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Auditory Hallucinations: A Comparison of Beliefs about Voices in Individuals with Schizophrenia and Borderline Personality Disorder


Correspondence to: Claire Rachel Hepworth, National Specialist CAMHS Dialectical Behaviour Therapy Service, Maudsley Hospital, Denmark Hill, London SE5 8AF, United Kingdom.




Individuals with borderline personality disorder (BPD) may experience distressing auditory hallucinations, phenomenologically similar to those seen in psychosis. However, access to effective intervention is limited. The cognitive model of auditory hallucinations highlights the role of appraisals in maintaining distress. Cognitive behavioural therapy (CBT) that targets such beliefs has shown efficacy in psychosis. This study examined appraisals about voices in individuals with psychosis and those with BPD to establish whether CBT for voices might have clinical utility for those with BPD.


Participants included 45 patients with distressing auditory hallucinations, recruited from the National Health Service. All participants received a structured clinical diagnostic interview and the Beliefs about Voices Questionnaire. Ten participants met criteria for BPD (22%), 23 met criteria for a diagnosis of schizophrenia (51%) and 12 met criteria for both disorders (27%).


Multivariate analyses confirmed that there were no group differences in beliefs about the malevolence or omnipotence of voices, or in behavioural resistance or engagement. Those with BPD and those with both diagnoses reported significantly greater emotional resistance than those with schizophrenia. Those with schizophrenia reported significantly greater emotional engagement with their voices.


Auditory hallucinations in psychosis and BPD do not differ in their phenomenology or cognitive responses (beliefs about the power and malevolence of their dominant voice). The main differential appears to be the affective response. CBT that focuses on appraisals and the relationship with voices may be helpful for distressing auditory hallucinations in individuals with BPD as well as psychosis. Copyright © 2011 John Wiley & Sons, Ltd.

Key Practitioner Message

  • It may be important to assess the presence of and experience of voices in those with a diagnosis of BP
  • It may be helpful to consider both beliefs about voices and the individual's affective responses to voices.
  • CBT designed to target voices in psychosis (focusing on both the appraisal and the relationship with voices) may be helpful for those with BPD.