# Auditory Verbal Hallucinations in Borderline Personality Disorder ###### tags: `Presentation` `results` `ViBE` --- --- ### What is Borderline Personality Disoder? ##### "Borderline" - Patients exits in a 'grey area' between neurosis and psychosis (Stern, 1939; Kernberg, 1967) ##### ICD-10: "Emotionally unstable personality disorder" #### DSM: "Some develop psychotic like symptoms (e.g.hallucinations, body distortions, hypnagogic phenemenon) during times of stress" ---- ### Auditory Verbal Hallucinations (AVH) ##### 50-90% of BPD patients report hearing voices that other people don't hear (Kingdon et al, 2010; Yee et al, 2005) ##### ~40% of patients at Sussex Voices Clinic have BPD diagnosis ##### Hearing voices in BPD is sig risk factor for suicide plans, attempts and hospitalisation (Miller et al, 1993; Slotema et al, 2016) ##### However, concept of 'pseudo'-hallucination has fostered idea that patients' AVH experiences may be malingered. ---- ### Aim: to understand the phenomenology (thoughts) and neurophysiology (BOLD fMRI) associated with AVH in BPD. --- # Methods * ##### 27 participants (mean age = 33, 20 females), 1 fMRI scan each * ##### Resting State (8 min) * ##### fMRI (3 x 8min runs) * ##### Participants had two main tasks: 1. ###### Press button when hearing AVH 2. ###### Press button when hearing externally played sound * ##### Thought-sampling probes after resting state and each run (x4) ---- ## Thought-Sampling Questions (n=18) 'I was thinking about an event that has happened or could take place' 'My thoughts at different points in time were all on the same theme' 'My thoughts dragged my attention away from the external world' 'My thoughts had recurrent themes similar to those I have had before' 'My thoughts involved future events' 'My thoughts involved myself' 'My thoughts involved others' 'My thoughts involved past events' 'My thoughts were about ideas rather than event or objects' 'My thoughts were detailed and specific' 'My thoughts were focused on the task I was performing' 'My thoughts were hard for me to stop' 'My thoughts were related to here and now/a distant time' 'My thoughts were spontaneous/deliberate' 'The content of my thoughts was negative/positive' 'I felt anxious' 'I felt happy or content' 'I felt sad' ---- ## AVH Questions (n=4) #### If answer to 'I heard my voice/s' = Yes: 'How distressing did your voice/s feel?' 'How loud were your voice/s?' 'What proportion of the time were you hearing your voice/s?' [0% / 100%] 'Where did your voice/s sound like they were coming from?' [Inside Head / Outside Head] --- # Analysis (1) --- ## Linear Mixed Model - Fixed effects = Thoughts - Random effects = Participant ; Run - DV: Mean AVH Duration (extracted from button presses in the scanner) #### To what extent do these effects account for changes in mean AVH duration? ---- ## Results (1)  ###### - Longer mean AVH length associated with greater anxiety and more intrusive thoughts. --- ## Analysis (2) ##### Another way of probing the data... --- ### Principle Componants Analysis 1. Extract thought componants 2. Extract AVH componants ##### Allows for an understanding of the underlying structure of ongoing thought. ---- ## Results (2) ---- ## Thought Sampling Questions PCA * 117 samples (missing cases replaced with group mean) * 6 componants extracted * 67% variance accounted for ---- ## Summary of Thought Componants  --- ## AVH Questons PCA * 66 samples * 2 componants * 72% variance accounted for ##### If answer to 'I heard my voice/s' = YES: 'How distressing did your voice/s feel?' 'How loud were your voice/s?' 'What proportion of the time were you hearing your voice/s?' [0% / 100%] 'Where did your voice/s sound like they were coming from?' [Inside Head / Outside Head] ---- ## Summary of AVH Componants  --- ## Results (2): Relating MW to AVH #### Aim: To assess the relationship between dimensions of thought and dimensions of AVH experience (Intensity / Location) ---- ## Multiple Linear Regression - #### IVs: Every probe instances' loading on each Thought Componant - #### DV: Each probe instances' loading on "AVH intensity" compoannt A significant regression equation was found [F(6,59) = 3.934, p = .002], R squared = .286. ---- #### However, significance only achieved with the addition of "Negative" (beta = 0.328) and "Spontaneous" (beta = – 0.374) componat scores.  ---- ### What have we learnt so far? - #### MLM: Longer hallucinations associated with increasd anxiety and intusive thoughts. - #### PCA: More intense hallucinations associated with negative affect and deliberate thoughts. --- ## "Pseudo"-hallucinations  --- #### "Pseudo"-Hallucination vs "Real"-Hallucinations  ##### r(66) = -.188, p = .130 - Percieved spatial location of AVHs is not associated with negative thoughts / affect. ---- #### Hallucination length and intensity associated with negative affect and intrusive thoughts, NOT percieved location. --- # Relating ongoing thoughts to symptoms data - This involves moving from the per-run level to the per-patient level (averaging across runs) --- ## Results (3) ### What patterns of ongoing thoughts predict greater hallucination symptom severity? ##### IVs: mean MW Componant Scores across runs per participant (x6) ##### DV: BSIS Voice Question (1= voices are the worst of my symptoms, 10= voices are the least) ----  [F(1,25) = 9.187, p = .006] ---- ### Note: AVH location is not related so voice severity.  --- # fMRI: GLM  ----  --- ### What is the relationship between Primary Auditory Cortex activity and AVH? ##### - Extracted COPE values from right A1 for periods of AVH across participants  ---- ### - LMM: - IVs = AVH 'Intensity' and AVH 'Location' Scores (per run) - DV = mean rA1 COPE value for periods of AVH (per run) ---- ### Results #### - Significant association between AVH 'Intensity' Scores and rA1 mean COPE values ###### Estimate = .062, t = 2.29, p = .048 #### - No significant association between AVH 'Location' scores and rA1 COPEs --- #### AVH location and percieved location ... ### - LMM: - IVs = AVH 'Intensity' and AVH 'Location' Scores (per run) - DV = mean rA1 COPE value for AVH > External contrast (per run) ---- ### Result Signifacnt association between AVH 'location' scores and mean COPE values in rA1 for AVH > External voice contrast ###### Estimate = -0.16, t = -2.3, p = .037 #### I.E The more AVHs were percieved as coming from _inside the head_, the greater the COPE values in rA1 during AVH (but only when contrasted against External Voices) --- # Discussion ---- - ##### Hallucinatory voice hearing is a negative experience - associated with distress, anxiety, sadness and intrusive thoughts. - ##### May explain why AVHs in BPD are a significant risk factor for suice attemtps etc ---- #### AVH intensity score (in scanner) AVH symptom severity (outside of scanner) associated with decreased loading onto "Spontaneous" thought componant - #### May be indicative of a psychological defense mechanism? - an increase in deliberate thinking to combat an internal experience dominated by AVHs ----  - #### Nothing in the data indicates that location of AVH (inside/outisde the head) has any bearing on the associated negative outcomes - Previous literature finding no qualitative difference (e.g. McCarthy-Jones et al, 2015) - #### Clinicians should re-think the use of the term "pseudo"-hallucination? ---  - BOLD activation associated with AVH in primary auditory cortex - This tells us the experience is neurally similar to _actually_ hearing something - This further supports the idea that these experiences are not 'psuedo'. ---- ## Future research idea #### What is the direction of causaility? #### Could we reduce AVH severity by modifying thoughts? ---- ## Summary ##### Longer AVHs associated with anxiety and intrusive thoughts ##### Intensity of AVH associated with negative, self focussed thoughts ##### Pseudo-hallucinations vs real-hallucinations is a pseudo-distinction ---- # Thanks to.. ##### Sarah, Hugo, Hao-Ting, Dennis, Lisa, Maxine, The Participants, Sussex Voice Hearing Clinic --- # Extras... --- Regression line  --- ### Signal Detection Theory  [r(21) = .653, p = .001] ---- - #### AVHs symptom severity associated with increased bias to erronously detect signal in noise in a psychophysical context - Issue with source monitering? --- rA1 cope 5 + avh thoughts   SPSS syntax: DATASET ACTIVATE DataSet5. MIXED cope5_rA1 WITH AVHF1_2 AVHF2_2 /CRITERIA=CIN(95) MXITER(150) MXSTEP(10) SCORING(1) SINGULAR(0.000000000001) HCONVERGE(0, ABSOLUTE) LCONVERGE(0, ABSOLUTE) PCONVERGE(0.000001, ABSOLUTE) /FIXED=AVHF1_2 AVHF2_2 | SSTYPE(3) /METHOD=REML /PRINT=SOLUTION TESTCOV /RANDOM=INTERCEPT | SUBJECT(patient) COVTYPE(ID) SOLUTION /REPEATED=run | SUBJECT(patient) COVTYPE(UN). ---- AVH location + AVH > external rA1 COPE  ---