Psykotiske symptomer hos pasienter med ustabil/borderline

Psykotiske symptomer hos
pasienter med ustabil/borderline
personlighetsforstyrrelse (BPF)
Benjamin Hummelen
Overlege/seniorforsker
Avdeling for forskning og utvikling
Forskningsgruppe Personlighetspsykiatri
Klinikk psykisk helse og avhengighet, Oslo universitetssykehus
Bakgrunn
Psykotiske symptomer er vanlige i befolkningen
 For
eks. Van Os et al. (2000) 8.7% delusions, 6.2% hallusinasjoner
Det niende BPF kriteriet:

Forbigående stressutløste paranoide tanker eller alvorlige disossiative symptomer
Hallusinasjoner er vanlige hos borderline personlighetsforstyrrelse
“Grensepsykotiske symptomer” bør ikke brukes

På engelsk: Quasi-psychotic symptoms or pseudohallucinations
Forskning på schizotyp lidelse/schizotyp PF; to faktorer:
1. Perseptuell dysregulering, assossiert med borderline PD
2. Oddness factor: Subtile tankeforstyrrelser
Er
psykotiske symptomer
(auditoriske og visuelle
hallusinasjoner (AH/VH) hos
pasienter med BPF kvalitativ
forskjellige fra AH/VH hos pasienter
med schizofreni spektrum lidelser?
Felix-Antoine Berube et al (2016): Phenomenology of
psychotic symptoms in borderline personality disorder
versus schizophrenia spectrum disorders or affective
disorders : a systematic review
Problemstilling

Er psykotiske symptomer (auditoriske og visuelle
hallusinasjoner (AH/VH) hos pasienter med ustabil/borderline
personlighetsforstyrrelse kvalitativ forskjellige fra AH/VH hos
pasienter med schizofreni spectrum lidelser?

Kvalitet

Varighet

Stress forårsaket av symptomene

Negativ innvirkning på fungering

Som reaksjon på stress (reaktivitet)

(Forhold til dissosiative symptomer)
Berube, Chanen et al. (2016)

To investigate current state of knowledge about psychotic symptoms
occurring in the context of BPD compared with psychotic symptoms
occurring in SSD or AD, in terms of their:

Quality

Duration

Distress associated with the symptoms

Functional impact

Relation to stressful life events

Relation to dissociative symptoms
Results - Flowchart
Records identified through database searching
(n = 4016)
Records excluded
(n = 3890)
Records definitely excluded
(n = 3879)
Records pending exclusion
(n = 11)
Records screened ‐ after duplicates removed (n = 4025)
Full‐text articles assessed for eligibility
(n = 135)
Records identified through hand searching
(n = 18)
Records identified through experts
(n = 6)
Records identified through routine screening
(n = 1)
Records identified through citation or references
(n = ?)
Number of studies definitely included in qualitative synthesis
(n = 14)
esults
Study
Psychotic Sx Ax
Main (relevant) findings
Gunderson • BPD: Subjects presenting initially with some psychotic BDP = 24
JG, Carpenter symptoms, excluding severe and continuous psychotic JR & Strauss symptoms or formal Dx of SSD, unless subject was JS (1975)
given a clinical diagnosis of BPD by psychiatrist
• SCZ: Subjects presenting initially with some psychotic symptoms + a clinical diagnosis of SCZ + at least one SCZ = 29
1st rank sx + 6 out of 12 Dx criteria for SCZ, matching the BPD group for age, sex, SES and race
• 52 items of the PSE (psychotic symptoms; dissociative experiences; affective symptoms)
• BPD: Depressive and paranoid delusions 45%; Hallucinations 20%; Other delusions 7%
• BPD<SCZ on number of psychotic Sx (p<.005 ‐ p<.025)
• BPD<SCZ on severity of psychotic Sx (p<.005)
Soloff PH (1981)
• BPD: Clinical Dx by treating physician, excluded if > 2 y BPD = 36
hospitalisation in the last 5 y or if continuous psychosis for > 3 y SCZ = 31
• SCZ = Dx of SCZ according to Research Diagnostic Criteria (RDC)
• MDD = MDD, non‐delusional; unipolar according to MDD = 27
RDC
• DIB
Soloff PH & Ulrich RF (1981)
• BPD: Clinical Dx by treating physician, chart review, excluded if > 2 y hospitalisation in the last 5 y or if continuous psychosis for > 3 y or if presentation typical of other PD • SCZ: Dx of SCZ according to Research Diagnostic Criteria (RDC)
• MDD: MDD, non‐delusional; unipolar according to RDC
• DIB
• BPD>SCZ: Transient psychotic symptoms and regressions and Brief psychotic depressed experience (p<.001)
• BPD = SCZ: Brief paranoid experiences; Psychotic experience with drugs
• BPD<SCZ: Drug‐free hallucinations or delusions and Manic episodes (p<0.001)
• BPD>MDD: Brief paranoid experiences, Psychotic experience with drugs and Transient psychotic symptoms and regressions (p<.001); Drug‐free hallucinations or delusions (p<.01)
• BPD = MDD: Brief psychotic depressed experience
• BPD>SCZ: Transient psychotic symptoms and regressions and Brief psychotic depressed experience (p<.005)
• BPD = SCZ: Brief paranoid experiences; Psychotic experience with drugs
• BPD<SCZ: Drug‐free hallucinations or delusions and Manic episodes (p<0.005)
• BPD>MDD: Brief paranoid experiences, Psychotic experience with drugs and Transient psychotic symptoms and regressions (p<.005); Drug‐free hallucinations or delusions (p<.05)
• BPD = MDD: Brief psychotic depressed experience
• BPD>SCZ: Anxious intropunitiveness (p<.001)
• BPD<SCZ: Paranoid projection (p<0.001); Perceptual distortion and Conceptual disorganization (p<0.01); HRS Paranoid ideations (p<.001)
• BPD>MDD: Paranoid projection and Grandiose expansiveness (p<.05); HRS Paranoid ideations (p<.001)
Soloff PH (1981)
Groups composition • BPD: Clinical Dx by treating physician + meet Spitzer‐
Endicott criteria for borderline (unstable) PD and/or schizotypal PD, excluded if > 2 y hospitalisation in the last 5 y or if continuous psychosis for > 3 y • SCZ: Dx of SCZ according to Research Diagnostic Criteria (RDC)
• MDD: MDD, non‐delusional; unipolar according to RDC
Group N’s
BPD = 23
SCZ = 22
MDD = 20
BPD = 17
SCZ = 19
MDD = 16
• IMPS
• HRS (item 20 = paranoid ideations)
Results
Study
Groups composition Group N’s
Psychotic Sx Ax
Main (relevant) findings
Perry JC (1988)
• BPD: DSM‐III and >150 on BPS
• BAD‐II: RDC
BPD = 16
BAD = 14
• LIFE‐ASP prospectively for 1 y
Zanarini MC, Gunderson JG & Frankenburg
FR (1990)
• BPD: DIB‐R + DIPD
• SCZ: DSM‐III (SCID)
BPD = 50
SCZ = 32
• DIB‐R cognitive section
• SCID psychosis section
Nishizono‐
Maher A et al. (1993)
Sbrana A et al. (2004)
• BPD: DSM‐III clinical Dx + Female
• MDD: DSM‐III clinical Dx: Female
BPD = 15
MDD = 15
• DIB cognitive section
• BPD: 44% had psychotic symptoms on follow‐up that were rated as Present wi
impairement or Chronic (impaired) vs BAD‐II: 7%
• Association between score on BPS and any psychotic Sx on follow‐up: r = 44 (p<0.1)
• No significant increase of psychotic Sx 8 weeks after stressful life event for bot
groups
• BPD>SCZ : on most scales of Disturbed thought, including Any disturbed thoug
(p<.0001); on all scales of Quasi‐psychotic thought (p<.0001)
• BPD=SCZ: Sixth sense, Telepathy, Clairvoyance, overvalued ideas (items on Disturbed thoughts)
• BPD<SCZ: DIB True psychotic thought – in fact 0% of the sample had any of tho
in the past 2 years (p<.0001); NB: 14 % of BPD had at least 1 life‐time occurrenc
true psychotic thought on the SCID, all of which could be accounted for by substance or depression
• BPD=MDD: no statistically significant difference between BPD and MDD group
trend toward more Brief psychotic depressed experience in the MDD group
BPD = 60
SCZ = 77
PM = 59
NPM = 98
BPD = 56
PSY = 81
• SCI‐PSY
BPD: DIB > 6
SCZ: SCID (DSM‐IV)
PM (psychotic mood d/o): SCID (DSM‐IV)
NOM (non‐psychotic mood d/o): SCID‐I (DSM‐IV)
BPD: DSM‐IV clinical Dx, SCID (DSM‐IV) and SCID‐II
PSY (Psychotic disorder – active): PANSS >3 on at least 1 positive subscale, BPRS, Operational Criteria Checklist for Psychotic illness (DSM‐III‐R diagnoses) + no BPD
Glaser JP et al. (2010)
•
•
•
•
•
•
Kingdon DG et al. (2010)
• BPD: DSM‐IV Clinical Dx + SCID (DSM‐IV) + SCID‐II
• SCZ: DSM‐IV Clinical Dx + SCID (DSM‐IV) + SCID‐II
BPD = 33
SCZ = 59
• PSYRATS‐H
• SCID
Hepworth CR, Ashcroft K & Kingdon DG (2011)
• BPD: DSM‐IV Clinical Dx + SCID (DSM‐IV) + SCID‐II + reporting AH
• SCZ: DSM‐IV Clinical Dx + SCID (DSM‐IV) + SCID‐II + reporting AH
BPD = 10
• BAVQ‐R
SCZ = 23
• Experience Sampling Method (ESM) 10 X 6 days assessment of stress and psychotic Sx
BPD<SCZ: Illusions; Delusions; Hallucinations; Catatonia (p<.05)
BPD=PM: Illusions; Delusions; Hallucinations; Catatonia (p<.05)
BPD>NPM: Delusions; Hallucinations (p<.05)
BPD=NPM: Illusion; Catatonia (p<.05)
BPD>SCZ: reacted strongly to stress by displaying more ESM psychosis (p<0.001
Dose response relation btw stress reactivity and number of BPD criteria across groups (p=.005)
• In BPD subjects, stress associated with both hallucinations and paranoia
•
•
•
•
•
•
BPD>SCZ: Distress (p=.019) and negative content of voices (p=.037)
BPD=SCZ: hallucinations
BPD<SCZ: SCID Paranoid delusions (p<.009)
BPD>SCZ: on emotional resistance (p=.02)
BPD=SCZ: on malevolence or omnipotence of voices, as well as behavioural resistance or engagement
• BPD<SCZ: on belief about benevolence of voices (p=.015) and emotional engagement (p=.004)
•
•
•
•
•
Results
dy
Groups composition Group Psychotic Sx
N’s
Ax
Main (relevant) findings
ma CW • BPD:DSM‐IV Clinical Dx + SCID‐II + AVH once (2012)
a month for > 1 year + Female + no: SCZ, SCZaffect, BAD, MDD with psychotic Sx, Schizotypal PD on CASH or SCID‐II
• SSD: Clinical Dx of SCZ or SCZ affect + CASH + AVH once a month for > 1 year + Female
BPD = 38
• PSYRATS‐H
• SCZ > BPD on “disruption of life” (p=.001)
• No other difference between SCZ and BPD on the PSYRATS‐H
• BPD: AH for a mean of 18 y, more than once a day for duration of at least several minutes, mean age at onset = 16 y (20 y for SCZ)
oeke S (2014)
BPD = 23
• PANSS
• FDS‐20 (DES‐20)
• SCID‐D items 134‐
157 + 202‐210 or integral SCID‐D if FDS > 12
• 32 questions on quality of AVH
• BPD>SCZ: Feeling controlled by voices and Voices heard for the first time when <18 y (p<.001)
• BPD=SCZ: Hallucinatory behaviour, excitement, suspiciousness and
hostility
• BPD<SCZ: Delusions, Conceptual disorganisation, Grandiosity and all
negative symptoms scales (p<0.01). Dialogues more frequent (p<.04
• SCZ: No comorbid Dx of Dissociative d/o
• BPD: 22/23 (96%) had a Dx of Dissociative d/o
• 78% DDNOS
• 18% DID
• BPD: No correlation between dimensional score of dissociation (FDS
and PANSS
• DIB‐R cognitive section
• Personal and Social Performance scale (PSP) – 2 y interval
• BPD>SCZ: Non‐delusional paranoia (p=0.001) was correlated with poor Personal and social relationship (r(54)=.54,p=.002) and poor Se
Care(r(54)=.34,p=.047), Quasi‐psychotic thought (p<.024), • BPD=SCZ; Odd‐thinking/unusual perception
• BPD<SCZ: Psychotic experiences (p<.001) True psychotic thought (p<0.001)
• BPD: 46.4% had true psychotic thoughts
• BPD: Clinical Dx + SCID (DSM‐IV) psychosis section + SCID‐II + female + AVH in last y
• SCZ: Clinical Dx + SCID (DSM‐IV) psychosis section + SCID‐II + female + AVH in last y
F et al. • BPD: Clinical Dx + at least 2 y in Tx + SCID )
(DSM‐IV) + SCID‐II
• SCZ: Clinical Dx + at least 2 y in Tx + SCID (DSM‐IV) + SCID‐II
SCZ = 51
BPD = 21
BPD = 28
SCZ = 28
udy
ser JP et al. 10)

Groups composition Group N’s
Psychotic Sx Ax
Main (relevant) findings
• BPD: DSM‐IV clinical Dx, SCID (DSM‐IV) and SCID‐II
BPD = 56
• Experience Sampling Method (ESM) 10 X 6 days assessment of stress and psychotic Sx
• BPD>SCZ: reacted strongly to stress by displaying more ESM psychosis (p<0.001)
• PSY (Psychotic disorder – active): PANSS >3 on at least 1 positive subscale, BPRS, Operational Criteria Checklist for Psychotic illness (DSM‐III‐R diagnoses) + no BPD
PSY = 81
• Dose response relation btw stress reactivity and number of BPD criteria across groups (p=.005)
• In BPD subjects, stress associated with both hallucinations and paranoia
Reactivity to stress
• Glaser (2010)
 Both hallucinations and paranoia reacted more strongly to stress in BPD group
 Psychotic symptoms not limited to periods of stress
• DIB studies found more transient phenomena
Konklusjon review Berube & Chanen

Psykotiske symptomer hos BPF er svært like psykotiske symptomer hos
schizofrenispektrumlidelser (SSL), særlig når det gjelder
hørselshallusinasjoner.

Noen studier fant subtile forskjeller


Hos BPF er psykotiske symptomer forbundet med mer stress (1), føler seg oftere kontrollert
av stemmene

Pasienter med BPF var ofte yngre da hørselshallusinasjonene begynte (2)

Ingen forskjell I varighet

Hørselshallusinasjoner hos SSL har oftere positivt innhold (1) og er mer forstyrrende (1)

Større reaktivitet (Glaser og van Os, 2008)
One study assessed other aspects of psychosis using the PANSS

Negative symptoms were more common, as well as conceptual disorganisation, grandiosity
and voices dialoguing
Behandling

Det antas at atypiske antipsykotika er effektive


Det mangler gode behandlingsstudier, dvs, randomiserte kliniske forsøk
Gjør en vurdering av alvorlighetsgrad av psykotiske symptomer
Oppsummering og noen flere punkter

Psykotiske symptomer er vanlige hos pasienter med BPF

Sannsynligvis dimensjonalt fordelt

Jo mer alvorlige psykotiske symptomer, desto mer alvorlig BPF

Fra et fenomenologisk perspektiv er det bare subtile forskjeller

Komplekst forhold til disossiative symptomer

Det trenges mer forskning!
Spørsmål?