Transient hallucinations during interpersonal stress in an adolescent with borderline personality disorder

To the Editor

Borderline personality disorder (BPD) has been recognized as a reliable diagnosis in adolescents as symptoms can be clearly distinguished from typical adolescence by their severity, pervasiveness and time course (Sharp and Fonagy, 2015). Psychotic experiences such as hallucinations have not been deeply investigated in adolescents with BPD. Many studies have been published about Adult BPD, but the subject remains controversial. Recent surveys found that hallucinations are no more prevalent in patients with BPD than in individuals with non-psychotic disorders (Kelleher and DeVylder, 2017). However, Glaser found that patients with BPD are more reactive to daily problems and stress in all symptoms of psychosis, including hallucinations. He stated that hallucinatory reactivity appears to be BPD-specific (Glaser et al., 2010).

A 16-year-old boy was referred to our Child Psychiatry Outpatient Unit due to emotional dysregulation, self-harm, anger with pantoclastic crises and dissociative aspects. All of these behaviors started 1 year beforehand, as a reaction to quarrels he was having with his online girlfriend, with whom he had a very possessive relationship. He also reported sleep-wake rhythm disturbances and cannabis consumption. Clinical interviews and personality assessments (Minnesota Multiphasic Personality Inventory-Adolescent [MMPI-A], Structured Clinical Interview for DSM-IV-TR Axis II Personality Disorders [SCID-2]) led to the diagnosis of BPD. His IQ was normal (Wechsler Intelligence Scale for Children-IV [WISC IV]). A combination of psychoeducation, psychotherapy and the administration of promazine during the periods of crisis stopped his self-harm behavior. At the age of 17, he reported visual and non-verbal auditory hallucinations, which started a few days after he had broken up with his girlfriend: in his hallucinations, he reportedly saw her having dinner with him and could hear chewing and cutlery noises. He refused pharmacological treatment because he felt he could manage to stop these symptoms by getting back together with his girlfriend. In fact, the psychotic symptoms stopped after he got back with his girlfriend 1 week later. At the age of 18, the patient was referred to the Adult Psychiatry Outpatient Unit with a stable clinical pattern: he did not report any further hallucinations even if that relationship had ended and he had several other romantic (and unstable) relationships.

The case above indicates that interpersonal stress may have significant effects on the psychological functioning of adolescents with BPD and could lead to psychotic symptoms, including visual hallucinations. Those experiences can be transient and can vanish with the resolution of the relational crisis. The improvement of interpersonal abilities and stress tolerance may affect the frequency of these psychotic symptoms.