode involves internalized punitive messages from childhood from the behaviour and reactions of significant others, leading to self-hatred, guilt and self-denial. Although patients with BPD frequently report auditory verbal hallucinations (AVHs) as manifestations of the PPM, this phenomenon is often overlooked in ST studies. We conducted semistructured interviews with 16 (ex)patients (63% female) from two Dutch mental health institutions to explore their experiences with the PPM before, during and after ST. An independent, double-coded systematic content analysis was performed. Approximately half of the participants reported AVHs linked to the PPM before therapy. The patients characterized the PPM by pervasive self-critical messages, contributing to intense emotional and physical distress and maladaptive coping strategies. Participants reported that ST techniques, including group therapy, imagery rescripting (ImRs) and the empty chair technique (ECT), effectively reduced the power and credibility of the PPM, including AVHs. The self-reported improvements included more adaptive coping mechanisms, increased social support and a general experience of reduced PPM. This study highlights the prevalence of the PPM as AVHs in individuals with BPD and demonstrates the efficacy of ST in reducing the impact of PPM, including in cases involving AVHs. Clinical implications include the need for relapse prevention plans and further exploration into how ST's effects can be enhanced. Future research should explore the broader spectrum of psychotic experiences in BPD and consider integrating PPM-related AVHs into the assessment and treatment of BPD.

Auditory Hallucinations in Borderline Personality Disorder and Schizophrenia: A Quantitative Comparison Using Patient Records

The phenomenological differences in auditory hallucinations between schizophrenia and borderline personality disorder (BPD) are unclear in the existing literature, in part due to underpowered studies and heterogeneous research populations that do not represent those in the acute clinical setting. This study addresses this by using patient records to compare auditory hallucinations at the point of clinical psychiatric assessment for 341 unique patients, 165 with BPD and 176 with schizophrenia. Patients with BPD were found to have more subjectively distressing and objectively negative hallucinations, as well as more command hallucinations. Furthermore, they possessed more insight and were less likely to incorporate hallucinations into delusions. These results support the hypothesis that, while descriptively similar, auditory hallucinations are interpreted differently between the two groups. This study also supports that electronic records of patient assessments are a feasible way to assess large numbers of reports of auditory hallucinations.

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 disorder and early psychosis: a narrative review

BACKGROUND

The purpose of the present review was to summarize the main literature contribution on the relationship between borderline personality disorder (BPD) and early psychosis. While retracing the historical path of the term "borderline", specific attention was paid to psychotic and psychotic-like symptoms in BPD. Its relationship with At Risk Mental State was evaluated, as well.

METHODS

This search was conducted on PUBMED/MEDLINE and PsycInfo, looking for "Borderline personality disorder, First Episode Psychosis, Early Psychosis, Ultra-High Risk AND/OR Clinical High Risk" for psychosis.

RESULTS

Eight pertinent papers were identified on this topic. Their main findings were then discussed. The term "borderline" has undergone different changes in meaning and use, despite always referring to states considered on the fence between neurosis and psychosis. However, considering the history of psychopathology and its relationship with diagnostic manuals, little attention has been given to its psychotic features. Being those symptoms highly burdensome, this neglect has often led to misdiagnosis and under-treatment.

CONCLUSIONS

Psychotic symptoms in BPD can be severe and distressing. Nonetheless they can be easily neglected, and when found they challenge clinicians in defining a differential diagnosis to distinguish between BPD and Psychosis Spectrum Disorders. Given specific needs and interventions for these different conditions, a dimensional, rather than categorical, approach should be considered, as well as specific care pathways and monitoring should be advised.