Borderline personality disorder. Neuropsychological testing results

Event-Related Potentials Altered in Patients with Borderline Personality Disorder during Working Memory Tasks

Whereas some studies have demonstrated impaired working memory (WM) among patients with borderline personality disorder (BPD), these findings have not been consistent. Furthermore, there is a lack of neurophysiological evidence about WM function in patients with BPD. The goal of this study was to examine WM function in patients with BPD by using event-related potentials (ERPs). An additional goal was to explore whether characteristics of BPD (i.e., impulsiveness and emotional instability) are associated with WM impairment. A modified version of the N-back task (0- and 2-back) was used to measure WM. ERPs were recorded in 22 BPD patients and 21 age-, handedness-, and sex-matched healthy controls (HCs) while they performed the WM task. The results revealed that there were no significant group differences for behavioral variables (reaction time and accuracy rate) or for latencies and amplitudes of P1 and N1 (all p > 0.05). BPD patients had lower P3 amplitudes and longer N2 latencies than HC, independent of WM load (low load: 0-back; high load: 2-back). Impulsiveness was not correlated with N2 latency or P3 amplitude, and no correlations were found between N2 latency or P3 amplitude and affect intensity scores in any WM load (all p > 0.05). In conclusion, the lower P3 amplitudes and longer N2 latencies in BPD patients suggested that they might have some dysfunction of neural activities in sub-processing in WM, while impulsiveness and negative affect might not have a close relationship with these deficits.

Impaired working memory and normal sustained attention in borderline personality disorder

Lazzaretti M, Morandotti N, Sala M, Isola M, Frangou S, De Vidovich G, Marraffini E, Gambini F, Barale F, Zappoli F, Caverzasi E, Brambilla P. Impaired working memory and normal sustained attention in borderline personality disorder.

Objective: Although reports in the literature describe deficits in working memory in borderline personality disorder (BPD), the evidence is limited and inconsistent. The aim of this study was to evaluate further this cognitive dimension and its clinical correlates in BPD.

Method: We compared the performance of 15 BPD patients to 1:1 matched healthy controls on verbal working memory as determined by the sequential letter N-back test and sustained attention as measured using the continuous performance test (CPT).

Results: BPD patients performed significantly worse on the N-back test compared to healthy controls (p < 0.05), but not on the CPT. The N-back deficit was more pronounced and significant in the 3-back condition and inversely correlated with impulsivity.

Conclusions: These results suggest the presence of working memory deficits in BPD that may be linked to greater impulsivity and sustained by impairment in the dorsolateral prefrontal cortex.

Borderline personality disorder and psychosis: a review

Early views of borderline personality disorder (BPD) were based on the idea that patients with this pathology were "on the border" of psychosis. However, more recent studies have not supported this view, although they have found evidence of a malevolent interpersonal evaluation and a significant proportion of BPD patients showing psychotic symptoms. For example, in one study, 24% of BPD patients reported severe psychotic symptoms and about 75% had dissociative experiences and paranoid ideation. Thus, we start with an overview regarding the prevalence of psychotic symptoms in BPD patients. Furthermore, we report findings of studies investigating the role of comorbidity (eg, post-traumatic stress disorder) in the severity and frequency of psychotic symptoms in BPD patients. We then present results of genetic and neurobiological studies comparing BPD patients with patients with schizophrenia or nonschizophrenic psychotic disorders. In conclusion, this review reveals that psychotic symptoms in BPD patients may not predict the development of a psychotic disorder but are often permanent and severe and need careful consideration by clinicians. Therefore, adequate diagnosis and treatment of psychotic symptoms in BPD patients is emphasized.

Borderline personality disorder: hypothalamus pituitary adrenal axis and findings from neuroimaging studies

Borderline personality disorder (BPD) is a complex and serious mental disorder that is commonly seen psychiatric practice. Although stress, especially early life stress, seems to be associated with the development of the disorder, there has been far less research on the function of the hypothalamic-pituitary-adrenal (HPA) axis in BPD, compared to other psychiatric disorders, such as major depressive disorder and post-traumatic stress disorder. Stress has been suggested to exert damaging effects on the brain, particularly the hippocampus; therefore, neuroimaging studies yield important insight into the neurobiology of BPD. This article reviews research on the HPA axis and neuroimaging studies in BPD and aims to integrate these findings.

Neural correlates of impaired emotional discrimination in borderline personality disorder: an fMRI study

A common approach to study neuronal aspects of emotional reactivity of borderline personality disorder (BPD) is to study the brain response to emotional faces with functional magnetic resonance imaging (fMRI). 10 BPD patients and 10 matched controls were submitted to an emotional discrimination task in which subjects had to identify an emotional face from a neutral face while fMRI data was acquired. BPD patients made more mistakes than controls in the discrimination task when negative faces were involved. The emotional discrimination task activated brain areas that are known to participate in processing of emotional faces (fusiform gyrus, insula and amygdala) regardless of the psychiatric condition. Additionally, BPD showed higher activation than controls in the middle and inferior temporal cortical areas, brain areas that participate in the processing of face features that carry emotional value. Furthermore, activity at this site correlated with impulsivity score in the Zuckerman-Kuhlman Personality Questionnaire. Our findings may be related to cognitive impairment that may be characteristic of the disorder.

The role of functional neuroimaging in exploring the overlap between borderline personality disorder and bipolar disorder

In light of the recent discussions of possible diagnostic overlap between borderline personality disorder and bipolar disorder, we explored the neuroimaging literature to determine if findings from this literature might illuminate the issue of overlap between the two diagnoses. We looked at studies of executive functions and emotion-related functions. Although similar brain areas have been explored in each population and several findings are suggestive of overlap, as well as differences between the two disorders, conclusions are limited because of the lack of studies that employed the exact same paradigm in the two patient groups. The authors suggest methods for conducting future neuroimaging research that may better clarify some of these issues of possible diagnostic overlap.

Advances in crisis management of the suicidal patient: perspectives from patients

This paper discusses crisis intervention with the suicidal client from the perspective of two clients who discuss both the strengths and challenges they have encountered while in crisis. The paper then discusses a model for understanding a suicidal crisis and a template for intervention.

The psychodynamics of borderline personality disorder: a view from developmental psychopathology

This article provides a contemporary view of the psychodynamics of borderline personality disorder (BPD) from a developmental psychopathology perspective. We first briefly describe the evolution of the borderline construct in psychoanalysis and psychiatry. Then we provide clinically and empirically informed model of domains of personality function and dysfunction that provides a roadmap for thinking about personality pathology from a developmental psychopathology standpoint and examine the nature and phenomenology of BPD in terms of these domains of functioning. Next, we describe prominent dynamic theories of etiology of BPD and examine these in relation to the available research. Finally, we describe psychodynamic conceptions of treatment and the way BPD phenomena manifest in treatment, followed again by consideration of relevant research, particularly on transference-countertransference constellations empirically identified in the treatment of patients with BPD.

Neuropsychological function in bulimia with comorbid borderline personality disorder and depression

BACKGROUND

In bulimia nervosa (BN), borderline personality disorder (BPD) and major depression (MDD) are frequently comorbid conditions. Executive function has been found to be impaired in BPD and MDD, but the impact of comorbidity on neuropsychological function has rarely been investigated.

OBJECTIVE

To investigate neuropsychological function in BN with a focus on comorbid BPD and MDD.

METHODS

One hundred forty-four medication-free female patients entering a study of psychological treatments for BN performed a brief battery of neuropsychological tests. Comorbid MDD and BPD were systematically identified using standard interviews. Neuropsychological test results were compared.

RESULTS

Forty-one subjects had comorbid BPD and 35 had comorbid MDD, while 15 had both. There was no effect of comorbid MDD, but there was a significant effect of BPD and a significant interaction between the diagnosis of MDD and BPD on executive tasks (trail making and Stroop). Thus, compared with subjects without BPD, subjects with BPD performed significantly worse on tests of executive function, while the group with both comorbidities performed even worse.

CONCLUSIONS

There appears to be an additive effect of BPD and MDD resulting in impaired executive neuropsychological function. Future studies on either disorder and on BN should examine and account for the effect of comorbidity.

Cognitive functions related to interpersonal problem-solving skills in schizophrenic patients compared with healthy subjects

Subjects with schizophrenia have cognitive alterations. The functional consequences of these deficits need to be fully determined, in order to implement more effective rehabilitation programs for patients with schizophrenia. This research explores the relationships between cognitive functioning and social problem-solving skills in a group of 20 chronic schizophrenic patients compared with those found in a group of 20 healthy subjects. The following cognitive domains were evaluated: verbal memory (Rey Auditory-Verbal Test; RAVLT), visuo-spatial organization and visuo-spatial memory (Rey-Osterrieth complex figure test; RF), executive functioning (semantic verbal fluency test; VF, design fluency task; DF and Wisconsin Card Sorting Test; WCST), attention (d 2 cancellation test) and general intellectual ability (Standard Progressive Matrices of Raven; SPM). Social problem-solving skills were assessed with a video-based test; the Assessment of Interpersonal Problem-Solving Skills (AIPSS). As a group, patients performed significantly worse than control subjects on every cognitive variable and on AIPSS receiving, processing and sending constructs. Among schizophrenic patients, correlations between AIPSS constructs and neuropsychological tests were observed for VF, DF, d2 and SPM whilst these associations were not replicated in healthy subjects. However, in the whole sample, after adjusting for age, gender and education, SPM displayed significant associations with all three AIPSS constructs. Moreover, after taking SPM into account, neither diagnostic groups (patients versus control) nor cognitive variables, except d2, provided an additional contribution to AIPSS performance. Cognitive impaired performances, mainly frontal, have a deleterious effect on social problem-solving skills in the schizophrenic group. It is suggested that alterations in social problem-solving skills may reflect social anxiety and/or " theory of mind " impairment. These factors may explain the lack of association among healthy subjects. The results support the inclusion of cognitive remediation programs designed to enhance social skills for patients where a cognitive deficit is clearly ascertained.

The neuropsychological correlates of borderline personality disorder and suicidal behaviour

OBJECTIVE

In subjects with borderline personality disorder (BPD), compared with subjects who attempted suicide, to review neuropsychological (NP) function that may predispose to suicidal behaviour along a continuum of high and low lethality.

METHOD

We undertook electronic searches of MEDLINE, PsycINFO, EMBASE, Biosos Reviews, and Cinhal. The searches were restricted to English-language publications from 1985 onward. The search terms borderline personality disorder, suicide, suicide attempt, self-harm behaviour, neuropsychological, executive function (EF), neurocognitive, and neuropsychological function produced 29 neuropsychology studies involving BPD and 7 neuropsychology studies of suicide attempters, regardless of psychiatric diagnosis.

RESULTS

Of the BPD studies, 83% found NP impairment in one or more cognitive domains, irrespective of depression, involving specific or generalized deficits linked to the dorsolateral prefrontal and orbitofrontal regions. The functions most frequently reported (in 71% to 86% of BPD studies) are response-inhibitory processes affecting executive function performance that requires speeded attention and visuomotor skills. Decision making and visual memory impairment are also most frequently affected; 60% to 67% of BPD studies report attentional impairment, verbal memory impairment, and visuospatial organizational impairment. Least affected processes in BPD appear to involve spatial working memory, planning, and possibly, IQ. The similarities in NP deficits found in BPD and suicide-attempt studies involve decision making and Trails performances. BPD studies, however, reflect more frequent impairment on the Stroop Test and Wisconsin Card Sort Test performance than the suicide-attempt studies, whereas verbal fluency appears to be more frequently impaired in those attempting suicide.

CONCLUSIONS

Impaired EF and disinhibitory processes, as indicated by verbal fluency, Trails, and Stroop performance, primarily associated with dorsolateral prefrontal cortical regions may represent a dominant executive pathway to suicide attempt. A primary motivational inhibitory pathway involving conflictual, affective, and reflexive decision-making processes associated with orbitofrontal brain regions, in combination with significant cognitive rigidity, may influence the repetitive expression of self-harm or low-lethality suicidal behaviour. The hypothesis of a specific trait-like cognitive vulnerability for suicidal behaviour involving dysregulatory, disinhibiting pathways awaits confirmation.

The development of impulsivity and suicidality in borderline personality disorder

Borderline personality disorder (BPD) is characterized by a broad pattern of impulsivity and suicidality. BPD usually begins in adolescence; the full clinical picture of the disorder is associated with developmental increases in impulsivity. However, BPD also has childhood precursors. The developmental pathways are similar to those found in other impulsive spectrum disorders, but children who later develop BPD probably have both externalizing and internalizing symptoms. Research in this area has made use of retrospective data from adults, prospective data from community studies, follow-up studies from children at risk, as well as research on "borderline pathology of childhood" (a condition with symptoms similar to adult BPD). Existing evidence suggests that both temperamental and environmental risk factors play a role in the development of the behavioral patterns associated with the disorder. These pathways also help account for the life course and outcome of BPD in adulthood.

Disinhibition and borderline personality disorder

We review different conceptions of inhibitory control that may be relevant to the regulatory problems featured in borderline personality disorder (BPD). These conceptions have often been framed with regard to personality traits of inhibitory control, but can also be related to cognitive measures of response suppression as well as affect regulation. Reactive behavioral inhibition is relatively unstudied in relation to BPD. A substantial amount of literature links executive function problems with BPD, but that literature has not isolated executive response inhibition nor been controlled for other personality disorder symptoms of antisociality, attention-deficit/hyperactivity disorder (ADHD), or depression, anxiety, or posttraumatic symptoms. We therefore conducted a study of this question looking at BPD symptoms in an adult sample with a small number of BPD subjects and other disorders. Results indicated that symptoms of BPD were correlated with response inhibition (measured by stop signal reaction time) even after controlling for the overlap of stop inhibition with ADHD, antisociality, and other Axis II disorder symptoms. We conclude by hypothesizing discrete developmental routes to BPD, based on different mechanism breakdowns, which would be amenable to empirical investigation at the cognitive or trait level of analysis.

An investigation of organic factors in the neuropsychological functioning of patients with borderline personality disorder

The hypothesis to be tested in this study was that the cognitive deficits that have been documented in patients with Borderline Personality Disorder (BPD) are largely the consequence of organic insult, either developmental or acquired. Using a cross-sectional design, 80 subjects (males and females) who met the criteria for BPD participated in the study. They completed a battery of neuropsychological tests and a comprehensive interview assessing organic status as well as measures of the potentially confounding factors of current levels of depression and anxiety. It was expected that BPD-patients with a probable history of organic insult would perform significantly worse than would BPD patients without such a history. Analyses of the results provided partial support for the hypothesis. Subjects with both BPD and a history of organic insult were significantly more impaired on several measures including measures of attention than were BPD only subjects. The results suggested that the impaired cognitive performance of persons diagnosed with BPD may, in part, be attributed to organic factors.

Impaired spatial working memory in adults with attention-deficit/hyperactivity disorder: comparisons with performance in adults with borderline personality disorder and in control subjects

OBJECTIVE

This study investigated a previous claim that working memory may be 'particularly impaired' in adult attention-deficit/hyperactivity disorder (ADHD), compared with other psychiatric disorders which affect frontal lobe-mediated executive functions.

METHOD

Performance on spatial working memory (SWM) and two additional tasks were investigated for adult patients selected on the basis of DSM-IV ADHD (n = 19), adult patients selected on the basis of borderline personality disorder (BPD) (n = 19), and non-clinical control subjects (n = 19). Groups were matched for age, verbal IQ and gender.

RESULTS

Analysis of variance showed that the ADHD group had significant impairment of SWM performance relative to the non-clinical controls. Although there was a trend towards impairment in the BPD group relative to non-clinical controls, this did not reach significance.

CONCLUSION

The results are consistent with the claim that aspects of working memory are 'particularly impaired' in adult ADHD. Also, the BPD group had a longer deliberation time for one of the additional tasks, compared with the ADHD group, which indicated that the patient groups may have different patterns of neuropsychological impairments.

Dopamine dysfunction in borderline personality disorder: a hypothesis

Research on the biological basis of borderline personality disorder (BPD) has focused primarily on the serotonin model of impulsive aggression. However, there is evidence that dopamine (DA) dysfunction may also be associated with BPD. Pertinent research and review articles, identified by Medline searches of relevant topics, books, references from bibliographies, and conference proceedings from 1975 to 2003, were reviewed. Evidence of DA dysfunction in BPD derives from the efficacy of traditional and atypical antipsychotic agents in BPD, and from provocative challenges with amphetamine and methylphenidate of subjects with the disorder. In addition, human and animal studies indicate that DA activity plays an important role in emotion information processing, impulse control, and cognition. The results of this review suggest that DA dysfunction is associated with three dimensions of BPD, that is, emotional dysregulation, impulsivity, and cognitive-perceptual impairment. The main limitation of this hypothesis is that the evidence reviewed is circumstantial. There is no study that directly demonstrates DA dysfunction in BPD. In addition, the therapeutic effects of antipsychotic agents observed in BPD may be mediated by non-DA mechanisms of action. If the stated hypothesis is correct, DA dysfunction in BPD may result from genetic, developmental, or environmental factors directly affecting specific DA pathways. Alternatively, DA dysfunction in BPD may be a compensatory response to alterations in the primary neural systems that control emotion, impulse control, and cognition, and that are mediated by the brain's main neurotransmitters, glutamate, and GABA, or in one or more other neuromodulatory pathways such as serotonin, acetylcholine, and norepinephrine.

Impulsivity in patients with borderline personality disorder

This study investigated features of impulsivity in patients with borderline personality disorder (BPD) using the self-report Attention-Deficit Scales for Adults (ADSA) and computer-administered neurocognitive tasks. Forty-one patients with DSM-III-R BPD and 35 nonclinical control subjects were assessed by the ADSA, the National Adult Reading Test, and two computerized tasks mediated by the frontal lobes. Mean scores for seven ADSA scales (six of which relate to aspects of impulsivity) were significantly higher in the patient group compared with the control group. Also, the ADSA ratings for impaired coordination were increased in the BPD patients. The findings indicate that a range of aspects of impulsivity, as well as impaired coordination, are associated with patients selected on the basis of BPD. Also, in the patient group, but not in the control group, associations of the neurocognitive tasks indicated that, first, performance on a planning task related to dorsolateral frontal lobe functioning is correlated with aspects of impulsivity reflected by ADSA scale III ratings (involving disorganisation and lack of perseverance) and, second, performance on a decision-making task related to orbitofrontal functioning is correlated with ratings of impaired coordination. Further work is needed to establish the specificity of the findings.

Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings

This study aims to determine whether specific neuropsychological performance impairments in borderline patients can be objectified and whether these findings indicate frontal dysfunctions. Twenty-three patients with borderline personality disorder and 23 normal controls were examined using a neuropsychological test battery to assess intelligence, attentiveness, proneness to interference, learning and memory, as well as planning and problem solving. All subjects filled out standardized questionnaires to assess aggressiveness and impulsiveness in the context of these cognitive performance areas. The neuropsychological test results of the borderline patients were comparable to those of the controls. Although there were no indications of frontal dysfunction of cognitive information processing, inverse correlations were found between the severity of borderline-related personality traits regarding impulsiveness and various areas of cognitive performance. Borderline personality patients show no indications of frontal cognitive dysfunction. Further research is needed to clarify the relationship between impulsiveness and cognitive information processing in borderline personality disorder, including a dimensional approach to personality and personality disorder.

Emotional processing in personality disorder

In the field of personality disorders, borderline and antisocial types are associated with emotional dysfunctioning. In borderline personality disorder (BPD), the hypothesis of emotional hyperresponsiveness can be supported by several experimental studies that suggest highly intensive and slowly subsiding emotions to primed and non-primed stimuli, as well as by data showing biased information, which processes in the context of emotions. In addition, the first neuroimaging data suggest that limbic hypersensitivity is a neurofunctional correlate of emotional vulnerability in BPD. In antisocial psychopathic personality disorder, data confirm the theory of emotional detachment, subsuming fearlessness, and, beyond that, emotional indifference to appetitive stimuli. Because of a fundamental dysfunction in the amygdala, psychopathic individuals appear to use alternative cognitive operations of processing affective material to compensate for the absence of appropriate limbic input, which normally provides prompt information about the affective characteristics of stimuli.

The role of the parietal lobe in borderline personality disorder

Many patients with a diagnosis of borderline personality disorder describe multi-modal hallucinations. A likely cortical origin for multi-modal hallucinations is the inferior parietal lobule. Neuropsychological testing of borderline personality disorder reveals deficits of visuospatial capacity; a function which is also localised to the inferior parietal lobule. It is hypothesised that this brain area is likely to be dysfunctional in those patients with borderline personality disorder who have multi-modal hallucinations. A deficit in the inferior parietal lobe could plausibly explain a number of other clinical features; the gender dimorphism of this disorder, the lack of expressive gesture and the specific response to clozapine. More speculatively; the increased concern over this disorder over the past 40 years could result from the normal population showing an increase in functional ability in the parietal lobe, leaving patients with parietal deficits relatively more disabled.

A Description of a Psychosocial/Psychoeducational Intervention for Persons with Recurrent Suicide Attempts

Summary: This paper gives a description of a psychosocial/psychoeducational group intervention for individuals with a history of recurrent suicide attempts. The intervention was conceived to reduce the risk of future suicidal behavior and to modify the client's psychopathology. Three features are felt to make the intervention unique from others described in the literature. First, the intervention is targeted at both men and women from an inner-city population who are often underhoused, underemployed, and undereducated. 24 of 48 clients (50%) lived alone, and 24 of those (92%) were living in subsidized housing; 33% lived in supportive housing, and one lived on the street at the time of assessment. 48% had a high-school education or less. Second, the principles of our approach stressed client validation and participation in the development and delivery of the therapy. Our frame of reference was to name ourselves as professionals with a set of skills and access to some kinds of information and clients as the experts on the experience in their lives. Third, the group content incorporated a multimodal approach to meet the varied needs of the clients. Future reports will discuss the empirical evaluation of this intervention; however, the development of specific, targeted approaches for unique individuals with recurrent suicide attempts is clearly needed.

Um caso de transtorno de personalidade borderline atendido em psicoterapia dinâmica breve

Trata-se de um caso de Transtorno de Personalidade Borderline, encaminhado para a área de Psicoterapia Dinâmica Breve (PDB) do Centro de Psicologia Aplicada da UNESP - Bauru/SP. O foco delimitado consistiu em trabalhar as características depressivas do paciente, buscando ajudá-lo a elaborar o luto pela perda de sua mãe. A análise deste caso veio corroborar a hipótese de que pacientes com transtorno de personalidade borderline também podem ser beneficiados com a PDB. A peculiaridade desta modalidade de atendimento está relacionada ao estabelecimento de objetivos terapêuticos (foco) condizentes com as reais possibilidades e limites de cada paciente.