ORIGINAL ARTICLE

A Study of Psychotic Symptoms in Borderline Personality Disorder Laura J. Pearse, MRCPsych,* Claire Dibben, MRCPsych,Þ Hisham Ziauddeen, MRCPsych,þ Chess Denman, FRCPsych,§ and Peter J. McKenna, MRCPsych|| Abstract: Patients with borderline personality disorder (BPD) report psychotic symptoms, but it has been questioned whether they are intrinsic to BPD. Thirty patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for BPD were drawn from a specialist personality disorder service. Exclusion criteria included a preexisting clinical diagnosis of nonaffective psychotic disorder. Participants underwent structured psychiatric interview using the Present State Examination (PSE), lifetime version. Approximately 60% of the patients reported psychotic symptoms unrelated to drugs or affective disorder. Auditory hallucinations were the most common symptom (50%), which were persistent in the majority of cases. A fifth of the patients reported delusions, half of whom (three patients) also met DSM-IV criteria for schizophrenia, who were previously undiagnosed. The form of auditory hallucinations was similar to that in schizophrenia; the content was predominantly negative and critical. Persistent auditory hallucinations are intrinsic symptoms of BPD. This may inform current diagnostic criteria and have implications for approaches to treatment, both pharmacological and psychological. The presence of delusions may indicate a comorbid axis I disorder. Key Words: Borderline personality disorder, hallucinations, delusions, psychotic symptoms, psychosis, schizophrenia, affective disorder (J Nerv Ment Dis 2014;202: 368Y371)

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orderline personality disorder (BPD) is characterized by identity disturbance, unstable and intense interpersonal relationships, impulsive and self-damaging behavior, anger dyscontrol, affective instability, problems tolerating being alone, and chronic feelings of emptiness. The use of the term borderline in connection with this constellation of symptoms dates from the original psychoanalytic conception of the disorder, which maintained that such patients were on the border between neurosis and psychosis. However, an enduring question is whether psychotic symptoms genuinely form part of the core symptoms of BPD. It has been suggested that ‘‘the borderline person’s capacity to develop regressive psychotic symptoms may be a pathognomonic feature’’ (Gunderson and Singer, 1975). This school of thought also suggests that psychotic symptoms usually take the form of brief psychotic episodes, induced by stress or illicit drugs, and are often accompanied by depersonalization or derealization. The presence of transient, stress-related paranoid ideation or severe dissociative symptoms in BPD is also recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV;

*Dorset Healthcare University NHS Foundation Trust, UK; †Norfolk and Suffolk NHS Foundation Trust, UK; ‡Department of Psychiatry, University of Cambridge, UK; §Cambridgeshire and Peterborough NHS Foundation Trust, UK; and ||Benito Menni Complejo Asistencial en Salud Mental and FIDMAG Research Foundation, Barcelona, Spain. Laura J. Pearse and Claire Dibben are joint first authors. Send reprint requests to Claire Dibben, MRCPsych, G Block, Hospital Rd, Bury St Edmunds, Suffolk, UK IP33 3NR. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20205Y0368 DOI: 10.1097/NMD.0000000000000132

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American Psychiatric Association, 1995). However, the presence of persistent psychotic symptoms in BPD has also been reported (Barnow et al., 2010; Yee et al., 2005). Conversely, one study reported that psychotic symptoms in BPD either occurred only in the context of an affective illness or were suspected to be factitious (Pope et al., 1985). This is supported by another study that found that psychotic symptoms occurred in BPD during a major depressive episode (Zanarini et al., 1990). However, this study also reported that some patients experienced what the authors termed quasi-psychotic experiences. These referred to delusions and/or hallucinations that were judged to be transient (less than two days duration) and circumscribed (affecting only one or two areas of the patient’s life). A related issue concerns the similarity or otherwise of psychotic symptoms in BPD to that in schizophrenia. Slotema et al. (2012) reported auditory hallucinations persisting for more than a year in 38 women meeting DSM-IV criteria for BPD. There were no significant differences from 51 schizophrenia/schizoaffective patients who also experienced auditory hallucinations in terms of frequency, duration, intensity, perceived location, beliefs about origin, negative content, and distress; only disruption of life was found to be lower in the BPD patients. Another study reported auditory hallucinations in patients with BPD that were more distressing than that in schizophrenic patients (Kingdon et al., 2010). Therefore, questions remain whether psychotic symptoms form a core part of BPD or are found only in the context of comorbid axis I disorder or illicit drug use. Do some patients with BPD also meet criteria for a psychotic disorder? There are also limited data on the qualitative nature of auditory hallucinations in BPD (Adams and Sanders, 2011). The objective of this study was to address these questions using structured psychiatric interviews.

METHODS Study Participants The sample was drawn from a specialist outpatient service for personality disorders in Cambridge, United Kingdom. All patients who enter this service undergo a detailed clinical assessment, and diagnoses are assigned according to DSM-IV criteria. All of the 90 patients with a diagnosis of BPD were invited to participate in the study. They were not selected on the basis that they had reported psychotic symptoms. All patients who agreed gave written informed consent. This study was approved by the Cambridge Local Research Ethics Committee. The main exclusion criterion was the presence of a preexisting clinical diagnosis of nonaffective psychotic disorder, including schizophrenia, delusional disorder, and psychotic disorder not otherwise specified (NOS). Other exclusion criteria were presence of a neurological disorder affecting brain function or a history of head injury. Patients were not excluded if they had a history of major affective disorder or if they showed comorbid drug or alcohol abuse.

Procedure The patients were interviewed using the Present State Examination (PSE), ninth edition (Wing et al., 1974). Interviews were

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carried out by three psychiatrists, who had been trained in the use of the interview, working in pairs. The PSE is the predecessor of Schedules of Clinical Assessment in Neuropsychiatry (World Health Organization, 1994). It is a detailed structured psychiatric diagnostic interview that establishes the presence or absence of many different types of psychotic and neurotic symptoms experienced in the past month. Symptoms are rated as absent (0), present in a fairly severe degree (1), or present in a severe degree (2). We used the lifetime version of the PSE to establish symptoms that occurred anytime in the past (McGuffin et al., 1986). When psychotic symptoms were elicited, additional questions were asked to establish their relationship to mood and drug or alcohol use. Ratings from the PSE, plus information in case notes, were used to establish presence of episodes of axis I disorders (e.g., schizophrenia, depression, mania, anxiety) according to DSM-IV over lifetime. For qualitative examination, descriptions of auditory hallucinations including their content were recorded as part of PSE interview. PSE transcripts were systematically analyzed for emerging themes by two researchers (C.R.M.D. and L.J.P.). Themes were coded manually. Codes included purely descriptive ones arising directly from the transcript and more interpretive codes. Then, the coded data were grouped according to related themes.

RESULTS Characteristics of the Patients Thirty patients agreed and were eligible to take part; the mean age was 39 years (range, 23Y55 years). Most of the patients were women, 27 (90%) of 30.

Psychotic Symptoms Of the total of 30 patients interviewed, 24 (80%) displayed psychotic symptoms at some point during their lifetime. In 18 cases (60%), psychotic symptoms were unrelated to comorbid drug use or affective disorder. Of these 18 cases, auditory hallucinations were reported by 15 patients (50% of the total sample); visual hallucinations by 9 (30%); delusions by 6 (20%); tactile hallucinations by 4 (13%); and olfactory hallucinations by 3 (10%). Many patients experienced more than one psychotic symptom. Three patients met the criteria for a psychotic disorder (10% of the total sample). Descriptions of psychotic symptoms in these 18 cases have been presented below. Only six patients experienced psychotic symptoms in the context of an affective episode (n = 4) or prescribed medication (n = 2). Three patients experienced psychotic symptoms as part of a bipolar disorder; and one, during psychotic depression; all four had hallucinations and delusions. One patient experienced psychotic symptoms in the context of methylphenidate; and the other, during withdrawal from prescribed diazepam. No patients reported psychotic symptoms in relation to alcohol or illicit drug use.

Auditory Hallucinations In most of the cases, the voices tended to be present for long periods with fluctuations, typically getting worse when feeling low (not clinically depressed). In all 15 cases, hallucinations were second person, with three patients additionally hearing voices talking about them (i.e., third-person auditory hallucinations). Half of the patients heard more than one voice. Many of them experienced several voices at the same time. Four patients described that they were able to carry on a two-way conversation with the voices. In most patients, the source of the voices was internal; the voices were external only in four patients. Eight patients also heard muttering and whispering. One described elementary hallucinations and hearing bells and whistles. * 2014 Lippincott Williams & Wilkins

Psychotic Symptoms in BPD

Visual Hallucinations Three of nine patients with visual hallucinations described fully formed images of people or insects. These images were often unpleasant. For example, one patient described seeing herself in a coffin and a dead boy; another saw spiders and maggots. The rest reported fleeting formless images such as flashes of light and shadows that were often interpreted as ghosts.

Delusions In all six cases, delusions were held with full conviction at some point. Two patients had delusions of religious and grandiose nature, such as being able to communicate with God or having a special power. One of them also had a delusion of mind being read, and the other had delusions of reference and misinterpretation. This patient stated that she received coded messages from music and that there was an account of abuse in the newspaper that referred to her. One patient reported fantastic/ sexual delusions. She described being abducted by aliens. Persecutory delusions, in particular, were notable by their absence. Three patients met the criteria for the olfactory reference syndrome (ORS) proposed by Phillips et al. (2006) (see Discussion). They had a longstanding belief that they gave off a smell, which was associated with distress, repeated bathing, and impairment in social and occupational functioning.

Psychotic Disorder Two patients experienced third-person auditory hallucinations and also two or more categories of delusions. Another patient had second-person auditory hallucinations plus sexual/fantastic delusions. These three patients could therefore be considered to have also met DSM-IV criteria for schizophrenia (10% of all BPD cases interviewed). These three patients were previously not known to have a diagnosis of nonaffective psychosis including schizophrenia. No patients reported thought block, insertion, withdrawal, or broadcasting. No patients rated on affective flattening, catatonic symptoms, or incoherent speech.

Nonpsychotic Symptoms Ideas of Reference Eight (27%) of the 30 patients described simple ideas of reference. These beliefs were not held with full conviction, and the patients realized that the feeling originated within them.

Depersonalization and Derealization In the total sample, five patients (17%) experienced either depersonalization or derealization lasting anything from a few seconds to a few weeks. One patient described periods lasting a few weeks in which she would feel in slow motion, as if everything were a pantomime and her body parts would feel detached. Some patients described experiences similar to ‘‘out-of-body experiences’’ in which they view themselves from the outside.

Sensory Distortion Four patients reported distorted visual perception such as seeing their own face as twisted in the mirror. Another patient reported seeing other people’s physical features as distorted. One patient reported heightened visual perception (brighter colors).

Axis I Disorders As well as meeting DSM-IV criteria for BPD, all 30 patients had also met criteria for an additional axis I diagnosis at some point in their lives. Twenty-seven met criteria for major depressive disorder and three patients met criteria for bipolar disorder (Table 1). www.jonmd.com

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TABLE 1. Lifetime DSM-IV Axis I Disorder in BPD Patients, n (%)

Diagnosis

Major depressive disorder Anxiety disorder (any type) Panic disorder with agoraphobia Generalized anxiety disorder Social phobia Anxiety disorder NOS Bipolar disorder Obsessive-compulsive disorder Anorexia nervosa ADHD

27 (90.0) 26 (86.6) 11 (36.7) 8 (26.7) 4 (13.3) 12 (40.0) 3 (10.0) 3 (10.0) 2 (6.7) 1 (3.3%)

ADHD indicates attention deficit hyperactivity disorder.

Three quarters of the patients had a history of alcohol and/or illicit drug use. Approximately half used both alcohol and drugs, such as cannabis, cocaine, heroin, stimulants, ecstasy, and LSD/other hallucinogens. Four patients had shown evidence of alcohol dependence in the past, but none had a history of drug dependence. All denied any current substance misuse.

Qualitative Examination of Auditory Hallucinations in BPD Auditory hallucinations in BPD were somewhat similar in content, whether they occur outside or in the context of an affective disorder, with a few recurring themes (see examples). The content was overwhelmingly critical and negative, calling the patient names and making derogatory comments. Only one patient described neutral or supportive voices. Of the patients who heard several voices at once, there was often an opposing dialogue of a good versus bad internal struggle. Sometimes, voices were attributed to God, the devil, or past abusers. Sometimes, voices gave commands to self-harm. Often, voices occurred in the evening when the patients were alone. Example 1: 38-year-old woman (BPD) I have a robot man’s voice inside my head. I have a little person telling me I am bad. On bad days I believe it. On good days I argue with it. It tells me to self-harm. If I disobey it I know something bad will happen, and the voice gets louder. There is also a second voice, a calm softer female voice who congratulates me when I’ve done well. I talk to her and she replies. Example 2: 42-year-old woman (BPD with comorbid major depressive disorder) I could hear two women and one man. The man was my grandfather; he abused me. The women talked about me. They were nasty. They told me to take myself to the river. They told me I was contaminated. They said, ‘‘kill yourself, go do it now and take your nieces with you’’. I could hear my grandfather laughing.

DISCUSSION Our findings demonstrate that psychotic symptoms are common in BPD. In total, 80% of our sample reported psychotic symptoms in their lifetime. Among the patients who reported psychotic symptoms outside an affective episode or prescribed medication, auditory hallucinations were the most common (50% of the total sample). In most cases, these were persistent for long periods, suggesting that psychotic symptoms should be considered as part of the core symptoms of BPD. Three patients with BPD also met DSM-IV criteria for schizophrenia, who were previously undiagnosed. All 30 patients also had a history of another axis I disorder, most commonly depression. 370

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In line with the findings of Yee et al. (2005) and Slotema et al. (2012), auditory hallucinations in our sample tended to be chronic and negative in content. Beyond this, the features of the voices were quite varied. For example, second and third-person auditory hallucinations, elementary hallucinations, single or multiple voices, and command hallucinations were all reported. The voices were commonly, but not exclusively, reported as being experienced internally, something also noted by Slotema et al. (2012). Overall, our findings support the conclusion of a recent literature review on this topic that ‘‘the voices in BPD do not differ significantly in their phenomenology from the voices found in psychosis’’ (Phillips et al., 2006). Indeed, a recent study suggests that psychotic symptoms in BPD may be governed by similar processes as in psychosis, as reflected by higher scores on the Cognitive Biases Questionnaire for Psychosis in patients with BPD (Moritz et al., 2011). Delusions were less prevalent than hallucinations, being present outside periods of major affective illness in 20% of the patients (six cases). Our findings here show some similarities to those of Kingdon et al. (2010), who found that delusions were present in less than a third of their BPD sample, whereas hallucinations were present in half. In our sample, three of these six patients with delusions met the criteria for schizophrenia. The remainder fulfilled the criteria for ORS (described below). On the other hand, delusions were also found in all four patients who reported psychotic symptoms in the context of a major affective episode (depression or mania). This suggests that the presence of delusions in BPD is an indicator of possible comorbid major axis I disorder and therefore should prompt further clinical examination. Of note, none of the participants in our sample met the criteria for persecutory delusions. This is surprising because childhood trauma is thought to play a role in the development of psychotic symptoms in patients with BPD, as in other populations (Schroeder et al., 2013). However, ideas of reference were present in a quarter of our sample (not held with full conviction). Thus, one explanation could be that although paranoid and referential ideations are common themes in BPD, when a rigorous instrument such as the PSE is applied, these beliefs are found not to be delusional. Three patients met the criteria for ORS, a diagnostic category first proposed by Phillips et al. (2006). These patients described a characteristic conviction that they gave off smell, which was accompanied with distress and/or behavioral changes. DSM-IV does not explicitly mention ORS but classifies it under delusional disorder, somatic type (McCarthy-Jones, 2012). However, there has been dispute over whether patients with ORS are psychotic. Fears about offensive body odor may also be present in, for example, social phobia. There is phenomenological overlap with body dysmorphic disorder, obsessivecompulsive disorder, and hypochondriasis (Feusner et al., 2010). In a recent systematic review of case studies, Begum and McKenna (2011) found an association of ORS with ‘‘Cluster C’’ personality traits. Similarly, in our study, all three BPD patients with ORS had also been given an additional axis II diagnosis of avoidant personality disorder; and in one case, obsessive-compulsive personality disorder. The high comorbidity of ORS in BPD is consistent with elevated self-disgust seen among individuals with BPD (Schienle et al., 2013). We excluded BPD patients who had a preexisting clinical diagnosis of nonaffective psychosis. Three patients in our sample could nevertheless have been considered to have met DSM-IV criteria for schizophrenia (10% of all 30 cases interviewed). This is in line with a previous study of 111 patients with BPD, in which 19 (17%) met DSM criteria for schizophrenia (Kingdon et al., 2010). Individuals with schizophrenia and comorbid BPD have been reported to have poorer long-term outcome (Bahorik and Eack, 2010). Unlike a previous study (Pope et al., 1985), our study does not suggest that psychotic symptoms in BPD outside drug use or major affective illness are factitious, feigned, or otherwise nongenuine. * 2014 Lippincott Williams & Wilkins

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The hallucinations described by our patients did not typically show ‘‘dissociative’’ features, such as multimodal hallucinations or being able to carry on a two-way conversation with the voices. Second, as witnessed by the low frequency of first-rank symptoms, the patients did not give indiscriminate positive responses to the questions in the psychotic sections of the PSE, something that might be expected if an individual was trying to simulate a psychotic state. The content of auditory hallucinations in BPD was overwhelmingly critical and negative. This is consistent with the notion of altered emotional perception characterized by heightened disgust in BPD. The presence of ORS in our sample, which is characterized by beliefs regarding foul body odor, is also in line with this idea. Limitations of the study include a small sample size. However, BPD is a difficult group to study as reflected by relatively small sample sizes in most previous studies on this topic. Our sample was drawn from a specialized personality disorder service. Therefore, they may represent severe forms of the disorder, so the findings may not be generalizable to BPD as a whole. The presence of additional types of personality disorder was not examined in all cases, some of which, for example, schizotypal personality disorder, may themselves be associated with psychotic-like experiences. However, 80% of the BPD patients reported psychotic symptoms, which is unlikely to be explained by comorbid schizotypal personality disorder alone. The occurrence of psychotic symptoms in BPD is important for a number of reasons, with implications for both clinical practice and research. Current diagnostic systems might require revision to emphasize persistent auditory hallucinations in BPD. As with the literature documenting psychotic symptoms in the healthy population (van Os et al., 2009), our findings also call into question the categorical concept of psychosis. These findings add to the debate of whether to use the dimensional or the categorical approach of understanding and classifying psychotic symptoms. The possible relationship of BPD with the newly refined category of schizoaffective disorder in DSM-5 is also relevant. Our findings have implications for treatment, both psychological and pharmacological. Although it is recognized that dialectical behavior therapy may be useful for BPD (Paris, 2010), its use in combination with cognitive behavioral therapy for psychosis could be considered. Our findings are also consistent with the clinical impression that patients with BPD are often given antipsychotics. In summary, our study found that chronic, persistent, and nontransient auditory hallucinations are a core feature of BPD. However, if delusions are present, a comorbid diagnosis of a major axis I disorder needs to be considered. ACKNOWLEDGMENTS The authors thank Golam M. Khandaker, PhD, MRCPsych, from the Department of Psychiatry, University of Cambridge, for his help with this manuscript. DISCLOSURES Peter J. McKenna is supported by the Instituto de Salud Carlos III, Centro de Investigacio´n en Red de Salud Mental, (CIBERSAM), Spain. The authors declare no conflict of interest.

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Psychotic Symptoms in BPD

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A study of psychotic symptoms in borderline personality disorder.

Patients with borderline personality disorder (BPD) report psychotic symptoms, but it has been questioned whether they are intrinsic to BPD. Thirty pa...
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