## Auditory Verbal Hallucinations in Borderline Personality Disorder: #### Cognitive, subjective and neural factors. --- ### Background #### “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 - Better categorize the cognitive, subjective and neural factors associated with AVH. ###### 1. Determine relationship between SDT measures and AVH symptoms ###### 2. a) Describe the subjective experience b) Determine the role of AVH location/intensity in effecting anxiety ###### 3. a) Determine the spatial pattern of activation associated with AVH (BOLD), b) Determine patterns of functional connectivity that are associated with symptoms --- # Methods ### 3 Phases: #### 1) Clinical assessment (questionaires - AVH Symptom Severity, Beliefs about Voices) (n = 48) ---- ### 2) Behavioural assessment (Signal Detection Task, n = 22) ###### - Perceptual sensitivity / Response bias  ---- #### Pearsons correlations: X: Perceptual sensitivity (d') & Response bias (_c_), Y: AVH Symptom Severity (BSIS-Voices: low score = more severe) ---- ### 3) Neuroimaging (fMRI) (n = 29) #### Task fMRI ##### - Three runs per particiapnt (5 blocks of 10 trials) #####  - Button pressed at onset of AVH, external voice and imagined voice ##### - 1. AVH 2. External voices 3. Imagined voices ##### - Contrasts: AVH > External; AVH > Imagined; AVH > External + Imagined ---- ### In-scanner experience sampling: #### If answer to 'I heard my voice/s' = Yes: 1. 'How distressing did your voice/s feel?' 2. 'How loud were your voice/s?' 3. 'What proportion of the time were you hearing your voice/s?' [0% / 100%] 4.'Where did your voice/s sound like they were coming from?' [Inside Head / Outside Head] ... 5.'How anxious do you feel?' ##### - Principle Componants Analysis (Q1-4)  ---- ##### - Linear mixed models: DV - Anxiety, IVs - PCA componant scores ---- #### Resting-state fMRI ##### - 8 minute, eyes-open, fixation cross ##### - Seed: Cluster from AVH > External + Imagined contrast ##### - Covariates: AVH symptom severity (BSIS-Voices) --- # Results --- ## Signal Detection Results  ##### - AVH symptom severity significantly correlated with response bias [r(19) = .65, p = .001, 95% CI [0.31, 0.85]]. ----  ##### - Second correlation indicated that AVH symptom severity not significantly related to perceptual sensitivity [r(19) = -.18, p = .443, 95% CI [-0.57, 0.28]]. --- ## Subjective experience ##### - A mean in-scanner distress score (Question 2, Table 1) of 61.72 was reported across the 21 participants who indicated they experienced AVH in the previous (task and rest) run (N responses = 60, SD = 25.50). ##### - Scores were higher for persecutory beliefs (N = 33, M = 4.56, SD = 2.57) than benevolent beliefs (N = 33, M = 1.41, SD = 2.00). ---- ### PCA on in-scanner questions  #### - 2 Componants: 1. AVH Intensity 2. AVH Location ---- ### Linear Mixed Model  ---- #### Model fit significantly improved with the inclusion of AVH Intensity, but not AVH Location - The inclusion of AVH Intensity significantly improved goodness-of-fit (X2(1) = 6.74, p = .009): Higher intensity was associated with increased reported anxiety (β = 8.36). - Goodness-of-fit was not significantly improved by modelling this AVH Location (β = 2.18, X2(1) = 0.36, p = .549). --- ## Task-based fMRI results  --- ## rs-fMRI results ---- ### Seed = BSIS-Voices score  --- # Discussion ---- #### Liberal response bias associated with greater AVH symptom severity - In agreement with multiple studies investigating other hallucinating groups (Brookwell et al, 2013) - Externalizing bias in source monitering? - Overly strong priors? (see Powers & Corlett, 2017) ---- #### AVH experience is distressing on a state level, and persecutory on a trait level. #### Overall, subjective experience of AVH is adverse. - Reflects what is found in schizophrenia (Slotema et al, 2012) ---- #### AVH Intensity but not AVH Location significantly modulated anxiety levels. - Percieved location of hallucination isn't clinically relevent - "Pseudohallucination" is a pseudoconcept (van der Zwaard, Polak, M. A. (2001)) ---- #### AVH associated with significant BOLD activation in Anterior Cingulate Cortex and Temporal langauge-specialized regions - Jardi (2011) meta-analysis in schizophrenic patients with AVH also highlighted language regions - Dyck (2016) - neurofeedback fMRI study found regulation of ACC actvity associated with positive changes to AVH symptoms ---- #### AVH associated with patterns of neural activation that is unique & distinct from deliberate auditory verbal imagary. #### Solidifies the varacity and validity of AVH in BPD. ---- #### Functional connectivity between ACC (seed) and Insula significantly covaries with AVH symptom severity ##### Coordinated processing in ACC-Insula enables dynamic control of internal bodily state (Medford & Cricthley 2010). ##### Interoceptive representation crucial reference for intact self-awareness (Tsakiris et al., 2007; Craig and Craig, 2009; Critchley and Harrison, 2013). ##### E.g. Damage to insula regions can contribute to anosagnostic denial of paralysis and somatoparaphrenia (Vallar and Ronchi, 2009) and insula activity has been found to predict the modulation of illusory experiences of body ownership in the RHI (Tsakiris et al., 2007). ---- #### Aberrant ACC-insula connectivity may be indicative of a dysfunction in the integrity of ‘biological selfhood’ and thus give rise to self-disturbance. #### Recent study using an experience sampling (ecological momentary assessment) study with heart rate monitoring of patients with schizophrenia (Kimhy et al., 2017): Periods of heightened cardiac autonomic arousal (including the withdrawal of vagally-mediated heart rate variability) predict transitory increases in auditory hallucinations. ---- ### Conclusion #### The current study aimed to characterize the AVH experience in BPD on three levels: The cognitive, the subjective, and the neural. ---- #### There was a broad consensus between these findings and the those of other studies investigating AVH in groups across the psychosis spectrum, on all three levels of assessment. ---- #### Our findings are in opposition to a historic trend that has labelled AVH in BPD as ‘pseudohallucinations’ and thus separated the experience in BPD from other groups. ---- #### They show a need to recontextualize AVH in BPD, and consider them a treatment priority, as they are in schizophrenia. ---- ##### Thanks to Hao-Ting, Maxine, Lisa, Dennis, Chris, Hugo and Sarah, everyone else who helped in recruitment and testing. #### :female-scientist: :male-scientist: ---- # :question: --- # Supplementary ---  ----