Meanwhile, back at the Borderline……

Meanwhile, back at the Borderline……

Psychosis and Borderline Personality Disorder

Chris HolmanOctober 2012

ISPS conference

• 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 HappensPub: 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

• Normative• Traumatic-intrusive• Psychotic• Organic Hallucinosis

Borderline Personlaity Disorder and Psychosis: a ReviewBarnow 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 studyCharles 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 perceptionSee 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’?