Delusions and hallucinations in patients with borderline personality disorder

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  • Psychiatry and Clinical Neurosciences (1 998) 52, 605-610

    Regular Article

    Delusions and hallucinations in patients with borderline personality disorder

    HIROSHI SUZUKI, M D , ~ CHIAKI TSUKAMOTO, MD, YOSHIYUKI NAKANO, M D , ~

    Department of Neuropsychiatry, Okayama University Medical School and 2Department of Psychiatry, Kawasaki Medical College, Okayama, Japan

    SHOZO AOKI, MD* AND SHIGETOSHI KURODA, MD

    Abstract To clarify the nature of delusional and hallucinatory symptoms in borderline personality disorder (BPD), the authors investigated five patients with BPD who developed those symptoms, and dis- cussed their duration, recurrence, types of variants and relation to the situation. The duration of these symptoms tended to vary widely, although six of 11 episodes lasted more than 7days. Epi- sodes tended to recur in all patients two or three times. Each episode could be classified into three types of delusions and hallucinations, such as delusions without hallucinations, complicated de- lusion and hallucination, and hallucinations without delusion. Delusions without hallucination occurred a total of four times in two patients and had a tendency to occur when the patient confronted personal adversities. They projected their feelings directly toward the person concerned. A complicated delusion and hallucination was observed three times in two patients. This type of symptom also tended to occur at the time of interpersonal problems but the patients attitude was more passive. Hallucination without delusion occurred a total of four times in three patients. This symptom tended to occur when the patient avoided an interpersonal relationship. In this case the patients isolated themselves from others and withdrew.

    Key words borderline personality disorder, delusion, hallucination, psychotic symptom.

    INTRODUCTION

    Borderline personality disorder (BPD) is characterized by instability in interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood. In the United States, BPD occurs in -2% of the general population. Previous researchers pre- sumed that BPD might be a subtype of schizophrenia. However, according to some phenomenological inves- tigations, BPD has since been distinguished from schizophrenia and other psychiatric disorders.24

    There have been some discussions about the role and prevalence of psychotic symptoms in BPD patients. Kolb and Gunderson suggested that mild psychotic experiences were very common in patients with BPD

    Correspondence address: Hiroshi Suzuki, MD, Department of Neu- ropsychiatry, Okayama University Medical School, Shikatacho 2-5-1, Okayama City, Okayama. Japan.

    Received 20 March 1998; revised 10 June 1998; accepted 3 August 1998.

    and that these symptoms were one of the important clinical features associated with the diagnosis of BPD. Tarnopolsky and Berelowitz reported that the item that discriminated best between BPD and controls was brief unsystematized psychotic e p i ~ o d e . ~

    In 1984 Jonas and Pope reviewed the literature and suggested that narrowly defined psychotic symptoms such as clear-cut delusions and hallucinations were rare in BPD, and broadly defined psychotic symptoms such as derealization and depersonalization were often reported.6 In the next year, Pope eral. published em- pirical study and came to the same concl~s ion .~

    In contrast, in 1986 Chopra and Beatson made a pilot study of 13 patients with BPD and observed non- drug-induced hallucinations in seven cases. Links et al. examined the occurrence of psychotic symptoms of BPD inpatients and found delusions and hallucinations in - 20% of the BPD inpatients. In 1993 Miller ef al. investigated the presence and duration of psychotic symptoms. They found that 27% of patients had psychotic episodes, typically lasting many weeks.

    There remained some disputes about the nature of delusions and hallucinations in BPD. Those were: (i)

  • H. Sumki et al. 606

    whether the duration of these symptoms was brief or not (the report by Miller et al. controverted previous opinions); (ii) did they repeat such symptoms fre- quently or not (about this point no researcher stated any suggestion); (iii) is there any variant of delusions and hallucinations (previous researchers included de- lusions and hallucinations in narrowly defined psy- chotic symptom); and (iv) how do their experiences relate to the situation in which they occurred. (The DSM commented that they occur most frequently in response to abandonment. Chopra and Beatson stated that their hallucinations appeared to be manifestations of the intense anxiety.)

    In the present paper, we attempt to resolve some of these subjects. We describe the case reports of five BPD patients who we observed for more than 5 years. Based on these observations, we characterized these symptoms according to the situation in which they occurred.

    SUBJECTS AND METHODS

    Upon admission to Okayama University Hospital, she became very reactive toward other patients and very aggressive toward our staff members. When Someone could'not answer her demands at once, her temper flared instantly. One day she complained that people were looking at her maliciously. She was ad- ministered anti-psychotic drugs (2 or 3 mg of fulphen- azinelday) and the delusions subsided within 7 days.

    When she was 18 years old, she was discharged from our hospital. Rather than returning to the high school, she enrolled in a correspondence course. She gradually isolated herself at home. She became increasingly irri- table and got angry with her family because she imagined that they were saying that she was stupid. This hallucinatory voice tormented her and disap- peared after a few days.

    One year later, she obtained her driver's license and took on a part-time job. Her doctor was very busy treating another borderline patient who was her friend. She was convinced that her doctor hated her and was going to kill her. As a result, she became hostile toward him. The doctor increased the number of treatment sessions and her delusional behavior subsided.

    Following these treatment sessions the patient at- tended a preparatory school and passed the entrance examination and entered college in the following spring.

    She repeated a delusional state without hallucination twice and unaccompanied hallucinations once. All ep- isodes were transient and deeply related to affective shift, especially her anger.

    The cases were five female patients with BPD who showed delusions and/or hallucinations. The patients were diagnosed according to the DSM-IV criteria for BPD and they did not have dual diagnosis such as substance-related disorder, schizotypal personal disor- der, paranoid personality disorder etcetera. The pa- tients were referred to Okayama University Hospital when they were 17 or 18years old and have been treated at our clinic as inpatients and outpatients also. The observation period ranged from 5 to 20years. All the patients had undergone both phannacotherapy and psychotherapy during that period.

    CASE REPORTS

    case 1

    A 17-year-old girl was referred to our hospital due to aggressive behavior toward her doctor. She was the single child of a wealthy traditional family in which the grandfather was the head of the family. Her grandfa- ther decided that she should be brought up by her grandmother .

    When she was 15years old, she entered a prestigious high school and lived in the school dormitory. She was unable to adapt to her new surroundings and demon- strated many somatic symptoms and emotional dys- function. Due to frequent emotional outbursts, she became unable to attend classes and was referred to a psychiatrist. She was hospitalized, however, due to frequent quarrels; her doctor referred her to Okayama University Hospital.

    case 2

    A 16-year-old girl suffered from several eating disor- ders including anorexia, bulimia, and binge eating. However, she did not receive medical attention. She was born to a middle-class family and received a strict upbringing by her mother. Although she was consid- ered to be a bright girl, she began to be truant from school at the age of 18, spending many nights with her boyfriend. Her parents took her to see a psychiatrist. After this episode, she showed mood instability and impulsive self-harming.

    When she was 21years old, her elder brother, to whom she felt very close, got married. She was shocked and demonstrated syncope, hyperventilation, a twilight state and other dissociative symptoms. At the same t h e , she complained that every sound she heard was very loud and noisy. These symptoms continued for several months but subsided gradually. The same symptoms recurred several years later.

    When she was 26years old, she got a part-time job and joined a theatrical company as an actress. The

  • Borderline personality disorder 607

    following year she got married but was unable to adapt to married life. She divorced and returned to her par- ents home. At that time, she fell into an acute paranoid hallucinatory state. She complained that men came to her house, looked into her room, saw what she was doing and criticized her behavior. She said that the men looked at her lewdly and despised her as a loose woman. She was administered anti-psychotic drugs (9- 18 mg of haloperidol/day). The delusions and halluci- nations subsided shortly thereafter.

    Her life remained very unstable, and she made sev- eral serious attempts at suicide, resulting in her ad- mission to the emergency unit. When she was 33 years old, she underwent surgical treatment for hemorrhoids. She became emotionally attached to her young sur- geon. Following surgery, she was forced to stay in a recovery ward with many people due to the unavail- ability of a single room. At that time, she complained that someone peeped into her room and called her lewd. She was moved to the psychiatric ward. However, because this ward was under construction, she saw many men at work. Thus, the conditions of her envi- ronment were unfortunately very similar to those of her delusional thoughts. Despite intensive pharmacho- therapy she remained in a paranoid hallucinatory state for several months. Her delusion and hallucination disappeared when the construction of the hospital ended. After that she returned to her unstable life as usual.

    She experienced a delusional hallucinatory state twice. The second episode was prolonged for more than 4 weeks and met criteria A for schizophrenia as de- scribed in the DSM-IV. However, her patterns of be- havior, which had an early onset and a long-standing course, conformed to characteristic features of BPD and it was very hard to regard them as a prodromal or residual state of schizophrenia. She could not meet criterion B for schizophrenia of DSM.

    Case 3 A 17-year-old girl was first referred to Okayama Uni- versity Hospital due to self-inflicted injury. She was the younger of two children born to a lower-middle-class family. Her father suffered from chronic depressive psychosis for 12 years prior to her self-inflicted injury. As a result, her mother was forced to work in order to support her family. The patient was a very cheerful girl but was very sensitive to her physical conditions.

    When she was 17years old, her elder brother devel- oped acute meningitis. Her mother spent much time caring for her son and she became depressed. She confided to her schoolmates that she wished to die. She slit her wrist and was admitted to our hospital that winter.

    She was unable to attend her high school the fol- lowing year and she was admitted to our hospital. She was very unstable emotionally in the psychiatric ward. She engaged in self-mutilation and self-poisoning and demonstrated symptoms of anorexia and bulimia. She was repeatedly admitted and discharged from our hospital and could not get along with the other patients or staff members.

    When she was 20years old, she developed urticaria while in our care. A dermatologist gave her a small dose of a corticoid drug (1 5 mg of prednisolone). After that she fell into an acute paranoid hallucinatory state. She complained that people at our hospital were looking at her critically and that someone had com- manded that she hurt herself. By increasing the dosage of the anti-psychotic drugs and stopping corticoid ad- ministration, these symptoms were eliminated almost immediately.

    She became withdrawn and spent most of her time in her room. When she was 21 years old, a patient com- mitted suicide by jumping from the roof of the hospital. The patient then began to experience auditory halluci- nations in which a voice commanded her to jump from the roof. These hallucinations lasted for a few days.

    Her emotional state remained unstable and she pre- sented with many other symptoms including total am- nesia, syncope, and self-inflicted injury. She also complained of altered perception, in which everything she looked at appeared to jump into her eyes.

    Her first episode occurred just when she took a small dose of corticoid drug. But the amount (1 5 mg of pre- dnisolone) was very small and the duration (1 day) was very short; it was difficult to consider that the episode was caused by the corticoid drug. In addition she had another history of non-substance-related psychotic episode. So we denied the additional diagnosis of sub- stance-related psychotic disorder.

    case 4 An 18-year-old woman was first referred to Okayama University Hospital with a chief complaint of anorexia. She was born to the younger of two children in a middle-class family. In junior high school. she was a member of the track and field team and proved to be an excellent athlete.

    She then went on to high school. However, she was unable to compete effectively on the athletics team. She changed schools and gave up athletics. She began preparing for her university entrance examinations when she was 18years old. During that time she be- came anorexic. She was then referred to our hospital and admitted. She gradually regained her bodyweight. However. she became emotionally attached to her psychiatrist and presented with many dissociative

  • 608 H. Suzuki et al.

    symptoms including syncope, psychogenic aphasia, a twilight state, and psychogenic fugue. She became bu- limic with accompanying depression. She experienced intense feelings of guilt that led her to attempt suicide on numerous occasions.

    Gradually she fell into social withdrawal. When she was 23 years old, she locked herself in her room, during which time she experienced auditory hallucinations. The voice criticized her strongly and she became ex- tremely sensitive. She refused to take oral medication because the hallucinatory voice forbade her to do so. As a result, she was administered anti-psychotic drugs by deposit injection. The auditory hallucinations sub- sided shortly thereafter.

    The following year she suddenly became unable to hear any sound. She began to experience auditory and visual hallucinations in which someone she knew well came to her bedside and criticized her and instructed her to harm herself. She was readmitted to our hospital. The phantoms decreased gradually over the course of 1 year.

    She experienced hallucination without delusion twice, and the second episode was prolonged for - 1 year. DSM stated that persistent auditory halluci- nation in the absence of any other features was in- cluded in psychotic disorder not otherwise specified. In this case, the episode complicated visual hallucination and other conversion symptom. So we regarded that her hallucination did not derive from psychotic disor- der not otherwise specified.

    case 5

    A 17-year-old girl was first referred to Okayama Uni- versity Hospital complaining of a confused state which left her powerless to speak. She was the only child of a lower-middle-class troubled family. Her father gam- bled away his entire salary, leaving no money for the

    family. As a result, her mother worked to support the family. The patient was a very independent child who often helped her mother with housework.

    She had trouble adapting to her high school life, especially with her classmates. Upon admission to our clinic, the patient developed an emotional attachment to her doctor and severe regression. Her depression improved slightly when she was not in school, but im- mediately worsened in the school environment. She attempted suicide many times.

    After she graduated from high school when she was 20years old, she attended a driving school where she claimed that someone was picking on her. This delusion continued until she began to take anti-psychotic drugs (3 mg haloperidol/day). Following her recovery, she got a driving license and attended a day-care program and took on a part-time job. But she had a lot of troubles with her colleagues.

    When she was 21 years old her grandmother died and many relatives visited her home. The patient once again fell into a delusional state in which she believed that her relatives hated her and were going to attack her. She was treated effectively using an anti-psychotic drug (6 9 mg of haloperidol). She has since not experienced any other delusions. However, she still occasionally expe- riences constant anger, episodic dysphoria and confu- sion.

    Her delusional episodes were not accompanied by hallucinations, and anti-psychotic drugs were effective. Whenever she fell into a delusional state, she also showed hostility to the persons concerned.

    DISCUSSION We observed 11 episodes of delusions and/or halluci- nations in our patients. They are summarized in Table 1. Each patient experienced such episodes at least twice. There were four episodes of delusional state

    Table 1. Patients and episodes profiles

    Case Observation period Episodes Type of episode Duration 1 5 years 1 Delusion < ldays

    2 Hallucination < ldays 3 Delusion < 4weeks

    2

    3

    4

    20 years 1 Delusion and hallucination < 4weeks 2 Delusion and hallucination Several months

    I years 1 Delusion and hallucination < ldays 2 Hallucination < Idays

    9 years 1 2

    Hallucination Hallucination

    < 4weeks N 1 year

    5 I years 1 Delusion < 4weeks 2 Delusion < 7days

  • Borderline personality disorder 609

    without hallucination, three episodes of the compli- cated delusion and hallucination, and four episodes of auditory or visual hallucinations. In two cases (cases 1 and 3), patients experienced different types of episodes. In the other cases, the patients experienced repeated episodes of the same type.

    The duration of the delusions and hallucinations experienced by the patients ranged from several days to N 1 year. Previous researchers regarded that the psy- chotic symptoms of BPD tend to be brief, lasting only minutes or hours. However, Miller etal. suggested that the symptoms are not always so brief. They reported 25 patients who had psychotic symptoms; of these pa- tients, only four had psychotic symptoms lasting 7 days or less. Sixteen patients had symptoms that lasted for 1-12 weeks, and four patients had symptoms that lasted more than 4months. In the present study none of the episodes lasted less than 24 h; four of the five patients had delusions and/or hallucinations that lasted more than 7 days, which supports the findings of Miller et al. In the present cases, the duration of these experiences were closely related to these situations. For example, in case 1, the delusional state subsided immediately after her doctor increased the number of treatment sessions. In case 2, delusion and hallucination continued until the construction of the hospital was finished. In gen- eral, improvement of the situation led to a rapid im- provement in the symptoms.

    Each patient experienced two or three episodes of delusions and/or hallucinations over the 5-20-year observation period (average: 9.6 years). Two large-scale studies have been carried out that focused on the oc- currence of delusion or hallucination (narrowly defined psychotic symptom) in BPD. Links etal. examined the occurrence of psychotic symptoms of BPD inpatients. They found delusions and hallucinations in N 20% of them. They concluded that such symptoms were un- common but not rare in BPD. Miller etal. found that 27% of patients had psychotic episodes and concluded that such symptoms were not universal but not un- common." However, they did not discuss the fre- quency of these symptoms. Our conclusion was that delusions and hallucinations in BPD had a tendency for recurrence but appeared not so frequently.

    Although Gunderson et al. reported that many types of psychotic symptoms may be observed, they did not discuss the difference in these symptom^.^ Jonas and Pope divided them into 'narrowly defined' psychotic symptoms such as clear-cut delusion and hallucination. and 'broadly defined' psychotic symptoms such as de- realization and depersonalization.6 In the present study, we observed three distinct types of delusions and hallucinations. Those were a delusional state without accompanying hallucinations, a complicated delusion

    and hallucination, and unaccompanied hallucination. Both the content and type of experiences were closely related to the situation of the patients.

    A delusional state without accompanying halluci- nations occurred a total of four times in two patients. In all cases, the delusion involved persecution by people around the patient. In case 1, the episode occurred when she entered a new environment (ad- mission and job) and she experienced abandonment by her therapist. She showed furious aggression to- ward her therapist. In case 5, the episodes were triggered by a gathering of students and relatives. She felt that she was shut out by them but she confronted her difficult situation. Distinctively both patients took a competitive position to the surrounding people. They projected their anger and hostility toward them directly.

    A complicated delusion and hallucination was ob- served in two patients. In case 2, the patient experi- enced the state twice. Her first episode occurred when her marriage failed. The second episode occurred when she was hospitalized in the surgical ward. In both epi- sodes she was involved in close relations with an adult man. The delusions concerned men who peeped into her room and criticized her. Her guilty feelings re- garding her sexual appetite were reflected in this delu- sion. The second episode was more prolonged, lasting for - 1 year because her environment was similar to the structure of her delusion. The complicated delusion and hallucination in case 3 occurred when she took a small dose of corticosteroids. At the time, the patient was having trouble adjusting to her admission to hospital also. The delusion was a reflection of her loneliness and helplessness at the time of her hospitalization.

    Hallucinations occurred a total of four times in three patients. Three of the hallucinations were auditory and one was a combined visual and auditory hallucination. None of the hallucinations was accompanied by delu- sions. They occurred when the patient could not com- municate with others and isolated themselves from society. The hallucinatory voices instructed and criti- cized the patients. The voices all belonged to people the patient knew well.

    In every episode the patients had difficulty in coping with their environment and internal relationships. However, there were some differences about the pa- tients' attitude to their environment between each type of these symptoms.

    In the case of delusions unaccompanied by halluci- nation, the patients tend to struggle with their environ- ment and the characters that appeared in the delusions were people the patients just confronted. They showed anger and hostility toward them at the same time. Their projection functioned directly and definitively.

  • H. Suzuki et al. 610

    In the case of a complicated delusion and halluci- nation the patients were passively involved in their environment. They could not take the initiative to cope with their situation. The character who appeared in their abnormal experiences tended to be a stranger who could not be identified. Patients restlessness reflected upon characters anonyms. They had no power to project their fear onto a real person.

    In contrast, in the case of unaccompanied halluci- nation, the patients isolated themselves from the world when they experienced such symptoms. They had seri- ous anxiety and fear for the external world and inter- personal relationships. They withdrew and avoided actual interpersonal relationships but could not dispose of their anxiety successfully. Their hallucinations functioned as an intermediary of their projection.

    CONCLUSIONS The present paper discusses five patients with BPD who developed delusionary and/or hallucinatory symptoms. The duration of these symptoms tended to vary widely, although in general they were longer than in previously reported cases. An analysis of these episodes revealed three types of delusions and hallucinations. Delusion without hallucination tended to occur when the patient was worried about an interpersonal relationship. They projected their feelings toward that person. A compli- cated delusion and hallucination also tended to occur at the time of interpersonal problems but their attitude was more passive. Hallucination without delusion tended to occur when the patient avoided an interper-

    sonal relationship. In this case they isolated themselves from others and withdrew.

    REFERENCES

    1. American Psychiatric Association. Diagnostic and Stat- istical Manual of Mental Disorders, 4th edn. American Psychiatric Association, Washington DC, 1994.

    2. Gunderson JG, Kolb JE. Discriminating features of borderline patients. Am. J . Psychiatry 1978; 135: 792-796.

    3. Gunderson JG, Kolb JE, Austin V. The diagnostic in- terview for borderline patients. Am. J. Psychiatry 1981; 138: 896-903.

    4. Soloff PH, Richard F, Ulrich MS. Diagnostic interview for borderline patients: A replication study. Arch. Gen. Psychiatry 1981; 38: 686-692.

    5. Tarnopolsky A, Berelowitz M. Borderline personality: Diagnostic attitudes at the Maudsley Hospital. Br. J. Psychiatry 1984; 144: 364-369.

    6. Jonas MJ, Pope HG. Psychosis in borderline personality disorder. Psychiatric Dev. 1984; 4: 29S308.

    7. Pope HG, Jonas JM, Hudson JI et al. An empirical study of psychosis in borderline personality disorder. Am. J . Psychiatry 1985; 142: 1285-1290.

    8. Chopra HD, Beatson JA. Psychotic symptoms in bor- derline personality disorder. Am. J. Psychiatry 1986; 143: 1605-1607.

    9. Links PS, Steiner M, Mitton J. Characteristics of psy- chosis in borderline personality disorder. Psychopatho-

    10. Miller FT, Abrams T, Dulit R etal. Psychotic symptoms in patients with borderline personality disorder and concurrent axis 1 disorder. Hosp. Community Psychiatry 1993; 44: 5p-61.

    logy 1989; 22: 188-193.

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