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! 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