859290 APY Australasian PsychiatryBeatson

Australasian
Psychiatry
Australasian Psychiatry

Borderline personality disorder 1­–4

© The Royal Australian and
New Zealand College of Psychiatrists 2019

and auditory verbal hallucinations Article reuse guidelines:

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DOI: 10.1177/1039856219859290
https://doi.org/10.1177/1039856219859290
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Josephine Beatson   Spectrum, Statewide Service for Personality Disorder, Eastern Health,
Richmond, VIC, Australia

Abstract
Objective: Auditory verbal hallucinations (AVH) frequently co-occur with borderline personality disorder (BPD)
and can lead to misdiagnosis with schizophrenia (SCZ) or other primary psychotic disorders. Misdiagnosis is more
common when AVH meet criteria for Schneiderian first rank symptoms (FRS). This paper’s objective is to improve
diagnostic accuracy by outlining particular clinical features that can assist the distinction between BPD and psy-
chotic disorders in these cases.
Conclusion: The overall clinical presentation when AVH occur in BPD can assist in determining a primary diagnosis
of BPD when frank psychotic disorder is absent. AVH in BPD cannot be distinguished phenomenologically from
AVH in SCZ. Clinical experience and increasing research suggest that AVH in BPD are often dissociative in origin
and highly correlated with the presence of FRS, elevated levels of dissociation and a history of childhood trauma.
When AVH occur in BPD in the absence of co-occurring psychotic disorder, formal thought disorder is usually
absent, negative symptoms minimal or absent, bizarre symptoms absent, affect reactive and the patient retains
sociability. Psychotropic medication may be less effective for the AVH in these cases, while they may improve or
remit during psychotherapy for BPD.

Keywords:  borderline, psychosis, hallucinations, dissociation, trauma

A
uditory verbal hallucinations (AVH) in patients
with borderline personality disorder (BPD) have
long been a source of misdiagnosis. These patients
are frequently diagnosed with psychotic disorder not
otherwise specified, schizophrenia (SCZ) or schizo-
affective disorder and treated for the psychotic disorder
alone. Iatrogenic harm results, because the symptoms
and maladaptive behaviours associated with untreated
BPD become entrenched, rendering treatment more dif-
ficult when it occurs, sometimes years later.
Misdiagnosis most commonly occurs with AVH in BPD
in three situations: when they meet criteria for first rank
symptoms (FRS); when heard from outside the head; and
when of lasting duration. Yet all three apply when AVH
occur in BPD in the absence of comorbid psychosis.1-5
Clinicians experienced with BPD regard these AVH as
dissociative in origin. They often meet criteria for FRS of
SCZ while their content usually relates to past trauma,
particularly childhood trauma or intrusions from disso-
ciated aspects of self. Hallucinations in other sensory
modalities, visual, olfactory and tactile, also frequently
occur in BPD.
There is now a body of research on the phenomenology
and symptomatology of AVH in BPD that can improve
diagnostic accuracy when BPD is the primary diagnosis.
The phenomenology and
symptomatology of AVH in BPD
Research shows that the phenomenology of AVH in BPD
cannot be distinguished from AVH in SCZ in terms of
location, number, loudness, person or conviction about
the omnipotence and/or malevolence of the voices.1-4
Voices in BPD can be heard from inside or outside the
head, be single or multiple and voiced in the second or
third person. They are highly distressing, more so than
AVH in patients with SCZ.4 AVH occur in 21–50% of
Corresponding author:
Josephine Beatson, Spectrum, Statewide Service for Personality
Disorder, Eastern Health, 1/17 Park Tower, 201 Spring Street,
Melbourne, VIC 3000, Australia.
Email: Josephine.Beatson@outlook.com

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Table 1.  First rank symptoms of AVH in BPD

Yee et al.6
Voices controlling behaviour, thought insertion, thought withdrawal, thought blocking
Tschoeke et al.3
Voices commenting, voices controlling behaviour, dialogue between voices
Korzekwa et al.8
Voices arguing or conversing; ‘made’ emotions, ‘made’ impulses, ‘made’ actions; thought insertion, thought withdrawal

AVH: auditory verbal hallucinations; BPD: borderline personality disorder.

Table 2.  Phenomenology of AVH in BPD

AVH in BPD cannot be distinguished phenomenologically from AVH in SCZ
They can:
•• be heard from inside or outside the head
•• be single or multiple
•• employ the second or third person
•• often meet criteria for FRS
•• begin in adolescence and persist over long periods

AVH: auditory verbal hallucinations; BPD: borderline personality disorder; FRS: first rank symptoms; SCZ: schizophrenia.

cases of BPD, particularly in severe cases associated with
increased likelihood of suicidal plans and actions, more
frequent hospitalizations and poor prognosis.5
Tschoeke et al.3 compared AVH in 23 patients with BPD
and 21 with SCZ and found that 52% of the BPD patients
felt controlled by their voices, compared with 5% of
those with SCZ and that childhood trauma correlated
with voices controlling behaviour. Kingdon et al.1 found
that paranoid delusions are less common in BPD than in
SCZ, occurring in 29% of patients with BPD, 59% with
SCZ and 65% with both disorders.1 Several studies have
noted the absence of bizarre delusions in BPD.1-3
Clinical and research findings that AVH in BPD fre-
quently meet criteria for FRS in the absence of co-occur-
ring psychotic disorder are of major importance for
improving diagnostic accuracy in these cases.2,3,5,6 Voices
conversing, commenting or arguing and passivity phe-
nomena including ‘made’ thoughts, feelings, impulses
and actions are well documented in BPD with AVH.3,5,6
Thought broadcasting may not occur in BPD in the
absence of co-occurring psychotic disorder.3,6 Certainly,
hearing voices emanating from external objects such as
the television does not occur in the absence of co-occur-
ring psychosis7 (see Table 1).
Other features characteristic of AVH in BPD are as fol-
lows: highly triggered by stress; formal thought disorder
and negative symptoms of SCZ are minimal or absent;
affect not flat; patients retain sociability; AVH may be of
lasting duration, often beginning in adolescence.2,3,6 It
can be difficult early in the course of illness to distin-
guish BPD from SCZ, because affect is not yet blunted
and negative symptoms not prominent. In these cases
longitudinal assessment is critical to diagnostic accuracy.
Tables 2 and 3 summarize the characteristics of AVH in
BPD.
Dissociation, childhood trauma
and AVH in BPD
In our opinion and that of many authorities, AVH meet-
ing criteria for FRS in BPD are frequently dissociative in
origin and the result of childhood trauma. They are
highly correlated with levels of dissociation and experi-
ences of childhood trauma, particularly emotional abuse
and neglect.1,3,6,7, 8 Kingdon et al.1 found that childhood
emotional abuse had occurred in 92% of a cohort of
patients with BPD, 43% with SCZ and 82% with both
disorders. Severe sexual abuse was experienced by 67%
of patients with BPD, compared with 20% with SCZ and
44% with both disorders.
Tschoeke et  al.3 found that childhood trauma scores
were positively correlated both with hearing voices and
dissociation and that the level of dissociation correlated
with voices first heard before the age of 18.
Dissociative symptoms occur in 66–75% of patients with
BPD.8,9 Dissociative levels are higher in BPD than in all

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Table 3.  Other features of BPD with AVH (in the absence of comorbid psychosis)
•• AVH in BPD are highly stress related, critical, very distressing
•• Formal thought disorder is absent
•• Negative symptoms minimal or absent
•• Bizarre delusions absent
•• Affect is not flat: remains reactive in absence of EPSE
•• Elevated levels of dissociation
•• History of childhood trauma usually severe
•• Sociability retained
AVH: auditory verbal hallucinations; BPD: borderline personality disorder.
other psychiatric disorders with the exception of diagnos-
able dissociative disorders and post-traumatic stress
disorder.8,9 Significantly, patients with BPD without ele-
vated levels of childhood trauma do not experience AVH.8
In our opinion, the hallucinations in other sensory
modalities (olfactory, visual and tactile) commonly pre-
sent in BPD are also of dissociative origin and relate to
past trauma, with their content frequently revealing the
nature of past traumatic events. Slotema et al.11 reported
that 79% of a cohort of 28 patients with BPD and AVH
experience at least one hallucination in a different sen-
sory modality, whereas 61% experienced hallucinations
in several modalities.
The high levels of distress associated with AVH in BPD
relate to their critical and derogatory content and/or to
commands to self-harm or suicidal behaviours. The
voices often repeat words said by past abusers or convey
the abuser’s perceived attitude to the victim when the
abuse occurred. Clinical experience shows that symbolic
elaborations of abuse, or of threats made about dire con-
sequences were the victim to reveal the abuse, are often
accompanied by vivid hallucinations in visual, olfactory
and tactile modalities. These can be a source of terror for
these patients whose severe associated stress can lead to
the development of delusional states, which may never-
theless remit when the triggering factors are understood.
Van der Hart et al.7 (p. 122), offer a vivid example.
Psychotherapy for AVH in BPD
Clinical experience suggests that AVH in BPD may
decrease or remit during psychotherapy when past
trauma that was formerly dissociated returns to con-
scious awareness and is worked through or when disso-
ciative intrusions diminish. Unfortunately, research
evidence in this area is scant, with research employing
prospective studies over the course of psychotherapeutic
treatments required. Whether AVH in BPD can arise from
other causes than dissociation awaits further research.
Psychotherapy in these cases should be undertaken by
an experienced psychotherapist using a validated
psychotherapy for BPD or employing factors common to
these.10 The ability to contain painful memories and
intense emotions is essential, together with the availa-
bility of supervision.
Antipsychotic medication for
AVH in BPD
Research on the efficacy of antipsychotic medication for
AVH in BPD is scant, although a recent systematic review
by Slotema et al.11 found that they tend to be beneficial
in these cases. Clinical experience suggests that psychia-
trists commonly prescribe low-dose antipsychotic medi-
cation for AVH in BPD, in keeping with APA and NHMRC
guidelines.12
Olanzapine is the most studied of these and shown to be
of benefit in doses from 2.5 to 10 mg daily. Aripiprazole
2.5–10 mg daily and quetiapine 50–150 mg also have
research support.13
Research needed treatment for
AVH in BPD
NHMRC in 2012 called for more research on the treat-
ment for psychotic symptoms in BPD.12 Table 4 offers
several promising areas.
Conclusion
A primary diagnosis of BPD can often be made when
AVH are present by examining the overall clinical pic-
ture. BPD should then be treated with one of the vali-
dated modalities of psychotherapy for BPD or structured
treatment that includes factors common to validated
psychotherapies.
FRS can no longer be used to distinguish psychotic
symptoms of BPD from those of SCZ. Misdiagnosis of
patients with AVH in BPD can often be avoided by assess-
ing the overall clinical presentation detailed in Tables
1–3. If the diagnosis remains uncertain, longitudinal
diagnostic evaluation is essential.
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Table 4.  Future research suggestions for AVH in BPD

•• Prospective studies of effects of psychotherapy
•• Further studies on effectiveness of antipsychotic agents
•• Effectiveness of CBT approaches to voice-hearing on these AVH
•• Effectiveness of DBT-PE
•• Effects of non-invasive brain stimulation
•• Search for biomarkers that distinguish diagnostic groups

CBT: cognitive behaviour therapy; DBT-PE: to dialectical behaviour therapy with prolonged exposure; AVH: auditory verbal
hallucinations; BPD: borderline personality disorder.

Disclosure 5. Slotema CW, Niemantsverdriet MB, Blom JD, et al. Suicidality and hospitalisation in
patients with borderline personality disorder who experience auditory verbal hallucina-
The author reports no conflict of interest. The author alone is responsible for the content and
tions. Eur Psychiatry 2017; 41: 47–52.
writing of the paper.
6. Yee L, Korner AJ, McSwiggan S, et al. Persistent hallucinosis in borderline per-
sonality disorder.[Erratum appears in Compr Psychiatry. 2005 May-Jun;46(3):238
Funding
Note: Yee, Leslie [corrected to Yee, Lesley]]. Compr Psychiatry 2005; 46: 147–154.
The authors received no financial support for the research, authorship, and/or publication of
this article. 7. Van der Hart O, Nijenhuis E and Steele K. Structural dissociation and the spectrum of
trauma-related disorders. In: The haunted self: structural dissociation and the treatment
of chronic traumatization. New York, NY: W.W. Norton & Company, 2006.
ORCID iD
8. Korzekwa MI, Dell PF, Links PS, et al. Dissociation in borderline personality disorder: a
Josephine Beatson https://orcid.org/0000-0002-8662-5479
detailed look. J Trauma Dissociation 2009; 10: 346–367.

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