Meanwhile, back at the Borderline…… Psychosis and Borderline Personality Disorder Chris Holman October 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 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 Normative Traumatic-intrusive Psychotic Organic Hallucinosis

Borderline Personlaity Disorder and Psychosis: a Review Barnow et al. (2010) Current Psychiatric Reports 12, 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, 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’?