Meanwhile, back at the Borderline……
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Transcript of 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
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
‘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