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Abstract A case series of 10 patients with a diagnosis of borderline personality disorder (BPD) presenting with auditory hallucinosis is examined. In this series, the hallucinations were persistent, longstanding, and a significant source of distress and disability. Extrapolating from this series to our sample of 171 patients with BPD suggests that a form of auditory hallucinosis may occur in almost 30% of this population. The failure to emphasize this phenomenon in current systems of classification risks misdiagnosis or inappropriate treatment. Use of terms such as pseudohallucination or quasi hallucination dismisses the phenomenon as unimportant or as “not real.” There is an emerging literature on the frequency of hallucinosis among nonpatients. A basis for understanding different forms of hallucination is discussed with reference to the concept of “normativity.” We propose a nomenclature for hallucinosis that is expressed in positive terms, reflecting the clinical significance of the phenomenon in different contexts: (1) normative hallucinosis, (2) traumatic-intrusive hallucinosis (as in our series), (3) psychotic hallucinosis, and (4) organic hallucinosis.

. Introduction This report concerns phenomena observed by those working with borderline personality disorder (BPD) but not widely recognized outside this field. A significant number of these patients experience persisting auditory hallucinosis. Information regarding this and related phenomena seems to be frequently withheld from medical attendants because of fears (or past experience) that disclosure may result in the diagnosis of schizophrenia. Originally, the term borderline personality disorder was used by Stern [1] to describe patients who manifested both neurotic and psychotic symptoms. These original descriptions did not refer to persistent auditory hallucinosis. More recently, the diagnosis has become operationalized, with greater emphasis on affective instability, core emptiness or depression, disturbance of identity, and behavioral features [2] and [3]. While it is recognized that “psychotic” symptoms such as auditory hallucinations and other positive symptoms of psychosis may occur, they are said, in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), to occur only for brief periods in situations of stress [2]. This follows the work of researchers such as Zanarini et al [4] who attempt to differentiate psychotic features in BPD from other psychotic disorders. The research of Zanarini et al [4] has found the rate of quasi-psychotic experiences in borderline patients to be 40% and also that quasi hallucinations are more common than quasi delusions. This type of disturbance of thought is felt to be so characteristic as to be “virtually pathognomonic for the borderline patients…(it) successfully discriminated them from those in each of the other groups” (other personality disorder, schizophrenia, and normal controls) [4]. They are, however, critical of earlier studies for using terms such as psychotic or psychotic-like too generally, believing we can rely on the “clear-cut departure from consensual reality described in DSMIII” to distinguish psychosis from nonpsychosis [4]. The differentiation of Zanarini et al [4] of quasi from true psychotic symptoms relies on criteria of (a) transiency, (b) circumscription (only affecting 1 or 2 areas of the patients life), or (c) atypicality (possibly reality-based or totally fantastic in content). In a 6-year prospective study by the same group, many cases of “quasi-psychotic” symptoms of thought and perceptual disturbances are persistent [5]. Later works also emphasize distorted dysphoric cognitive abnormalities as most specific for BPD [6] and [7]. Skodol et al [8] are critical of the current DSM classification for omitting regression-proneness and for only making indirect reference in criterion 9 to lapses in reality testing. Other studies have demonstrated a significant incidence of such symptoms in general population samples [9], [10] and [11]. Auditory and visual hallucinations are also commonly recognized in other, perhaps more controversial diagnostic entities, such as dissociative identity disorder (DID) or dissociative (hysterical) psychosis [12] and [13]. In this article, we identify a significant group of patients with a diagnosis of BPD who have ongoing symptoms including auditory hallucinations and other phenomena, such as thought insertion, that are more commonly associated with psychosis. The tendency when confronted with positive psychotic phenomena is for the clinician to either make a diagnosis of schizophrenia or other major psychotic disorder or to dismiss the phenomenon in question by resorting to a concept such as “pseudohallucination.” This term was coined initially by Hagen in 1868 to describe hallucinations that were not “real” hallucinations, although the debate about what had constituted genuine hallucinations had been going on considerably longer [14]. Berrios and Dening point out that this amounts to casting the concept into “the unpleasant role of being a ‘joker’ in the diagnostic game: by taking different clinical values it allows clinicians to call into question the genuineness of some true hallucinatory experiences that do not fit into a preconceived psychiatric diagnosis” [14]. In fact, it is difficult for clinicians to distinguish between “true” hallucination and “pseudohallucination,” and empirical efforts to assess the validity and reliability of this distinction have failed [15] and [16]. From a clinical point of view, if the distinction cannot be made in a reliable way, then it amounts to either a concept that lacks utility or a “nonconcept.” The case series presented in this article arose out of the clinical experience of one of the authors (LY) who was treating patients who presented with distress and concern in relation to auditory experiences. These were described as “voices” that had been present for long periods and persisted consistently during therapy. The subjects came from a treatment program for BPD in which diagnoses are made by experienced psychiatrists using updated versions of DSM (DSM-IV at the time of this study) criteria for the disorder [17]. Having become interested in the phenomenon, LY sought to evaluate a larger group of patients from this program.

4. Results From the total sample of 171 patients with BPD enrolled in the treatment program, 50 reported they “heard voices” (29.2%) on the SCL-90. 4.1. Dissociative Experiences Scale From the case series of 10 patients, the majority had scores on the DES indicative of a substantial number of dissociative experiences, with 7 patients scoring in a range considered highly clinically significant (see Table 1). Hallucinosis, as indicated by the “percentage of time” occupied by the experience in the DES format, showed this phenomenon to be frequent, occupying on average 70% of their time. Only 2 patients scored the experience as occurring less than 50% of the time. There was no clear pattern on the DES in terms of the most common type of dissociative experience on the 3 subscales, yet it was noteworthy when looking at the least common experiences, these were items (items 4, 5, 8, 3, and 6) that belonged mainly to the amnesia subscale. As this subscale would be expected to be high in patients with DID, the data did not appear to support this diagnosis. Table 1. Dissociative Experiences Scale n (%) Scores > 20% (dissociative experiences) 9 (90) Scores > 30% (indicative of DID) 7 (70) Table options 4.2. Structured Clinical Interview for DSM-IV Dissociative Disorders Most patients described the voices as having the quality of true perceptions, although paradoxically, 8 patients also described the experience as similar to thoughts (see Table 2). All patients described talking silently to themselves in the sense of having a conversation with the voices, with the majority of the sample experiencing the voice internally. In addition, most of the sample reported talking aloud to themselves, although 6 patients also had written conversations with their voices. Table 2. Structured Clinical Interview for DSM-IV Dissociative Disorders: voice quality n (%) Voice quality as true perception 9 (90) Voice quality as thoughts 8 (80) Experience voice internally 8 (80) Silent conversation with voices 10 (100) Audible conversation with voices 8 (80) Written conversation with voices 6 (60) Voices communicate directly with therapist 5 (50) Voices represent memories, behavior, or feelings other than own 7 (70) Voices part of personality 2 (20) Voices separate and part of personality 4 (40) Voices separate to personality 4 (40) Table options Half the sample believed the voices could communicate directly with the therapist, 3 did not believe this to be possible, 1 was not sure, and 1 commented, “I won't let them.” Seven patients answered affirmatively to the question, “Does it feel as if these dialogues represent different memories, behaviors, or feelings than your own?,” suggesting a sense of the experience as ego-alien (Table 2). However, this was less clear in response to the question: “Does it feel as if the dialogues represent a part of your personality, or do they feel separate?” Here, only 4 patients saw the voices as separate from themselves, while another 4 described them as both separate and a part of themselves, and 2 were clear the voices were part of their personality (Table 2). Table 3 indicates that 7 patients believed increasing stress led to an increase in intensity of the voices (in volume, frequency, and/or sense of influence). Nine experienced the voices as distressing; commonly citing the voices were “outside their control.” Most described the voices as taking control of actions or behavior, generally referring to self-harming or self-destructive behaviors (eg, self-laceration, taking of illicit substances, acts of aggression, etc). All patients reported a critical quality of the voices as being the predominant tone. Four patients also described an element of protectiveness at times. Of these, one patient experienced the voices as making distinctly positive comments. Table 3. Structured Clinical Interview for DSM-IV Dissociative Disorders: patient perceptions n (%) Increasing hallucinosis with stress 7 (70) Distress with voices 9 (90) Voices control behavior 9 (90) Voices negative and critical 10 (100) Voices protective 4 (40) Visual images 7 (70) Table options Furthermore, 7 patients endorsed other modalities of hallucinosis, predominantly visual images, with 5 of these cases reporting their visual images as complex and concrete with associated names and the other 2 cases describing the images as less clear with no associated names (Table 3). 4.3. Opcrit Questionnaire Four items were endorsed by the majority of respondents: the phenomena of thought insertion, thought blocking/withdrawal, feeling under an external influence or power, and paradoxically, that these thoughts were not caused by an outside agent (Table 4). Other experiences that were somewhat less common included thought broadcast, auditory hallucinations other than voices, visual hallucinations, and olfactory hallucinations. Visual hallucinations were reported in 3 patients. The discrepancy between Opcrit and SCID-D with respect to the outcome on visual perceptions may be accounted for by the latter identifying visual imagery while the former is identifying visual hallucination. Table 4. Opcrit Questionnaire n (%) Thoughts insertion 10 (100) Thought blocking/withdrawal 9 (90) Feeling under external influence 7 (70) Thoughts not caused by outside agent 10 (100) Thought broadcast 1 (10) Auditory hallucination—not voices 3 (30) Visual hallucination 3 (30) Olfactory hallucination 3 (30) Table options 4.4. Additional information Additional items included the age of onset, disclosure, and long-term aims of their voices. Six patients indicated their voices had “always been there,” 1 remembered onset as a young child, and 3 recalled onset in high school years. Many described having heard them “always” but only later reported having become aware of them in the sense of being “outside common experience.” With regard to disclosure, all patients expressed mistrust of sharing this information. Five had not previously disclosed. Of the 5 cases that had, 3 resulted in prescription of antipsychotic medication, 2 patients being diagnosed with schizophrenia, and 1 with mania. All 3 were distressed and, subsequently, were more reluctant to share the information. The other 2 disclosures were satisfied with support received. Five said they would not volunteer information but would answer truthfully if asked. In terms of dealing with their voices, 4 patients desired to be free of them, 3 wished to retain them, and 3 were ambivalent or undecided.