Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 20, 239–245 (2013)

Published online 4 October 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.791

Auditory Hallucinations: A Comparison of Beliefs

about Voices in Individuals with Schizophrenia
and Borderline Personality Disorder
Claire Rachel Hepworth,1* Katie Ashcroft2 and David Kingdon3
1
National Specialist CAMHS Dialectical Behaviour Therapy Service, Maudsley Hospital, London, UK
2
Hampshire Partnership NHS Trust, Hampshire Early Intervention in Psychosis Service, Southampton, United
Kingdom
3
Hampshire Partnership NHS Trust, Royal South Hants Hospital, Southampton, United Kingdom

Objective: Individuals with borderline personality disorder (BPD) may experience distressing auditory
hallucinations, phenomenologically similar to those seen in psychosis. However, access to effective inter-
vention 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.
Methods: 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%).
Results: Multivariate analyses confirmed that there were no group differences in beliefs about the malevo-
lence 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.
Conclusion: Auditory hallucinations in psychosis and BPD do not differ in their phenomenology or cog-
nitive 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 BPD.
• 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.

Keywords: Borderline Personality Disorder, Psychosis, Voices, Auditory Hallucinations, Cognitive Behaviour
Therapy

INTRODUCTION perception, and is not amenable to direct and voluntary con-

Hallucinations have been defined as ‘any percept like experi-
ence which occurs in the absence of the appropriate stimu-
lus, has the full force or impact of the corresponding actual
*Correspondence to: Claire Rachel Hepworth, National Specialist
CAMHS Dialectical Behaviour Therapy Service, Maudsley Hospital,
Denmark Hill, London SE5 8AF, United Kingdom.
E-mail: claire.hepworth@iop.kcl.ac.uk
trol by the experiencer’ (Slade & Bentall, 1988, p. 23).
Traditionally, auditory hallucinations have been consid-
ered to be indicative of an underlying psychotic disorder;
however, there is now substantial evidence to suggest that
hallucinations are also prevalent in those without psychotic
disorder, at rates of up to 25% (Slade & Bentall, 1988) or 30%
(Romme, Honig, Noorthorn, & Escher, 1992), although
other studies have suggested that these are overestimates
and the reality may be closer to 4% (Johns & van Os, 2001).

Copyright © 2011 John Wiley & Sons, Ltd.

240
One key predictor of clinical caseness is the level of distress,
which some have argued varies according to the content of
the voice—the meaning that the individual ascribes to experi-
encing the voice (Chadwick & Birchwood, 1994), or the
relationship the hearer has with the voice (Abba, Chadwick,
& Stevenson, 2008). For example, there is evidence to suggest
that there is less distress among evangelical voice hearers
(Davis, Griffin, & Vice, 2001). Furthermore, it is this distress
that will influence help seeking (Romme et al., 1992).
Clinically, it is observed that phenomenologically similar
experiences may occur in individuals who do not meet diag-
nostic criteria for psychosis but may, e.g., meet diagnostic
criteria for personality or affective disorders (Lowe, 1973).
There is controversy as to whether distressing hallucinations
in non-psychotic populations are ‘pseudo-hallucinations’—a
term coined in 1911, by Jaspers (Jaspers, 1998, 1911). One
main differential has previously been defined by whether
the voice hearer is aware (pseudo-hallucinations) or not
(hallucinations)—that the voices are internally generated
and are not heard by others (Sedman, 1966).
However, despite the clinical prevalence, there has been
a paucity of research that considers the experience of audi-
tory hallucinations in individuals with a diagnosis of bor-
derline personality disorder (BPD) and subsequently how
best to intervene. Traditionally, these were described as
‘pseudo-hallucinations’; however, a recent account sug-
gests that 30% of those meets criteria for BPD experience
voices (Yee, Korner, McSwiggan, Meares, & Stevenson,
2005). Yee and colleagues showed that these hallucina-
tions were persistent and long-standing and a significant
source of distress and disability, using a case series of 10
patients with a diagnosis of BPD and presenting with
auditory hallucinations. Following from this, the authors
then considered a sample of 171 patients with BPD and
found that 30% of the sample experienced voices that
would meet criteria for auditory hallucinations.
Recently, there has been an examination of subjective
stress and its relationship with the intensity of psychotic
experiences (Glaser, van Os, Thewissen, & Myin-Germeys,
2010). The authors considered 56 patients with BPD, 38
patients with cluster C personality disorder, 81 patients
with psychotic disorder and 49 healthy controls from a
general population sample. The authors found that across
all patient groups, psychotic experiences were more
reactive to daily life stress than in controls, but that this
was greatest in those with BPD.
A preliminary investigation of lifetime mood and
psychotic spectrum features in patients with BPD
(Benvenuti et al., 2005) identified that for those with
BPD-M, the manic–hypomanic component was correlated
with psychotic symptoms including hallucinations and
delusions, suggesting that emotional changes may play a
key role in the presentation of voices.
Most recently, Kingdon and colleagues (Kingdon et al.,
2010) explored the presentation of voices, trauma and
Copyright © 2011 John Wiley & Sons, Ltd.
C. R. Hepworth et al.
paranoia across individuals with a diagnosis of schizophre-
nia, BPD and those who met criteria for both disorders.
The authors reported that the groups were similar in their
experiences of voices, including the perceived location of
them. However, those who met criteria for BPD alone
reported greater distress and more negative content than
the other groups. High rates of trauma were reported across
all clinical groups; however, significantly greater levels of
childhood trauma were reported by those who met diagnos-
tic criteria for BPD alone and those who had comorbid
schizophrenia, than reported by those with a diagnosis of
schizophrenia only. The greater levels of distress reported
by those with BPD might be hypothesized to reflect the
increased level of trauma experienced by this group. For
some, distressing voices might reflect some of the traumatic
content of these experiences.
These figures concur with other findings in clinical samples.
For example, in a review of 39 studies of female inpatients
and 7 studies of female outpatients, where at least half
the patients were diagnosed with psychosis, 69% reported
(CSA) Child Sexual Abuse and (CPA) Child Physical Abuse;
a review of 31 studies of patients suggested that 59% of male
patients experienced CSA or CPA (Read, van Os, Morrison,
& Ross, 2005). There is a particularly strong relation between
experience of trauma and hallucinatory experience (Read &
Argyle, 1999). The authors reported that 54% of schizophrenic
symptoms in adult inpatients who had been abused were
clearly linked by content to their abuse (e.g., command
hallucinations, were identified to be the voice of the abuser).
Romme and Escher (1989) reported that 70% of voice hearers
developed these experiences following a traumatic event.
Honig et al. (1998) compared the form and content of auditory
hallucinations across patients with schizophrenia, patients
with a dissociative disorder and non-patients who heard
voices. The authors found that a traumatic event or an event
that activated the traumatic memory of an earlier event,
preceded the onset of voices for the majority of patients, but
not non-patients, suggesting that distress and help seeking
in response to voices is associated with trauma.
Therefore, there is preliminary evidence to suggest that
those with BPD do hear voices that may be similar to
those seen in psychosis, that they cause significant distress
and that they may be influenced by mood, trauma or
stress. A failure to consider these experiences in more
detail may lead to misdiagnosis, inappropriate treatment
or impediment of access to intervention. It is important
to understand whether these are similar experiences to
the auditory hallucinations observed in those with
psychotic disorders, and if so whether similar approaches
that target cognitive appraisals might be helpful for those
with voices and BPD.
There is good evidence from studies of individuals with
psychosis that once established auditory hallucinations are
maintained by both the use of safety behaviours (Morrison,
1998a) and also meta-cognitive beliefs about the voices e.g.,
Clin. Psychol. Psychother. 20, 239–245 (2013)
Auditory Hallucinations
‘I must not have unpleasant thoughts’ (Lobban, Haddock,
Kinderman, & Wells, 2002). Chadwick proposed a model
of positive psychotic symptoms that conceptualized these
experiences as intrusions into awareness (e.g., hallucina-
tions) and culturally unacceptable interpretations of these
intrusions (e.g., delusions) (Chadwick & Birchwood, 1994).
Chadwick argued that it is the interpretation of the intru-
sion rather than its existence that causes distress and
disability. Once developed, the positive symptoms of
psychosis are known to be maintained by mood, arousal
and maladaptive cognitive–behavioural responses (e.g.,
avoidance) (Morrison, 2001).
Cognitive models of psychosis have identified that
appraisals account for at least some of the distress
associated with a hallucinatory experience. Beliefs that
voices are malevolent and harmful are associated with more
negative emotions and resistance/escape (Chadwick &
Birchwood, 1994). Attitudes towards voices can be both
positive and negative (Miller, O’Connor, & Di Pasquale,
1993). Chadwick and Birchwood (1995) proposed that
emotional and behavioural reactions to voices reflect not
only the content and form of the voices but also the meaning
given to them, including beliefs about the identity, purpose,
omnipotence and the consequences of compliance or resist-
ance. The Beliefs about Voices Questionnaire (BAVQ-R) was
developed from this model (Chadwick & Birchwood, 1995)
and was revised to incorporate a Likert scale to pick up
individual differences and to incorporate further assess-
ment of omnipotence.
Clinically, it is observed that individuals with psychosis
often report a complex relationship with the voices that they
hear, including beliefs about their omnipotence and judge-
ments as to their benevolence and/or malevolence. For ex-
ample, an individual not only might report feeling both
controlled and fearful of their voice but also believe that it
provides some guidance, protection or comfort. The
complexity of the beliefs that an individual holds about their
voice/s would be expected to impact on the way that the
individual resists or engages with their voice/s. This is
confirmed by the current evidence base. Furthermore, there
is some preliminary evidence to suggest that individuals
appear to be more likely to act on command hallucinations,
specifically, where there is a strong belief in their omnipo-
tence and where the individual uses other safety behaviours
(Hacker, Birchwood, Tudway, Meaden, & Amphlett, 2008). It
is therefore important to understand the individuals’
beliefs about their voices in order to successfully
intervene. It is as yet unknown whether this complex
relationship with voices is unique to individuals who
meet criteria for psychotic disorders.
The implication, therefore, is that it is not only the
experience of hearing voices that should be a target of
intervention but also the individual’s relationship with
the voices that they hear. If these phenomena also occur
across other clinical populations and are not unique to the
Copyright © 2011 John Wiley & Sons, Ltd.
241
psychotic experience, this suggests that a transdiagnostic,
symptom-focused approach that considers auditory hallu-
cinations as intrusive internal experiences and considers
meta-cognitive beliefs may be helpful. The cognitive model
of hallucinations suggests that distress is related to beliefs
rather than phenomenology. Kingdon et al. (2010) reported
that auditory hallucinations that present in individuals
with BPD are phenomenologically similar to those in
individuals with psychosis. It is further important to
consider whether the experiences of those hearing voices
(including the cognitive, emotional and behavioural
responses) are similar, despite differential diagnoses. This
has important implications for the assessment and
treatment of auditory hallucinations.
Currently, individuals with BPD may be excluded from
accessing evidence-based interventions for auditory halluci-
nations, but they may also be excluded from evidence-based
treatments for BPD (e.g., dialectical behaviour therapy;
Linehan, 1993) if they are presenting with significant audi-
tory hallucinations. Diagnostic systems are recognized as
having limitations in their validity (e.g., Regier et al., 1998).
Kingdon et al. (2010) used diagnostic instruments to demon-
strate that clinical groups can overlap, i.e., that dichotomizing
between diagnoses, e.g., between psychosis and personality
disorder, are invalid. Although diagnoses continue to be used
in developing and evaluating interventions, the common
features of symptoms such as voices across diagnoses can
also mean that a symptom-focused approach to delivering
interventions may be appropriate.
In summary, recent evidence indicates that auditory
hallucinations experienced by individuals who meet
criteria for BPD may be phenomenologically similar to
those seen in individuals with psychosis and that they
cause significant distress (Kingdon et al., 2010; Yee et al.,
2005). The BAVQ-R (Chadwick, Lees, & Birchwood,
2000) provides an assessment of individuals’ beliefs,
feelings and behaviours associated with auditory halluci-
nations. Auditory hallucinations are prominent in both
psychosis and BPD; however, it is not yet known whether
the psychological relationship with voices differs across
diagnosis. The current research considers whether an
individual’s experience of voices (their relationship with
their most dominant voice) and the way that the individ-
ual responds to them differs across clinical groups and
whether deriving beliefs about voices might aid in assess-
ment and intervention.
METHODS
Participants
The participants were individuals with a clinical diagnosis
of BPD or schizophrenia who were currently under the
care of mental health services in Hampshire and Dorset.
Clin. Psychol. Psychother. 20, 239–245 (2013)
242
Participants were recruited from inpatient wards, rehabili-
tation and forensic services and community teams. Prior
to approaching the patient, permission was sought from
the psychiatrist in charge of the individual’s care. The
research was granted approval by the Local Research Ethics
Committee and the Research and Development Offices of
Hampshire Partnership and Dorset NHS Trusts. The sample
used in this study are the sample described in the study
conducted by Kingdon et al. (2010). This paper reports
further information from previously unreported scales.
A total of 45 patients reported that they experienced
auditory hallucinations and completed the BAVQ-R and
thus were included in the study. Ten participants met cri-
teria for BPD alone (22%), 23 met criteria for a diagnosis
of schizophrenia alone (51%) and 12 met criteria for both
BPD and schizophrenia (27%). Of the 45 patients, 18 were
men and 27 were women. For those with BPD, the male :
female gender ratio was 1:9; for those with schizophrenia,
the ratio was 15:8; and for those with both, the ratio was
2:10. Ethnicity was predominantly White; one participant
was from a minority ethnic group.
The average age of the participants identified with BPD
was 33.70 years; for those identified with schizophrenia,
the average age was 36.13 years; and for those with both
disorders, the average age was 32.60 years. Of the whole
sample, 21 (47%) were inpatients and 24 (53%) were outpa-
tients at the time of the study. Two (20%) of the patients with
BPD were inpatients and eight (80%) were outpatients; 14
(61%) of those with schizophrenia were inpatients and 9
(44%) outpatients at the time of interview. Five (42%) of
those individuals who met criteria for both disorders were
inpatients and seven (58%) were outpatients. The average
duration of illness was 7 years across all groups.
Interviews and Questionnaires
All participants were interviewed using the Structured
Clinical Interview for Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (SCID; First & Gibbon,
2004). Axes 1 and 2 were relevant to the diagnosis of schizo-
phrenia and BPD to confirm, or otherwise, their diagnosis
and to identify patients who met criteria for both conditions.
The assessors were psychiatrists who had previously
received training in the diagnosis of mental disorders, and
this was supplemented by training in the use of SCID
by one of the authors (D. K.). Video role plays of SCID I
and II interviews were used to confirm agreement and
inter-reliability for diagnosis was established (intra-class cor-
relation coefficient = 1). This was supplemented through
discussion during the study and examination of details
taken for SCID between D. K. and the individual psychiatrist
when any doubt existed, to ensure that criteria were met.
Regardless of diagnosis, if a participant reported that they
experienced auditory hallucinations, then they were
Copyright © 2011 John Wiley & Sons, Ltd.
C. R. Hepworth et al.
interviewed using the BAVQ-R. The BAVQ-R is a 35-item
self-report measure of patient’s beliefs, emotions and
behaviour with regard to auditory hallucinations. Respon-
dents are asked to complete the measure with respect to
their most ‘dominant voice’. Three subscales relate to
beliefs: malevolence, benevolence and omnipotence. Two
further subscales assess the emotional and behavioural
relationships with auditory hallucinations: ‘engagement’
and ‘resistance’. Behavioural engagement refers to the
individual’s attempts to engage with their voice, whereas
resistance refers to the individual’s attempts to ignore,
avoid or suppress the experience. Emotional engagement
(e.g., ‘the voice reassures me’) refers to a positive emotional
impact of the voice that is welcomed, whereas emotional
resistance (e.g., ‘my voice frightens me’) refers to a negative
emotional impact.
Each item is measured on a four-point scale, which ranges
from 0 (disagrees) to 3 (agree strongly). The measure has
good reliability and validity (Chadwick et al., 2000).
Statistical Methods
Data were normally distributed. Multivariate analyses of
variance were administered to assess whether those with
a diagnosis of BPD, schizophrenia or both differed along
the dimensions of the BAVQ-R. All statistical analyses
were performed using SPSS 17 (SPSS Inc., Chicago, IL,
USA), and statistical significance is considered if p < 0.05.
RESULTS
Multivariate analyses of variance confirmed that there were
no group differences in beliefs about the malevolence or
omnipotence of voices (see Tables 1 and 2). In addition,
there were no group differences in behavioural resistance
or engagement (see Tables 1 and 2). Those with a diagnosis
of schizophrenia reported more beliefs about the benevo-
lence of voices than those with BPD or who met criteria
for both diagnoses; however, levels of benevolence were
low across all groups and mean differences were small
(see Table 3). Given the small sample size, statistical ana-
lyses would be misrepresentative.
Those with BPD and those who met criteria for BPD and
schizophrenia reported significantly greater emotional re-
sistance towards the voices than those with schizophrenia,
and those with schizophrenia reported significantly
greater emotional engagement than the other groups.
Post hoc comparisons revealed that those with a diagnosis
of BPD alone reported significantly greater emotional resist-
ance than those with schizophrenia (mean difference = 3.55,
p = 0.02, confidence interval [CI] = 1.43–5.67). There was
no significant difference in emotional resistance between
those with BPD and those with both BPD and schizophrenia
Clin. Psychol. Psychother. 20, 239–245 (2013)
Auditory Hallucinations 243

Table 1. Means and standard deviations of beliefs about voices In terms of emotional engagement, those with
across groups schizophrenia reported significantly greater emotional
SCID Standard engagement than those with BPD (mean difference = 1.02,
diagnosis Mean deviation n p = 0.00, CI = 5.14 to 1.02). There were no differences in
emotional engagement between those with BPD and both
Beliefs about BPD 13.00 4.22 10 BPD and schizophrenia, or schizophrenia and both
malevolence Schizophrenia 9.57 5.66 23 (see Table 3).
of voices Both 12.00 4.91 12
Beliefs about BPD 0.30 0.68 10
benevolence Schizophrenia 3.60 4.13 23
of voices Both 3.08 3.26 12 DISCUSSION
Beliefs about BPD 12.00 3.46 10
omnipotence Schizophrenia 10.48 4.70 23 This study was designed to investigate whether
of voices Both 12.00 5.11 12 individuals with BPD and psychosis differ in their
Emotional BPD 0.00 0.00 10
psychological responses to phenomenologically similar
engagement Schizophrenia 3.09 3.51 23
Both 1.33 1.72 12 auditory hallucinations.
Behavioural BPD 2.10 2.13 10 The results identified that individuals with psychosis and
engagement Schizophrenia 2.21 2.47 23 BPD hold similar levels of beliefs about the omnipotence
Both 2.50 2.90 12 and malevolence of their most dominant voice. However,
Emotional BPD 10.90 1.44 10 those with a diagnosis of BPD, or both BPD and schizophre-
resistance Schizophrenia 7.35 3.21 23 nia, experience greater emotional resistance towards their
Both 10.50 2.64 12
Behavioural BPD 8.70 3.74 10 most dominant voice than those with a diagnosis of schizo-
resistance Schizophrenia 8.43 4.98 23 phrenia alone (i.e., the voice is reported to have a greater
Both 9.33 4.31 12 negative impact for those with BPD). This supports the
finding reported by Kingdon et al. (2010) that for those with
BPD = borderline personality disorder. SCID = Structured Clinical Inter-
view for Diagnostic and Statistical Manual of Mental Disorders, Fourth
BPD, the voices are experienced as more distressing and
Edition. that there is greater negative content even than those with
schizophrenia. Although levels of trauma are high across
all clinical groups, rates of CSA are highest in those with
BPD in this sample. The BAVQ focuses on the most domin-
Table 2. Statistical differences in Beliefs about Voices ant voice, and it may be that the level of distress reflects the
Questionnaire—Revised subscales possibility that the voice is experienced as that of an abuser.
Degrees of Observed In this study, reported beliefs about the benevolence of
BAVQ subscale freedom F Significance power voices were low across all groups. The BAVQ-R asks
respondents to focus specifically on their most ‘dominant
Beliefs about 2 1.84 0.17 0.36 voice’; it might be that other more benevolent voices are
malevolence also experienced, but these are just not the dominant
of voices
Beliefs about 2 3.31 0.05 0.60
voice, and thus, this information is lost in reporting.
benevolence Diagnostic clarity in this study was confirmed using
of voices individual diagnostic interviews conducted by independ-
Beliefs about 2 0.62 0.54 0.14 ent psychiatrists trained in the use of the SCID and using
omnipotence confirmation via inter-rater reliability assessments. Further-
of voices more, the experience of voices was assessed using a
Emotional 2 8.18 0.00 0.94
well-validated and reliable measure (the BAVQ-R).
resistance
Behavioural 2 0.15 0.86 0.07 The sample size was limited in this study, which used
resistance opportunistic sampling methods, as the researchers
Emotional 2 4.99 0.01 0.78 approached all individuals with a clinical diagnosis of
engagement BPD or schizophrenia and who were currently under the
Behavioural 2 0.08 0.92 0.06 care of mental health services in Hampshire and Dorset,
engagement recruited from inpatient wards, rehabilitation and forensic
BAVQ = Beliefs about Voices Questionnaire. services and community teams. However, the use of this
methodology ensured that the sample is clinically represen-
tative of those currently under the care of mental health and
(see Table 3). Those with both BPD and schizophrenia reported forensic services.
significantly greater emotional resistance than those with schizo- A subgroup of this cohort’s presenting difficulties meeting
phrenia alone (mean difference = 0.99, p = 0.00, CI = 1.16–5.15). psychiatric diagnostic criteria for both schizophrenia and

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 20, 239–245 (2013)
244 C. R. Hepworth et al.

Table 3. Statistical comparisons in Beliefs about Voices Questionnaire—Revised subscales between groups with post hoc paired
analyses where differences are significant

95% confidence interval

Mean Standard
BAVQ subscale Diagnosis Diagnosis difference error Significance Lower bound Upper bound

Benevolence BPD Schizophrenia 3.3087* 1.30234 0.015 5.9369 0.6805

Both 2.7833 1.47215 0.066 5.7543 0.1876
Schizophrenia BPD 3.3087* 1.30234 0.015 0.6805 5.9369
Both 0.5254 1.22437 0.670 1.9455 2.9962
Both BPD 2.7833 1.47215 0.066 0.1876 5.7543
Schizophrenia 0.5254 1.22437 0.670 2.9962 1.9455
Emotional resistance BPD Schizophrenia 3.5522* 1.05063 0.002 1.4319 5.6724
Both 0.4000 1.18762 0.738 1.9967 2.7967
Schizophrenia BPD 3.5522* 1.05063 0.002 5.6724 1.4319
Both 3.1522* 0.98772 0.003 5.1455 1.1589
Both BPD 0.4000 1.18762 0.738 2.7967 1.9967
Schizophrenia 3.1522* 0.98772 0.003 1.1589 5.1455
Emotional engagement BPD Schizophrenia 3.0870* 1.01990 0.004 5.1452 1.0287
Both 1.3333 1.15288 0.254 3.6599 0.9933
Schizophrenia BPD 3.0870* 1.01990 0.004 1.0287 5.1452
Both 1.7536 0.95883 0.075 0.1814 3.6886
Both BPD 1.3333 1.15288 0.254 0.9933 3.6599
Schizophrenia 1.7536 0.95883 0.075 3.6886 0.1814

BAVQ = Beliefs about Voices Questionnaire. BPD = borderline personality disorder.

*= difference significant at > .005.

BPD is representative of the clinical picture. In clinical
services, clients often present with both auditory hallucina-
tions and emotion regulation difficulties; however,
traditionally, their access to intervention would be deter-
mined by using diagnostic categorization alone. This
research further supports the notion that therapeutic
intervention should be symptom driven and patient
centred, focused on the clear formulation of the client’s
needs, including careful consideration of the relationship
(or lack of it) between voices and emotion regulation diffi-
culties. Clinicians need to be strategic when considering
what is to be treated first.
The message is clear: auditory hallucinations that are
experienced by those with psychosis and BPD do not differ
in either their phenomenology or the cognitive responses to
them (an individual’s beliefs about the power and malevo-
lence of their dominant voice). The main differential is in
terms of the affective response. This study therefore
provides evidence to suggest that a cognitive model of
auditory hallucinations can be applied to the understanding
and treatment of distressing voices in those with BPD.
Clinicians should apply and evaluate a wide range of cogni-
tive models and methods, from the classic cognitive therapy
(e.g., Morrison, Haddock, & Tarrier, 1995) to those including
newer methods such as mindfulness (e.g., Chadwick, Hughes,
Russell, Russell, & Dagnan, 2009; Chadwick, Newman-Taylor,
& Abba, 2005; Dannahy et al., 2011).
This study has identified that individuals who would
traditionally meet criteria for different clinical diagnoses
may present with phenomenologically similar auditory
hallucinations and that their cognitive and behavioural
responses are also similar. The level of emotional distress
experienced may be the differential between clinical groups.
Assessment of beliefs about voices in individuals who
experience distressing auditory hallucinations, regardless
of diagnosis, is vital and may provide important targets
for intervention.
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