Negative Beliefs about Voices in Patients with Borderline Personality Disorder Are Associated with Distress: A Plea for Cognitive-Behavioural Therapy?

BACKGROUND: Auditory verbal hallucinations (AVH) are experienced by 21-54% of patients diagnosed with a borderline personality disorder (BPD), and ensuing distress is often high. Little is known about the beliefs these patients foster about their voices, and the influence thereof on distress and need for hospitalisation. METHODS: In a convenience sample of 38 BPD outpatients with AVH, data were collected with the aid of the Psychotic Symptom Rating Scales (PSYRATS), Beliefs about Voices Questionnaire (BAVQ), Social Comparison Rating Scale (SCRS), and Voice Power Differential Scale (VPDS). RESULTS: The majority of patients with BPD who experience AVH rate their voices as malevolent and omnipotent, and higher in social rank than themselves. Moreover, their resistance against them tends to be high. These parameters correlate positively and significantly with high levels of distress experienced in relation to these AVH. The need for hospitalisation, in turn, is associated with high scores for omnipotence of the voices and distress due to AVH. However, these findings could not be confirmed in regression analyses. CONCLUSIONS: As negative beliefs can be altered with cognitive-behavioural therapy (CBT), we expect CBT to be beneficial in the treatment of AVH in BPD patients, whether or not in combination with antipsychotic medication.

Auditory Verbal Hallucinations in Borderline Personality Disorder and the Efficacy of Antipsychotics: A Systematic Review.

Background: Auditory verbal hallucinations (AVH) are experienced more frequently by patients with borderline personality disorder (BPD) than previously assumed. However, consensus is lacking on how to treat them. Objective: To provide a systematic review of studies reporting on AVH in patients with BPD, with a focus on the efficacy of treatment of psychotic symptoms. Methods: For this review a systematic search was made in the PubMed and Ovid databases, and mean weighted prevalence rates, adjusted for sample size, were computed. Results: The search yielded 36 studies describing a total of 1,263 patients. Auditory hallucinations (including AVH) were reported in 27% of hospitalized BPD patients; AVH were reported in 25% of all patients and in 24% of outpatients. Of the hallucinating patients, 78% experienced AVH at least once per day, for a duration of several days to many years. On the whole, patients with BPD regarded their voices as malevolent and omnipotent in nature. Compared to patients with schizophrenia, the phenomenological characteristics of AVH were similar and the ensuing distress was equal or even higher, whereas scores for other positive symptoms were lower. The presence of AVH in BPD was associated with an increase of suicide plans and attempts, and more frequent hospitalization. Moreover, AVH in the context of BPD were associated with higher prevalence rates for post-traumatic stress disorder and emotional abuse. The efficacy of antipsychotics was investigated in 21 studies. Based on these studies, we conclude that both typical and atypical antipsychotics tend to have positive effects on AVH experienced in the context of BPD. The efficacy of cognitive-behavioral therapy and non-invasive brain stimulation has not yet been systematically assessed. Conclusions: These findings indicate that AVH experienced in the context of BPD are in need of proper diagnosis and treatment, and that antipsychotics tend to be beneficial in treating these (and other psychotic) symptoms.There is an urgent need for studies assessing the efficacy of cognitive-behavioral therapy and non-invasive brain stimulation in this underdiagnosed and undertreated group.

Comorbid Diagnosis of Psychotic Disorders in Borderline Personality Disorder: Prevalence and Influence on Outcome.

BACKGROUND: A diagnosis of psychotic disorder is traditionally considered incompatible with borderline personality disorder (BPD), even though patients sometimes fulfill the diagnostic criteria for both disorders. How often this happens is barely known, as is the influence of comorbid psychotic disorders on the outcome of BPD. Since studies on isolated auditory verbal hallucinations in patients with BPD indicate that these perceptual symptoms have severe consequences and are associated with suicidal behavior and hospitalization, patients with comorbid psychotic disorders are unlikely to fare better. OBJECTIVE: To examine the point prevalence of psychotic disorders in patients with BPD, their association with the outcome of BPD, and their predictive value for outcome. METHODS: In a cross-sectional design, 84 female outpatients diagnosed with BPD were interviewed with the aid of the MINI-International Neuropsychiatric Interview to establish the point prevalence of comorbid psychotic and other comorbid disorders. After termination of their treatment at a specialized outpatient clinic, the type of referral was considered to be a "good" outcome when they were referred to their general practitioner or to basic psychiatric care for noncomplex patients, and a "poor" outcome when referred to a specialized psychiatric department or to a psychiatric district team for patients with severe psychiatric disorders. RESULTS: Psychotic disorders were present in 38% of the patients with BPD. With a prevalence of 20%, psychotic disorder not otherwise specified (NOS) was the most common subtype; the least common types were schizophrenia (2%), substance-induced psychotic disorder (2%), and brief psychotic disorder (1%). Among six types of comorbid disorders, only psychotic disorders were associated with a poor outcome; they were also predictors for a poor outcome, along with comorbid mood disorders, eating disorders, and somatoform disorders, as well as the severity of BPD, and, counterintuitively, more years of education. CONCLUSION: Psychotic disorders, notably of the psychotic disorder NOS subtype, are common among patients with BPD, and their presence is associated with a poor outcome. This implies that adequate diagnosis and treatment of both disorders is warranted in this subgroup with a dual diagnosis.

Determinants of right ventricular outflow tract conduit longevity: a multinational analysis.

OBJECTIVE: The need for conduit replacement in the growing child remains a major problem after right ventricular outflow tract reconstruction. We compared two diverse surgical centers with considerable practice variation in Europe and the United States to identify modifiable risk factors that can increase conduit longevity. DESIGN: Retrospective analysis of 194 patients (56 Europe, 138 United States) who underwent primary right ventricular to pulmonary artery conduit placement between January 1987 and March 2003. PATIENTS: Diagnoses included tetralogy of Fallot with pulmonary atresia, truncus arteriosus, transposition of the great arteries with ventricular septal defect and pulmonary stenosis, and double-outlet right ventricle. RESULTS: Median age was 7.3 months (range 2 days-29.9 years). Types of conduits included aortic homografts (n = 111), pulmonary homografts (n = 48), Contegra conduits (Medtronic, Inc, Minneapolis, MN) (n = 23), and synthetic conduits (n = 12). Freedom from conduit failure at 5 years was 50% (58% Europe, 48% United States, P = NS). On multivariate analysis, smaller conduit diameter (hazard ratio [HR] 1.15, P < .001) and conduits other than pulmonary homografts (synthetic conduits [HR 3.17, P = .01], Contegra conduits [HR 2.80, P = .02], aortic homografts [HR 1.56, P = .05]) predicted shorter time to conduit failure. In addition, time to failure was longer for patients undergoing transcatheter intervention. Different surgical techniques in conduit preparation and insertion did not influence conduit longevity. CONCLUSIONS: Analysis of the two diverse surgical centers showed that to increase conduit longevity, one should choose the largest possible conduit, use a pulmonary homograft, and consider children whose conduits develop obstruction as candidates for transcatheter intervention.