Delusions and hallucinations in patients with borderline personality disorder

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<ul><li><p>Psychiatry and Clinical Neurosciences (1 998) 52, 605-610 </p><p>Regular Article </p><p>Delusions and hallucinations in patients with borderline personality disorder </p><p>HIROSHI SUZUKI, M D , ~ CHIAKI TSUKAMOTO, MD, YOSHIYUKI NAKANO, M D , ~ </p><p>Department of Neuropsychiatry, Okayama University Medical School and 2Department of Psychiatry, Kawasaki Medical College, Okayama, Japan </p><p>SHOZO AOKI, MD* AND SHIGETOSHI KURODA, MD </p><p>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. </p><p>Key words borderline personality disorder, delusion, hallucination, psychotic symptom. </p><p>INTRODUCTION </p><p>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 </p><p>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 </p><p>Correspondence address: Hiroshi Suzuki, MD, Department of Neu- ropsychiatry, Okayama University Medical School, Shikatacho 2-5-1, Okayama City, Okayama. Japan. </p><p>Received 20 March 1998; revised 10 June 1998; accepted 3 August 1998. </p><p>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 . ~ </p><p>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 .~ </p><p>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. </p><p>There remained some disputes about the nature of delusions and hallucinations in BPD. Those were: (i) </p></li><li><p>H. Sumki et al. 606 </p><p>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.) </p><p>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. </p><p>SUBJECTS AND METHODS </p><p>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. </p><p>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. </p><p>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. </p><p>Following these treatment sessions the patient at- tended a preparatory school and passed the entrance examination and entered college in the following spring. </p><p>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. </p><p>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. </p><p>CASE REPORTS </p><p>case 1 </p><p>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 . </p><p>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. </p><p>case 2 </p><p>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. </p><p>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. </p><p>When she was 26years old, she got a part-time job and joined a theatrical company as an actress. The </p></li><li><p>Borderline personality disorder 607 </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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 </p></li><li><p>608 H. Suzuki et al. </p><p>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. </p><p>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. </p><p>The following year she suddenly became unable to hear any sound. She began to experience auditory and visual hallucinations in which someone she k...</p></li></ul>

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