Meanwhile, back at the Borderline……
Psychosis and Borderline Personality
Disorder
Chris Holman
October 2012
ISPS conference
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Introduction
What do people with BPD say?
What do I think BPD is?
What is the range of psychotic
experiences people describe?
• What is going on to cause the
experiences?
• Does this tell us anything interesting
about psychotic experiences?
…something about words…
schizophrenia = “schizophrenia”
borderline PD = “borderline PD”
psychosis = psychosis
Psychosis ?= Dissociation
DSM 4
• ‘Transient, stress-related paranoid ideation
or severe dissociative symptoms’
• Pseudohallucinations
• Berrios and Dening (1996), Pseudohallucinations: a
conceptual; history. Psychological Medicine, 26, 753 – 64
Rachel’s story
• Auditory hallucinations
• Visual hallucinations, associated with hallucinatory
experiences in other modalities
• Paranoia
• Other psychotic experiences
• Triggers and things that help
• Why does she not tell people?
• Difference from flashbacks
Borderline Personality Disorder
• Stern A., (1938) Psychoanalytic
investigation and therapy in borderline
group of neuroses. Psychoanalytic
Quarterly 7, 467-8
BPD
5 of:
• Efforts to avoid abandonment
• Unstable/intense relationships
• Unstable identity
• Damaging impulsivity
• Recurrent suicide/self-harm
• Affective instability
• Chronic emptiness
• Inappropriate anger
• Paranoia/dissociation
BPD
• Central Place of Affect Regulation
– Affective Instability
– Inappropriate anger
– Suicide/self-harm
• Interpersonal Difficulties
– Unstable/intense relationships
– Efforts to avoid abandonment
– Chronic emptiness
• Impaired Sense of Self
– Unstable identity
– Impulsivity
BPD
• Paranoia and Dissociation
?
What is BPD?
Fonagy, P, Gyorgy, G, Jurist, E, Target, M,
(2004)
Affect Regulation, Mentalisation and the
Development of the Self
Pub: Karnac
• Social Bio-feedback theory of affect mirroring
• Primary Carer (Maternal) Attachment Style and
Infant Development
Antonio Damasio (2000) The Feeling of What
Happens
Pub: Vintage
• Construction of the Sense of Self
….a few recent studies….
‘Persistent hallucinosis in borderline
personality disorder’, Yee et al (2005)
Comprehensive Psychiatry 46, 147 – 154
• Survey of a series of 171 people: ‘auditory
hallucinations occur in 30%’
• 10 people who reported hallucinations described in
detail
• Hallucinations are persistent and an important part
of their experience
• Associated with Abuse
‘Persistent hallucinosis in borderline
personality disorder’, Yee et al (2005)
Comprehensive Psychiatry 46, 147 – 154
Types of hallucination
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Normative
Traumatic-intrusive
Psychotic
Organic Hallucinosis
Borderline Personlaity Disorder and
Psychosis: a Review
Barnow et al. (2010) Current Psychiatric
Reports 12, 186 - 195
• Vague distinctions between hallucinations,
paranoia and dissociation
• No theoretical formulation
• Agree psychotic phenomena are related to
trauma history
Olanzapine for the treatment of borderline
personality disorder: variable dose 12-week
randomised double-blind placebo-controlled
study
Charles Schulz et al. (2008) BJPsych 193, 485 492
• 52 centre study of 385 participants, Olanzapine vs
Placebo
• Main measure Zanarini rating scale (include others,
but no measure of Psychosis)
• Both Olanzapine and Placebo showed significant
improvement at 12 weeks
…things we might conclude…
• Hallucinations in all modalities are common in
people with BPD
• They are persistent, troubling, and often
experienced as directing the person to self-harm or
other behaviours
• They are trauma-related
• Paranoia is a common state of mind
• Other psychotic experinces occur but are not so
common
• They are not the same as flashbacks
• They are not the same as dissociation
…so what’s going on...?
Dissociation
• Direct trauma response: ‘coping strategy’
• over-regulation in response to overwhelming terror
• Emotional Personality EP (as against Apparently
Normal Personality ANP)
(Nijenhuis et al. (2010) Trauma-related structural dissociation of the
personality Activitas Nervosa Superior 52, 1 – 23)
• Related to flashbacks and over-arousal (PTSD)
…so what’s going on...?
Hallucinations
• Disturbance of Perception
• More likely when disturbed or isolated
• Involve distress-related experinces
Affect and perception
• Capgras syndrome: absence of affective ‘label’
robs face of significance
• Misperceptions by bereaved people
• Misidentify self in the mirror
Affective labelling trumps sensory evaluation
Affect and perception
See it with feeling: affective predictions during
object perception. L F Barrett and Moshe Bar
(2009) Phil Trans Roy Soc B 364, 1325 – 1334
• The mind/brain is constantly producing hypotheses about
external perceptions and internal experiences (‘resting brain’)
• The Proactive Brain: using analogies and associations to
generate predictions (M Bar (2007) Trends in Cognitive
Sciences 11, 280)
• Affective response to provisional perception occurs early
Affective experience is at least equal with cognitive
in generating hypotheses
Hallucinations and Perceptual Set
A set of affective and cognitive conditions
which regulate perception
Implies:
• improved affect regulation will reduce vulnerability
• Grounding and mindfulness are useful interventions
• ‘Violating the Perceptual Set’ will resolve the
hallucination
Conclusions
• Psychotic experiences are common and sustained
in many people with BPD
• Hallucinations in BPD are trauma-related
• They can be understood if one places affect at the
heart of the experience of external reality
• (Say something about Paranoia)
• These are not the same as Dissociative experiences
Discussion
• Does this tell us anything we did not know
already?
• Is this different from the process causing
Hallucinations in ‘Schizophrenia’?