# Auditory Verbal Hallucinations in Borderline Personality Disorder ### Cognitive, phenomenological and neurophysiological factors ###### 08/09/2020 --- ### 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 - Better categorize the phenomonological, cognitive and neurophsyiological factors associated with AVH. ###### 1. Determine the role of AVH location in effecting anxiety ###### 2. Determine whether response bias (SDT) is associated with AVH, as in other groups ###### 3. Determine the spatial pattern of activation associated with AVH (BOLD) ###### 4. Determine patterns of functional connectivity that are associated with symptoms --- # Methods #### 3 Phases: ##### 1) Clinical assessment (questionaires - AVH Symptom Severity, Beliefs about Voices etc) (n = 48) ---- ##### 2) Behavioural assessment (Signal Detection Task) ###### - Response bias  ---- ##### 3) Neuroimaging (fMRI) (n = 29) ###### - Measured thoughts; quality and quantity of AVH; and brain activity (BOLD) and functional connectivity (rs-sbfc) #### 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] ... 'How anxious do you feel?' --- # Results ---- ### Signal Detection Task  ###### - Response bias correlated with AVH symptom severity (r = .653, p = 0.001, n = 21) and persecutory beliefs (r = -.637, p = 0.006, n = 17) ---- ## Factors related to anxiety   ###### - Anxiety related to AVH Intensity (r = .352 , p = 0.004, n = 66) not AVH location (r = -.109, p = 0.382, r = 66) ---- # Task - fMRI Analysis  ---- # Rest - fMRI Analysis  --- # Discussion ---- ## Signal Detection - Response Bias significantly related to AVH symptom severity, and Persecutory beliefs - May represent an 'externalizing bias' in source monitering. - This may be a trait-like risk factor that increases vulnerability to hallucinatons across different hallucinating groups (Brookwell et al, 2013) ---- ## Anxiety - Hallucination intensity, NOT percieved location, modulated anxiety. - 'Pseudohallucination': a pseudoconcept (Zwaard & Polak, 2001) ---- ## Task based fMRI  - Auditory cortex activity suggests the experience of an AVH is neurally consistent with actually hearing something ---- ## Functional Connectivity at Rest - Found FC between ACC <-> Precuneus & rA1 <-> Cuneus increased as AVH lenth increased. - Suggests a pattern of coupling that may be important for the the maintainence of hallucinations (not just genesis) ---- 5. Coupling between ACC and insula may serve as mechanism that is protective against AVH --- ## To summarize: ###### Cognitive Factors: Externalizing Bias ###### Phenomenological Factors: AVH intensity, not location ###### Neurophysiological Factors: Primary Auditory Cortex #### - The evidence here substantiates and legitamizes the experience of AVH for those with BPD #### - It reframes the experience from one that is seen as 'psuedo', to one that is comparible in terms of severity to hallucinations in schizophrenia --- # Any Questions? --- To calculate this bias measure, for each participant we calculated their hit and false alarm rates. The hit rate is the probability of reporting “voice” when a voice was present. The false alarm rate is the probability of reporting “voice” when a voice was absent. Then, c is given by -0.5*(Z(hit rate) + Z(false alarm rate)), where z is the standard z-score.