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.

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.

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.

[Auditory verbal hallucinations in patients with borderline personality disorder]. / Auditieve verbale hallucinaties bij patiënten met een borderline-persoonlijkheidsstoornis.

BACKGROUND: Traditionally, auditory verbal hallucinations (AVH) experienced by patients with a borderline personality disorder (BPD) are considered to be rare, to have a 'pseudo'-quality, and to cause little distress. AIM: To provide an overview of studies of the prevalence and phenomenological characteristics of AVHs in patients with a BPD, and of the ensuing degree of suffering. METHOD: We performed a systematic literature search using PubMed and the Ovid database. RESULTS: 27% of patients with a BPD experience AVH. Phenomenologically, these percepts are indistinguishable from those experienced by patients with a schizophrenia spectrum disorder. Hallucinations in several modalities were present in 50% of the patients with BPD. The mean time-span in which AVH were experienced was 17 years, the mean frequency was several minutes per day. The degree of suffering was high and the patient's life was interrupted to a moderate degree. CONCLUSION: AVH and other hallucinations are common in BPD. We advise clinicians to inquire directly whether patients experience them and to provide treatment whenever possible. However, one of the problems is, that evidence-based treatment methods such as antipsychotics, cognitive-behavioural therapy and transcranial magnetic stimulation have not yet been studied systematically for this specific patient group.

[Treatment strategies for auditory verbal hallucinations]. / Behandelmogelijkheden voor auditieve verbale hallucinaties.

BACKGROUND: Auditory verbal hallucinations (AVH) are experienced not only by patients diagnosed with schizophrenia, but also by patients with other disorders (some of which may be psychiatric) and in the general population. The ensuing affliction may be severe and can sometimes result in dangerous behaviour. Although various treatment options are available for AVH, only a few have been investigated in randomised placebo-controlled trials. AIM: To provide an overview of the literature relating to the effectiveness of antipsychotics, cognitive-behavioural therapy (CBT), electroconvulsive therapy (ect), and transcranial magnetic stimulation (TMS) in the treatment of avh. METHOD: This review paper is based on the Ph.D. study of the first author; in addition, a literature search was carried out using PubMed. RESULTS: Antipsychotics have never been studied specifically with regard to their effect on AVH, but they are known to lead to a significant decrease in the severity and frequency of hallucinations in general. cbt can reduce the torment caused by AVH, but not the severity or frequency. ect can be helpful in the treatment of drug-resistant psychosis, but it has never been studied specifically with regard to its effect on avh or on other types of hallucinations. tms is effective for the treatment of drug-resistant AVH, but in the cases where it has been used so far, the beneficial effects seem to have been of limited duration. CONCLUSION: Very few of the available treatment strategies have been used specifically to relieve the distress caused by avh. tms and cbt have proved reasonably effective, but there is a need for further research into additional treatment strategies, particularly into those involving TMS.

Reproducibility of brain activation during auditory verbal hallucinations.

Previous studies investigated fMRI-guided repetitive Transcranial Magnetic Stimulation (rTMS) as an alternative treatment for auditory verbal hallucinations (AVH). This tailor-made treatment focuses at directing the rTMS coil to the location where hallucinatory activation is maximal, as identified with fMRI scans of individual patients. For the effective use of such treatment it is important to determine whether brain activation during AVH can be reliably detected using fMRI. Thirty-three psychotic patients indicated the presence of AVH during two subsequent scans. Reproducibility was measured by calculating 1) the distance between local maxima of significantly activated clusters and 2) percentage overlap of activation patterns over the two scans. These measurements were obtained both in single subjects and on group-level in five regions of interest (ROIs). ROIs consisted of the areas that were most frequently activated during AVH. Scans were considered reproducible if the distance between local maxima was smaller than 2 cm, as rTMS-treatment may target an area of approximately 2-4 cm. The median distance between local maxima was smaller than 2 cm for all ROIs on single-subject level, as well as on group-level. In addition, on single-subject level median percentage overlap varied between 14 and 38% for the different ROIs. On group-level, this was substantially higher with percentages overlap varying between 34 and 98%. Based on these results, AVH-scans may be considered sufficiently reproducible to be suitable for fMRI-guided rTMS treatment.

Meta-analysis of repetitive transcranial magnetic stimulation in the treatment of auditory verbal hallucinations: update and effects after one month.

OBJECTIVE: Several meta-analyses considering repetitive transcranial magnetic stimulation (rTMS) for auditory verbal hallucinations (AVH) have been performed with moderate to high mean weighted effect sizes. Since then several negative findings were reported in relatively large samples. The aim of this study was to provide an update of the literature on the efficacy of rTMS for AVH and to investigate the effect of rTMS one month after the end of treatment. DATA SOURCES: A literature search was performed from 1966 through August 2012 using Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase Psychiatry, Ovid Medline, PsycINFO and PubMed. Randomized, double blind, sham-controlled studies with severity of AVH or severity of psychosis as an outcome measure were included. STUDY SELECTION: Data were obtained from 17 randomized studies of rTMS for AVH. Five studies fulfilled the criteria for the meta-analysis on the effect of rTMS one month after the end of treatment. DATA EXTRACTION: Standardized mean weighted effect sizes of rTMS versus sham were computed on pre- and posttreatment comparisons. DATA SYNTHESIS: The mean weighted effect size of rTMS directed at the left temporoparietal area was 0.44 (95% CI 0.19-0.68). A separate meta-analysis including studies directing rTMS at other brain regions revealed a mean weighted effect size of 0.33 (95% CI 0.17-0.50) in favor of real TMS. The effect of rTMS was no longer significant at one month of follow-up (mean weighted effect size=0.40, 95% CI -0.23-0.102). Side effects were mild and the number of dropouts in the real TMS group was not significantly higher than in the sham group. CONCLUSIONS: With the inclusion of studies with larger patient samples, the mean weighted effect size of rTMS directed at the left temporoparietal area for AVH has decreased, although the effect is still significant. The duration of the effect of rTMS may be less than one month. More research is needed in order to optimize parameters and further evaluate the clinical relevance of this intervention.

Auditory verbal hallucinations in patients with borderline personality disorder are similar to those in schizophrenia.

BACKGROUND: Auditory verbal hallucinations (AVH) in patients with borderline personality disorder (BPD) are frequently claimed to be brief, less severe and qualitatively different from those in schizophrenia, hence the term 'pseudohallucinations'. AVH in BPD may be more similar to those experienced by healthy individuals, who experience AVH in a lower frequency and with a more positive content than AVH in schizophrenia. In this study the phenomenology of AVH in BPD patients was compared to that in schizophrenia and to AVH experienced by non-patients. METHOD: In a cross-sectional setting, the phenomenological characteristics of AVH in 38 BPD patients were compared to those in 51 patients with schizophrenia/schizoaffective disorder and to AVH of 66 non-patients, using the Psychotic Symptom Rating Scales (PSYRATS). RESULTS: BPD patients experienced AVH for a mean duration of 18 years, with a mean frequency of at least daily lasting several minutes or more. The ensuing distress was high. No differences in the phenomenological characteristics of AVH were revealed among patients diagnosed with BPD and those with schizophrenia/schizoaffective disorder, except for 'disruption of life', which was higher in the latter group. Compared to non-patients experiencing AVH, BPD patients had higher scores on almost all items. CONCLUSIONS: AVH in BPD patients are phenomenologically similar to those in schizophrenia, and different from those in healthy individuals. As AVH in patients with BPD fulfil the criteria of hallucinations proper, we prefer the term AVH over 'pseudohallucinations', so as to prevent trivialization and to promote adequate diagnosis and treatment.

Follow up of patients with signs and symptoms of polyneuropathy not confirmed by electrophysiological studies.

The outcome and final diagnoses of patients with symptoms and/or signs suggestive of polyneuropathy, but with normal electrophysiological studies, were investigated. All patients who presented at the outpatient clinic between 1993 and 1998 with signs and symptoms suggestive of polyneuropathy, but in whom electrophysiological studies were normal, were included. We retrospectively collected data from the medical records and then interviewed the patients and used the Sickness Impact Profile scale to investigate functional status at least 2 years after presentation. We included 74 patients, of whom 39 had neurological signs at neurological examination at the first visit. A final diagnosis was made in 24 of the 39 patients with neurological signs, and in three of the 35 patients without neurological signs but with symptoms. One (3%) of the 35 patients without neurological signs at the first visit had a poor outcome versus 15 (39%) of the 39 patients with neurological signs. In 11 (41%) of the 27 patients in the group with a final diagnosis the outcome was poor versus 5 (11%) of 47 patients without a final diagnosis. In 11 patients we concluded that they probably had small fibre neuropathy. Patients presenting with symptoms of polyneuropathy but who have neither neurological signs of polyneuropathy nor electrophysiological studies confirming a polyneuropathy have a good outcome at least 2 years after presentation. Further investigations are not indicated, except for patients fulfilling the criteria of small fibre neuropathy. In patients with neurological signs, as the outcome depends on the diagnosis and an explanation for these signs is often found, repeated investigations in this group are mandatory.