Hallucinations and Other Psychotic Symptoms in Patients with Borderline Personality Disorder

Abstract

Background Psychotic symptoms in BPD are not uncommon, and they are diverse and phenomenologically similar to those in schizophrenia spectrum disorders. Despite their prevalence in BPD patients, knowledge about the characteristics and severity of hallucinations is limited, especially in modalities other than auditory. Aim This review summarises the causes, phenomenology, severity, and treatment options of hallucinations and other psychotic symptoms in BPD. Methods The PubMed database was used with the following key terms: “borderline personality disorder” and ‘hallucinations’ and “psychotic symptoms”. Articles were selected between January 1990 and May 2021. The primary keyword search yielded a total of 545 papers, of which 102 articles met the inclusion criteria and were fully screened. Papers from the primary source reference lists were also screened, assessed for eligibility, and then added to the primary documents where appropriate (n = 143). After the relevance assessment, 102 papers were included in the review. We included adult and adolescent studies to gather more recent reviews on this topic. Results Hallucinations are significantly prevalent in BPD, mainly auditory, similar to schizophrenia spectrum disorders. The relationship between hallucinations and depression, anxiety, suicidality, schizotypy, and loneliness in BPD has been discovered but requires more research. Studies for treatment options for hallucinations in BPD are lacking. Conclusion Recognition of psychotic symptoms in patients with BPD as distinguished psychopathological phenomena instead of diminishing and overlooking them is essential in the clinical assessment and can be useful in predicting complications during treatment. More focused research in this area is needed.

Time to put aside the false dichotomy between personality disorders and psychotic symptoms

“…A study comparing the phenomenology of psychotic symptoms across a wide range of disorders found no evidence of clear phenomenological disparities between auditory and visual hallucinations across diverse psychiatric disorders (e.g., BPD, schizophrenia, PTSD, mood disorders; Schutte et al, 2020). Among patients with BPD, the most frequent (and most studied) symptoms are auditory verbal hallucinations (AVH; i.e., voices), with prevalence estimates of approximately 30%–50% (Belohradova Minarikova et al, 2022). Those AVHs usually take the form of imperative hallucinations, that is, the conviction that one has been given a specific task (in 56% of cases; Slotema et al, 2018).…”

“…Even though knowledge on the matter is more limited, some evidence suggests that patients with PDs might show other psychotic symptoms as well. Those include hallucinations pertaining to diverse sensory modalities (i.e., gustatory, visual, tactile, and olfactory; Beatson, 2019; Belohradova Minarikova et al, 2022). Delusions, including ideas of reference and thought insertion, have a prevalence of 26% (Niemantsverdriet et al, 2022).…”

“…What is more, patients might present with remarkably diverse personality features including the “traditional” prodromes (e.g., social withdrawal, affective flattening) usually associated with schizotypal PD, but also other signs that were associated with BPD (e.g., interpersonal instability, emotional dysregulation; Boldrini et al, 2019)—that is, with a disorder that was typically considered “less” related to psychosis (Zandersen et al, 2019). Thus, just like research has mostly failed to find clear boundaries between neurological and psychiatric disorders from neurobiological and symptomatic standpoints (e.g., David & Nicholson, 2015), the traditional “PD vs. psychosis” differential diagnosis seems to be essentially a false dichotomy (Belohradova Minarikova et al, 2022), especially among severe cases (Luyten & Fonagy, 2022; Tyrer et al, 2022).…”

“…delinquency; e.g., Eaton et al, 2011;Westen et al, 2012). A third category of psychopathological symptoms-more controversial and poorly understood-refers to psychotic or thought dysfunction symptoms (e.g., hallucinations, persecutory delusions, ideas of reference; Belohradova Minarikova et al, 2022;Newton-Howes et al, 2008).…”

“…Personality disorders (PDs) are characterized by numerous psychopathological manifestations, which are generally summarized into internalizing (e.g., negative emotions, anxiety, low self‐esteem, feelings of emptiness, identity diffusion) and externalizing symptoms (e.g., impulsivity, aggressiveness, abuse of psychoactive substances, delinquency; e.g., Eaton et al, 2011; Westen et al, 2012). A third category of psychopathological symptoms—more controversial and poorly understood—refers to psychotic or thought dysfunction symptoms (e.g., hallucinations, persecutory delusions, ideas of reference; Belohradova Minarikova et al, 2022; Newton‐Howes et al, 2008).…”