Persistent hallucinosis in borderline personality disorder
Introduction
This report concerns phenomena observed by those working with borderline personality disorder (BPD) but not widely recognized outside this field. A significant number of these patients experience persisting auditory hallucinosis. Information regarding this and related phenomena seems to be frequently withheld from medical attendants because of fears (or past experience) that disclosure may result in the diagnosis of schizophrenia.
Originally, the term borderline personality disorder was used by Stern [1] to describe patients who manifested both neurotic and psychotic symptoms. These original descriptions did not refer to persistent auditory hallucinosis. More recently, the diagnosis has become operationalized, with greater emphasis on affective instability, core emptiness or depression, disturbance of identity, and behavioral features [2], [3]. While it is recognized that “psychotic” symptoms such as auditory hallucinations and other positive symptoms of psychosis may occur, they are said, in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), to occur only for brief periods in situations of stress [2]. This follows the work of researchers such as Zanarini et al [4] who attempt to differentiate psychotic features in BPD from other psychotic disorders.
The research of Zanarini et al [4] has found the rate of quasi-psychotic experiences in borderline patients to be 40% and also that quasi hallucinations are more common than quasi delusions. This type of disturbance of thought is felt to be so characteristic as to be “virtually pathognomonic for the borderline patients…(it) successfully discriminated them from those in each of the other groups” (other personality disorder, schizophrenia, and normal controls) [4]. They are, however, critical of earlier studies for using terms such as psychotic or psychotic-like too generally, believing we can rely on the “clear-cut departure from consensual reality described in DSMIII” to distinguish psychosis from nonpsychosis [4].
The differentiation of Zanarini et al [4] of quasi from true psychotic symptoms relies on criteria of (a) transiency, (b) circumscription (only affecting 1 or 2 areas of the patients life), or (c) atypicality (possibly reality-based or totally fantastic in content). In a 6-year prospective study by the same group, many cases of “quasi-psychotic” symptoms of thought and perceptual disturbances are persistent [5]. Later works also emphasize distorted dysphoric cognitive abnormalities as most specific for BPD [6], [7]. Skodol et al [8] are critical of the current DSM classification for omitting regression-proneness and for only making indirect reference in criterion 9 to lapses in reality testing.
Other studies have demonstrated a significant incidence of such symptoms in general population samples [9], [10], [11]. Auditory and visual hallucinations are also commonly recognized in other, perhaps more controversial diagnostic entities, such as dissociative identity disorder (DID) or dissociative (hysterical) psychosis [12], [13]. In this article, we identify a significant group of patients with a diagnosis of BPD who have ongoing symptoms including auditory hallucinations and other phenomena, such as thought insertion, that are more commonly associated with psychosis.
The tendency when confronted with positive psychotic phenomena is for the clinician to either make a diagnosis of schizophrenia or other major psychotic disorder or to dismiss the phenomenon in question by resorting to a concept such as “pseudohallucination.” This term was coined initially by Hagen in 1868 to describe hallucinations that were not “real” hallucinations, although the debate about what had constituted genuine hallucinations had been going on considerably longer [14]. Berrios and Dening point out that this amounts to casting the concept into “the unpleasant role of being a ‘joker’ in the diagnostic game: by taking different clinical values it allows clinicians to call into question the genuineness of some true hallucinatory experiences that do not fit into a preconceived psychiatric diagnosis” [14]. In fact, it is difficult for clinicians to distinguish between “true” hallucination and “pseudohallucination,” and empirical efforts to assess the validity and reliability of this distinction have failed [15], [16]. From a clinical point of view, if the distinction cannot be made in a reliable way, then it amounts to either a concept that lacks utility or a “nonconcept.”
The case series presented in this article arose out of the clinical experience of one of the authors (LY) who was treating patients who presented with distress and concern in relation to auditory experiences. These were described as “voices” that had been present for long periods and persisted consistently during therapy. The subjects came from a treatment program for BPD in which diagnoses are made by experienced psychiatrists using updated versions of DSM (DSM-IV at the time of this study) criteria for the disorder [17]. Having become interested in the phenomenon, LY sought to evaluate a larger group of patients from this program.
Section snippets
Subjects
Three patients were treated by LY, a psychotherapist affiliated with the Westmead Hospital's BPD treatment program, with an additional 7 patients randomly selected from a larger group enrolled in the BPD research (and treatment) program. The 3 patients of LY were selected on the basis of their self-report during therapy of auditory hallucinosis as part of their experience. The other 7 patients were selected after they had indicated, on completion of the Symptom Checklist 90 (SCL-90) [18], that
Case series
- 1.
R was a 30-year-old single woman with full-time work. She reported hearing “voices” 20% of the time and that these had been “present since high school.” They were characterized as “like conversations inside my head”; they were worse under stress, at which times, she sensed them “take over.” They were perceived as negative and critical, and she felt “under their control.” Specifically, she believed they “paralyze” her and prevent her from making decisions. She believed them to be separate from
Results
From the total sample of 171 patients with BPD enrolled in the treatment program, 50 reported they “heard voices” (29.2%) on the SCL-90.
Discussion
This case series provides limited evidence for the occurrence of auditory hallucinosis and other positive “psychotic” symptoms occurring in a significant proportion of patients with BPD. This is part of a growing literature on the occurrence of hallucinatory phenomenon and other “psychotic” symptoms occurring outside the context of psychotic illness (eg, Refs [9], [10], [11], [12], [23]). The phenomenological grounds for making valid diagnostic distinctions among psychosis, BPD, and some other
Conclusions
At present, clinicians are taught that psychotic phenomena only occur briefly as part of a “transient psychotic state” in people with BPD. Patients with BPD are frequently aware that if they disclose symptoms of this kind, they will be seen as “crazy” and treated differently. Hence, patients tend to underreport. While replication of our findings in a larger sample is necessary, this series suggests that a significant percentage of patients with BPD have hallucinatory phenomena that are not
References (36)
- et al.
The borderline diagnosis 1: psychopathology, comorbidity, and personality structure
Biol. Psychiatry
(2002) - et al.
Schneiderian symptoms and childhood trauma in the general population
Compr. Psychiatry
(1992) - et al.
Pseudohallucinations: a pseudoconcept? A review of the validity of the concept, related to associate sympomatology
Compr. Psychiatry
(2001) - et al.
Psychotic symptoms in depression and borderline personality disorder
J. Affect. Disord.
(1993) Psychoanalytic investigation of and therapy in the border line group of neuroses
Psychoanal. Q.
(1938)Diagnostic and statistical manual of mental disorders
(1994)Practice guideline for the treatment of patients with borderline personality disorder
Am. J. Psychiatry
(2001)- et al.
Cognitive features of borderline personality disorder
Am. J. Psychiatry
(1990) - et al.
Borderline personality disorder: a review of data on DSM-III-R descriptions
J. Personal. Disord.
(1991) - et al.
The pain of being borderline: dysphoric states specific to borderline personality disorder
Harv. Rev. Psychiatry
(1998)