New research shows that many people with BPD hear voices ordering self-harm.
New research has revealed that many people with borderline personality disorder (BPD) hallucinate.
The study sampled people with BPD who had auditory hallucinations and found that some types of hallucinations are more common than others, with themes of self-harm being common within voices heard.1
The study was conducted by Hayward et al. and published in a 2022 edition of the journal Clinical Psychology and Psychotherapy.
The results suggested that people with BPD tend to hallucinate about voices that speak directly to them, with 93 percent of the people saying that the voices talk to them in comparison to 52 percent who said that they heard the voices talking to each other.
The majority (78 percent) said that the voices discussed topics that related to them, with 78 percent saying that the voices tell them what to do, although only 29 percent said they do what the voices tell them to do. Researchers cited evidence that 50 to 90 percent of people with BPD have auditory hallucinations2; therefore, caregivers and clinicians need to be aware that many people with BPD hear voices—and some might carry the risk of self-harm.
Themes of Self-Harm in Hallucinations With BPD
The researchers examined whether the hallucinations tend to involve topics of self-harm and harming others, with the results showing that 76 percent of the people with BPD heard voices that command them to hurt themselves, and 33 percent heard voices ordering them to hurt others.
Many people with the disorder interacted with the voices, with 60 percent having a conversation with them (in which they heard the voices answering back), but only 29 percent said that they did whatever the voices told them to do.
Therefore, some people with BPD could be at risk of self-harm that is associated with the auditory hallucinations.
Insight Into Hallucinations in BPD
The researchers examined whether the people with BPD had insight into the idea of the hallucinations not being real, and found that 58 percent believed the voices are real, although 69 percent recognised that they heard the voices because of their mental illness.
This suggests that, although people with BPD might recognise that the voices are connected to the disorder, the voices nonetheless seem and feel real to them. In most cases, the hallucinations represented strangers, because only 31 percent said that the voices sounded like people they know, and most people tended to hear a variety of voices—with only 29 percent hearing just one type of voice while hallucinating.
Voices Inside or Outside the Head
The origin of the voices was felt to be from within the head among 51 percent, but outside the head among 49 percent.
The experience of having auditory hallucinations related to the sense of derealisation that can be felt by people with BPD, with 23 percent of people in the sample saying that they tend to hear voices in times when their surroundings seem unreal, although 13 percent associated the hallucinations with times when they had alcohol or drugs.
Hallucinations Distressing to People With BPD
Auditory hallucinations were found to be one of the most distressing symptoms of BPD, with 69 percent of people with the disorder saying that hallucinations are one of the most high-impact symptoms of the disorder. Other symptoms ranked high on impact by people who took part in the study included moodiness, unstable relationships, feeling angry, and feelings of emptiness.
Hallucinations in BPD and the Brain
The same team of researchers published findings from the study that focused on functional magnetic resonance imaging (fMRI) results from the sample of 48 people with BPD who had taken part in the study and completed one structural scan of their brain and 32 minutes of tasks together with functional MRI scans.
The study was published in the International Journal of Neuropsychopharmacology in 2022.
The 32 minutes of tasks were divided into four segments of eight minutes each, starting with one resting-state scan, followed by three tasks presented in randomised order.
The results suggested that people with BPD who suffered severe auditory hallucinations had weaker connections between the anterior cingulate and bilateral insular cortices of their brain.
The research suggested that when people with BPD experienced auditory hallucinations, this activated blood oxygenation within their anterior cingulate cortex to a greater extent than occurred when they heard external voices or voices that were deliberately imagined.
This supports the perception held by people with BPD of the voices being real and illustrates why many of them find auditory hallucinations very distressing.
Supporting People With BPD
Although the sample size was small, the new research sheds important light on auditory hallucinations as symptoms that some people with BPD experience, and which clinicians and people who care for people with BPD need to be aware of because of the implications for distress and self-harm.
The research shows that the hallucinations feel very real to many people with the disorder, and this was supported by fMRI evidence about activity within the brain, illustrating why having hallucinations can be very distressing for people with BPD.
The new research shows that many people with BPD who have auditory hallucinations report that the voices tell them to harm themselves, and around one-third might be at risk of doing what the voices tell them to do.
Therefore, caregivers of people with BPD need to be vigilant about the risks of self-harm among people with the disorder who have auditory hallucinations.