What is the nature of psychotic symptoms in Borderline PD? Current Opinion Psych: Jan.2013

17.01.2013

Psychotic symptoms are regarded as part of phenomenology in Borderline Personality Disorder (BpD). However,clinical concepts and diagnostic systems do not provide much clarity  on the nature of these experiences. Transient, stress-related paranoid ideation is the only  criterion in DSM-IV BpD related to psychotic symptoms and in the proposed revision of the BpD criteria in DSM-V, even this will no longer be included. Clinically these experiences are described as pseudo hallucinations or  as quasi psychotic thoughts. Pseudo hallucinations differ from real hallucinations in that they are recognised as such by the individual and are experiences ‘inside the head‘. However, in one study,  one-third  of subjects  with Schizophrenia consider their auditory hallucinations as coming  from outside, another one-third it as coming from ‘inside’ and rest report it as coming from both locations (Copolov et al). If location criteria is used, it could be argued that  hallucinatory experiences that occur in PTSD and dissociative disorders are true psychotic symptoms.

Katrin Schroeder, Helen L. Fisher, and Ingo Schafer  review the prevalence and management of psychotic experiences in BpD.The study by Zanarini et al  showed that 40% had quasi psychotic thoughts, 26% quasi hallucinations and 14% true psychotic thoughts.(Quasi psychotic = experiences that are transient ie less than 2 days, circumscribed i.e.  affecting not more than two areas of the patients’ life , atypical of psychotic disorders ie possibly reality based or totally fantastic in content. Psychotic=Schneiderian first-rank symptoms or other gross departures from reality )

Many studies found no differences with regard to conviction, frequency or beliefs about the location of auditory hallucinations between BpD and schizophrenia ( eg: Kingdon et al 2010). Slotema et al (2012) reported that  prevalence of AVH (auditory, visual hallucinations) do not differ from those with schizophrenia. AVH in BpD caused less disruption in life and it occurred at least once, and majority experienced it inside the head.

Studies also indicate that psychotic experiences may not be transient ie may last weeks.  Some studies suggest depression or substance use may explain these psychotic experiences. This may be the case more so often in cases where psychotic experiences are prolonged.

Child hood trauma  significantly predicts visual and auditory hallucinations later in life (Shevlin et al 2011) as well as delusional experiences ( Schafer et al 2011). Vast majority of BpD individuals report childhood abuse.It is also shown that psychotic experiences in BpD occur in reaction to stressful events (high sensitivity to stress). PTSD as  expression of childhood trauma also needs to be considered.

Management

Case series and open studies report reduction of psychotic symptoms with various antipsychotics. Two controlled studies showed that olanzapine is better than placebo. (Zanarini  2001, 2011). However, another RCT (Schulz et al 2008) did not find Olanzapine as beneficial.Aripiprazole was found effective in one RCT  (Nickel at al 2006). There are only 4 RCTs in this area,  and they suggest antipsychotics as beneficial. As psychotic symptoms  are often related to acute emotional crisis or stress, psychological interventions might also be useful. A pilot study ( Laddis et al 2010) supports this idea.

Conclusions: Up to half of BpD patients report psychotic symptoms.These experiences  should be explored  to understand its nature in terms of phenomenology , duration and effects. Atypical antipsychotics are likely to help in managing these experiences.

Summary of the article:

Psychotic symptoms in patients with borderline personality disorderprevalence and clinical management.

Schroeder K, Fisher HL, Schäfer I. Curr Opin Psychiatry. 2013 Jan;26(1):113-9

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