Neuropsychological functioning in patients with borderline personality disorder

Neuropsychological Functioning in Patientswith Borderline Personality Disorder

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June Sprock, Theresa J. Rader,Jeffrey P. Kendall, and Carol Y. YoderIndiana State University

Although results have been variable, studies suggest that individuals withborderline personality disorder (BPD) exhibit cognitive deficits suggestiveof frontal- and temporal-lobe dysfunction. Patients diagnosed with BPD(n 5 18) using two structured interviews, and who were carefully screenedfor neurological and substance-use disorders, were compared to depressedpatients (n 5 18) and a nonpsychiatric control group (n 5 18) on a seriesof neuropsychological tasks. The role of emotion on cognitive functioningwas assessed by including emotional stimuli and interference on severalof the tasks. Little support was found for the neurobehavioral hypothesisof BPD. The BPD group performance did not differ from the normal groupon most tasks of executive functioning or memory, and the introduction ofemotional stimuli did not impair performance. The depressed group per-formed less effectively than the other groups. Reasons for variable find-ings and factors affecting the cognitive functioning of patients with BPDare discussed. There may be considerable heterogeneity in the cognitivefunctioning of BPD patients, with those exhibiting significant cognitivedeficits comprising only a subgroup. © 2000 John Wiley & Sons, Inc. JClin Psychol 56: 1587–1600, 2000.

Keywords: borderline personality disorder; neuropsychology; cognitivefunctioning

Introduction

It has been suggested recently that individuals with borderline personality disorder (BPD)demonstrate difficulties with emotional and behavioral regulation due to neurologicaldysfunction. Interpersonal problems result from impulsivity, deficits in attention, mem-ory, and processing complex information. Physiological studies using EEG are not entirelyconsistent but provide some evidence that at least a subset of individuals with BPD have

Theresa Rader is now at Bloomington Hospital, Bloomington, IN, and Jeffrey Kendall is at the North Missis-sippi Medical Center, Tupelo, MS.Correspondence concerning this article should be addressed to: June Sprock, Psychology Department, IndianaState University, Terre Haute, IN 47809.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 56(12), 1587–1600 (2000)© 2000 John Wiley & Sons, Inc.

cerebral dysfunction that may serve as a vulnerability to borderline pathology, even whenthose with a history of neurological insult have been excluded (Ogiso et al., 1993). Addi-tionally, several studies have demonstrated that, compared to normals, individuals withBPD show deficits on neuropsychological tests suggestive of temporal- and/or frontal-lobe dysfunction.

The research, however, is limited, and specific findings have been variable. Whilesome studies have found that patients with BPD have deficits on tasks such as copy andrecall of a complex figure, story recall, the Stroop Color–Word Test (Stroop, 1935) andthe Wechsler Adult Intelligence Scale (WAIS-R; Wechsler, 1981), others have failed tofind significant decrements in performance compared to normals on some of these tasks(Carpenter, Gold, & Fenton, 1993; Judd & Ruff, 1993; O’Leary, Brouwers, Gardner, &Cowdry, 1991; Swirsky-Sacchetti et al., 1993; van Reekum, Conway, Gansler, White, &Bachman, 1993). Reasons for the inconsistencies include small sample sizes (generallyless than 20 patients) and differing samples (e.g., inpatients vs. outpatients, males vs.females, medicated vs. medication free), selection criteria, and diagnostic assessments.

The present study compared the cognitive functioning of patients with BPD todepressed patients in order to control for generalized effects of psychopathology. Patientswith depressive disorders represent an ideal control group due to the frequent co-occurrenceof depression with BPD (Gunderson & Phillips, 1991). A second control group consistedof individuals without a history of mental disorder. Patients were recruited from inpatientand outpatient facilities in central Indiana via referrals from their therapists. All weretested as outpatients and remained on their treatment regimen. Like most of the previousresearch, all participants were women since both BPD and depression are three timesmore common in women (Sprock & Yoder, 1997; Widiger & Weissman, 1991).

All participants were administered two structured interviews to diagnose axis I and IImental disorders and a health questionnaire to screen for substance use, psychotic, neuro-logical, or sensory disorders that would affect performance. Due to time considerations,computerized structured interviews were used for screening, followed by face-to-faceinterviews. After meeting selection criteria, participants were administered a battery ofneuropsychological tests to assess cognitive functioning. Because not all participantscompleted all parts of the battery, results are presented separately for tasks that assessmotor and executive functioning, and for memory tasks.

Part I

Preliminary work suggests that at least a portion of patients with BPD demonstrate evi-dence of frontal-lobe system dysfunction (Swirsky-Sacchetti et al., 1993; van Reekumet al., 1993). The focus of Part I of this study was on tasks sensitive to deficits in frontal-lobe functioning, including motor performance, visuomotor integration, and inhibition ofautomatic verbal responses.

In addition, two experimental versions of the Stroop Color–Word Test (Stroop, 1935)were constructed to examine O’Leary et al.’s (1991) hypothesis that the observed deficitsmight be exacerbated by affect-laden material. Stroop performance is affected negativelywhen psychopathology-specific words are substituted for the neutral words in the task(Williams, Mathews, & MacLeod, 1996). For example, depressed patients exhibited apoorer performance with depression-related compared to neutral or euphoric words (Bentall& Thompson, 1990). In this study, anger and sadness words were used because of theirrelevance to the symptomatology of BPD and depression.

It was hypothesized that patients with BPD would demonstrate poorer performance(time and errors) than the normal group and poorer quality of performance than the

1588 Journal of Clinical Psychology, December 2000

depressed patients, who would perform tasks at a slower rate than the normal group. Bothtypes of emotional stimuli were expected to affect the performance of BPD patients,while depressed patients were expected to show a decrement in performance for sadnesswords.

Method

Participants

The participants were 18 women with BPD, 17 women with a depressive disorder (cur-rent major depressive episode or dysthymia), and 16 women with no mental disorder. Allwere Caucasian but one, reflecting the demographic characteristics of the region. Despiteefforts to match the groups, BPD participants were older than the normal group andperformed better than the depressive group on Block Design (see Table 1). There were nosignificant differences between the patient groups in level of depression or any of thetreatment variables.

Table 1Demographic Characteristics of the Participants in Parts I and II:Means and Standard Deviations

Participants

Variable BPD Depressed Normal

Part IAgea 37.6 (5.3) 32.7 (9.7) 30.3 (5.9)Education 13.8 (2.3) 15.8 (5.5) 15.5 (1.7)Estimated IQb 103.9 (7.0) 100.8 (9.6) 102.7 (9.6)

Vocabulary 9.9 (2.3) 10.1 (2.3) 10.3 (1.9)Block Design 11.5 (1.8) 9.8 (1.5) 10.8 (2.3)

Depressionc 28.2 (13.5) 31.7 (9.7) 5.6 (5.2)Inpt Hospd 1.7 (2.0) 1.7 (2.6) 0.0 (0.0)No. Inpt Dayse 21.9 (43.1) 32.5 (54.7) 0.0 (0.0)No. Outpt Txf 2.0 (1.3) 2.3 (1.4) 0.0 (0.0)

Part IIAge 32.0 (9.8) 36.6 (5.6) 32.4 (7.2)Education 13.7 (2.3) 14.1 (1.9) 15.3 (1.9)Estimated IQb 103.2 (6.5) 100.2 (8.2) 106.0 (8.3)Depressionc 26.2 (15.2) 31.4 (10.0) 5.6 (5.1)Inpt Hospd 1.6 (2.0) 1.7 (2.5) 0.0 (0.0)No. Inpt Dayse 21.3 (43.4) 30.3 (53.2) 0.0 (0.0)No. Outpt Txf 2.1 (1.3) 2.8 (2.2) 0.0 (0.0)

aAge was significantly different for part I,F(2,48)5 4.27,p 5 .019, with participants in the BPDgroup significantly older than those in the normal group,t(34)5 3.73,p 5 .001.bEstimated IQ based on WAIS-R Vocabulary and Block Design. While there was not a significantdifference between groups on estimated intelligence, there was a difference on Block Design forPart I, F(2,48)5 3.75,p 5 .031, with the BPD group performing significantly better than thedepressive group,t(35)5 3.09,p 5 .004.cScores from the CES-D:#15.55 no depression, 16–20.55 mild depression, 21–30.55 mod-erate depression, 31 and higher5 severe depression (Barnes & Prosen, 1984).dLifetime number of psychiatric hospitalizationseTotal number of inpatient daysfTotal number of courses of outpatient treatment

Borderline Personality Disorder 1589

Measures

Structured Interviews.Three structured interviews based on the Structured ClincialInterview for DSM-III-R (SCID-II; Spitzer, Williams, Gibbon, & First, 1987) were usedto confirm clinical diagnoses and diagnose DSM-III-R (American Psychiatric Associa-tion, 1987) disorders. The MiniSCID and AutoSCID-II (First, Gibbon, Williams, & Spitzer,1994) are interactive computerized versions of the SCID-II that screen for axis I and axisII disorders, respectively. The AutoSCID-II contains an interactive program called theSCID-II Personality Questionnaire (SCID-II PQ), which screens for axis II personalitydisorders. The interviewer then uses the more comprehensive SCID-II questions to probeall items answered positively by the respondent on the computer version. The authorspurport that reliability and validity of the computer versions is equivalent to the SCID-II.The computerized interviews were selected for this study to save time compared to face-to-face interviews. At the time these data were collected, structured interviews for DSM-IV(American Psychiatric Association, 1994) diagnoses were not available. However, giventhe few changes to the criteria for BPD and the depressive disorders, all participantswould meet DSM-IV criteria for the target diagnoses.

Demographic/Health Questionnaire.A demographic questionnaire also screened formedical, neurological, and sensory disorders and collected information on current andpast psychiatric/psychological treatment (medications, hospitalizations, psychotherapy).

Wechsler Adult Intelligence Scale-Revised (WAIS-R).WAIS-R (Wechsler, 1981) Vocab-ulary and Block Design was used to estimate intelligence (Sattler, 1992, p.851). Esti-mated IQ based on this short form correlates up to .91 with Full Scale IQ (Sattler, 1990).

Center for Epidemiological Studies Depression Scale (CES-D).The CES-D (Radloff,1977) is a self-report measure of the frequency of cognitive, affective, and behavioralsymptoms of depression during the prior week. Radloff demonstrated good test–retestreliability for the CES-D.

Trail-Making Test, Part B.The Trail-Making Test, Part B (Trails B; Army IndividualTest Battery, 1944) requires connecting a series of circles in numerical and alphabeticalorder, alternating between numbers and letters, and is considered a measure of visualscanning/search, fine motor control, cognitive flexibility, and ability to maintain cogni-tive set. The score on the test is completion time. Trails B has good test–retest reliabilityand has been shown to be useful in differentiating between normal and organically impairedsubjects (Lezak, 1983).

Rey–Osterreith Complex Figure Test.The Complex Figure Test, developed by Rey(1941) and elaborated by Osterreith (1944), includes a copy phase followed by immedi-ate recall and delayed (20 min) recall. The test requires perceptual organization, visuo-motor integration, planning, incidental learning, and nonverbal visual memory. Qualityof the reproduction was assessed using Lezak’s (1983) scoring system, which has excel-lent interrater reliability (Spreen & Strauss, 1991). Time was measured for the copy phaseonly.

Porteus Mazes.The Porteus Mazes (Porteus, 1955, 1959, 1965) test consists of threeseries of mazes ordered in increasing difficulty; the Adult maze from each of the serieswas used. Examinees are required to trace their way through the maze without lifting


their pencil. Successful performance requires visual scanning, planning, and visuomotorskills. The mazes are scored for errors, but completion time also was used since theperformance of normal adults may reach a ceiling.

Stroop Color-Word Test.The Stroop Test (Stroop, 1935) was used to assess the abil-ity to shift and maintain cognitive sets and to inhibit competing responses. In Condition 1(color naming), examinees name the ink color of a series of dots arranged in rows andcolumns. In Condition 2 (color-neutral words), examinees name the ink color of a seriesof words in the same format. Condition 3 (color-color words) is the most demandingbecause the words are the names of colors; examinees must name the ink color and ignorethe content of the word, which is the name of another color. Scoring is based on numberof errors and time to read the list for each condition. Due to time considerations, theGolden (1976) short version of the test was used.

Two experimental versions (Condition 4—anger words, Condition 5—sadness words)of the Stroop were developed to examine the effects of emotional interference. The wordswere selected from Hamlet and Egeth (1989) to elicit common emotional themes andissues relevant to BPD and depression. In addition to time and errors, change scores (i.e.,the difference in performance compared to the neutral word condition) were calculatedfor each of the emotional interference conditions.

Procedures

Participants were recruited from inpatient and outpatient mental health facilities andthrough advertisements (normal group). All were screened with the structured interviewsto determine axis I and axis II diagnoses. Exclusion criteria included substance use,psychotic, neurological, sensory, and motor disorders that could impair performance. Anage limit of 45 was used due to the effects of age on the cognitive tasks. Participants inthe depressed group could not meet criteria for BPD or any other personality disorderwhile those in the normal group could not meet criteria for any axis I or axis II mentaldisorder.

One of two advanced doctoral students in clinical psychology who had courseworkand experience in neuropsychological assessment administered the cognitive tasks tar-geting frontal-lobe functioning as part of a larger battery. Tests requiring subjective judg-ments in scoring were independently scored by two raters, blind to the hypotheses of thestudy, to assess interrater reliability. Pearson correlations revealed good-to-excellent agree-ment in scoring the WAIS-R Vocabulary subtest (r 5 .98), Rey–Osterreith ComplexFigure (copy:r 5 .88, immediate recall:r 5 .95, delayed recall:r 5 .93), and the PorteusMazes (Maze 1:r 5 .88, Maze 2:r 5 .89, Maze 3:r 5 .89). Scoring discrepancies thatexceeded a predetermined criterion were resolved by an experienced clinician.

Results

The data were analyzed using analysis of the covariance (ANCOVA); age and BlockDesign were used as covariates since these variables differed between the groups andboth were significantly related to performance on several of the cognitive tasks. The onlygroup difference was for time on Stroop Condition 2 (neutral words); both patient groupstook significantly longer than the nonclinical group to complete the task (see Table 2). Itshould be noted that the depressed patients were significantly slower than the normalgroup for Trails B and Stroop Condition 3, and they made more errors than both other


groups on Stroop Condition 3 using ANOVA (allp , .05), but these differences were notsignificant using the covariates.

ANCOVA showed that use of emotional stimuli on the Stroop (Conditions 4 and 5)had little differential effect on performance of the BPD or other groups. Additionally,analysis of variance (ANOVA) revealed no significant differences between the groups intime-change scores for Condition 4 (sadness words),F(2,48)5 .49,p 5 .616, or Condi-tion 5 (anger words),F(2,48)5 .54, p 5 .688. Likewise, there were no significant dif-ferences between the groups on error-change scores for sadness words,F(2,48)5 .87,p 5 .427, or anger words,F(2,48)5 1.31,p 5 .280.

The effect of examiner (two graduate students) and site (six mental health facilities)was examined using two MANOVAs, one for the time variables and one for the quality(error) measures. Results suggested no differences in the time measures,F(1,49)5 .516,

Table 2Part I. Results of ANCOVA (Using Age and Block Design as Covariates)Comparing Performance (Time in Seconds, Quality Scores, Errors)of the Three Groups on the Motor/Executive Functioning Tasks

Participant Groups

Task BPD Depressed Normal F a Differencesa

Trailmaking-Btime 68.22 86.52 62.37 1.26

Rey–Osterreithb

Copy: time 142.11 149.41 121.63 2.51quality 33.39 32.21 34.88 1.64

Immed: quality 21.44 21.15 24.59 2.06Delayed: quality 20.61 20.23 22.72 1.21

Porteus Mazesc

Maze 1: time 61.27 81.11 40.63 1.51errors 3.83 3.94 2.38 1.14

Maze 2: time 98.67 108.12 80.81 .28errors 4.39 4.65 4.81 .32

Maze 3: time 82.17 120.47 84.19 1.54errors 4.56 3.41 2.93 1.03

Stroopd

Cond. 1: time 14.17 14.59 12.17 1.28errors .11 .18 .06 .25

Cond. 2: time 16.50 16.88 13.69 3.34* D . N, B . Nerrors .11 .24 .00 .87

Cond. 3: time 26.28 29.06 21.88 2.58errors .83 2.00 .75 2.79

Cond. 4: time 16.17 16.24 14.44 1.43errors .17 .12 .13 .27

Cond. 5: time 15.94 16.35 14.60 .69errors .06 .06 .00 .71

aLevel of significance: *p , .05. Significant differences between groups (usingt-tests) are designated in the last column.B 5 BPD, D 5 Depressed,N 5 Normal.bTime is recorded for the copy phase only; quality of the reproduction is scored (using Lezak’s system) for all conditionscThe three Adult mazes.dThe first three are the standard Stroop conditions. The two experimental conditions used affective words (condition 45 anger;condition 55 sadness) to test the effect of emotional stimuli on cognitive functioning


p5 .475,or the quality measures,F(1,49)5 2.56,p5 .116, based on examiner, nor weredifferences found based on site for speed,F(5,45)5 .008,p 5 .994 or errors,F(5,45)5.899, p 5 .490. However, individual ANOVAs of each dependent variable revealed asignificant difference based on site for Porteus Maze 3,F(5,45)5 3.17,p 5 .016, and asignificant difference between examiners for time on Stroop Condition 1,F(1,49) 53.15,p 5 .016.

Part II

Initial studies suggest that BPD patients may have a dysfunction in encoding and recal-ling complex visual and verbal information, which can be exacerbated by stress or increasedemotional arousal (Farrell & Shaw, 1994; Sternbach, Judd, Sabo, McGlashan, & Gunderson,1992). Part II focused on memory tasks, including immediate and delayed recall of com-plex visuospatial and verbal material. Both simple and complex stimuli were included,although it was hypothesized that individuals with BPD would have the most difficultyrecalling complex stimuli.

In addition, the effect of affect on memory was examined by manipulating the affec-tive content of a theme story in a free-recall task and by including emotional and neutralinterference in a verbal-learning task. Earlier, Swirsky-Sancchetti et al. (1993) found atrend for BPD patients to be more susceptible to emotional interference than normals ona verbal-learning task. It was anticipated that BPD patients would show impairment onthe recall of positive and negative emotional elements of the story while depressiveswould display deficits, particularly in the recall of positive emotional elements (Bower,1981). On the verbal-learning task, BPD patients were expected to score the lowest, withdeficits most evident under conditions of emotional interference.

Method

Participants

The participants were 18 women with BPD, 18 women with a depressive disorder (cur-rent major depressive episode or dysthymia), and 18 women with no mental disorder. Allwere Caucasian and met the inclusion criteria described above. There were no significantdemographic differences between the groups, and the two patient groups did not differsignificantly on level of depression or any of the treatment variables (see Table 1).

Measures

Structured Interviews and Screening Measures.The three structured interviews (SCID-II; MiniSCID; AutoSCID-II) and the demographic/health questionnaire described abovewere used to assign diagnoses and to screen for exclusion criteria. As in Part I, WAIS-RVocabulary and Block Design was used to estimate IQ, and the CES-D was used to assesslevel of depression.

Rey–Osterreith Complex Figure Test.Immediate and delayed recall of the complexfigure was used to assess nonverbal visual memory (see Part I).

Wechsler Memory Scale—Revised (WMS-R; Wechsler, 1987).The following sub-tests of the WMS-R were administered: Logical Memory (immediate and delayed recall),Figural Memory, and Digit Span. The remaining subtests were not utilized since they lack


sensitivity (Wechsler, 1987) or previous research failed to find impaired performance forBPD patients. The WMS-R has acceptable to good test–retest reliability, and good inter-scorer reliability for Logical Memory (Wechsler, 1987; Woloszyn, Murphy, Wetzel, &Fisher, 1993).

Story Recall Task.A story-recall paradigm was administered to assess memory forcomplex verbal material and the influence of emotional themes on recall. The story wasa narrative about a woman’s day (modified from Breslow, Kocsis, & Blekin, 1981) con-taining ten positive, ten negative and ten neutral elements. Participants simultaneouslyread and listened to an audiotape of the 350-word theme story. Both immediate and15-minute delayed recall (i.e., written responses) were used. Two raters scored each pro-tocol for the total number of idea units recalled and for both theme elements.

Verbal Recall with Interference.A verbal-recall task consisted of two lists of eightneutral words presented on paper. After each list, and again after a one-minute period ofinterference, participants were asked to recall the list of words. Order of lists and inter-ference conditions were counterbalanced to control for learning effects. The neutral inter-ference consisted of serial sevens (i.e., counting backwards from 100 by 7) while theemotional interference required subjects to tell a story about Thematic ApperceptionCard #13 MF, which often evokes stories about rape or murder (Swirsky-Sacchetti et al.,1993).

Procedures

Tests were administered as part of the overall cognitive battery, and emotional conditionswere administered near the end to avoid carry-over effects. Tests requiring subjectivejudgments in scoring were scored independently by two raters, blind to the hypotheses ofthe study, in order to assess interrater reliability. Interscorer reliability coefficients for allWMS-R Logical Memory measures were excellent (Logical Memory I:r 5 .99, LogicalMemory II: r 5 .98). For story recall, interrater reliabilities for both theme elements andidea units were calculated by having the two raters independently score 15 protocols (5cases from each group). Split-half reliabilities ranged from .98 to 1.00 for the recall ofpositive, negative, and neutral elements in both immediate- and delayed-recall conditionsand was .99 for idea units for both the immediate- and delayed-recall conditions.

Results

ANCOVA was used to analyze the results; education and estimated intelligence wereused as covariates due to their significant correlation with the dependent measures. Therewere no significant differences between the groups on the WMS-R or verbal-learningtasks. However, the depressives performed significantly worse than the BPD and thenormal group on most of the measures on the story-recall task. The BPD group performedas well as the normal group on all memory tasks except they recalled fewer neutral wordson delayed-story recall (see Table 3).

The use of emotional interference in the word-recall task did not affect the perfor-mance of the BPD or the other two groups. Also, BPD patients did not recall feweremotional (positive or negative) story themes than the normals. While depressives didrecall fewer positive words than the other groups, they were outperformed in recall ofneutral and negative (delayed recall) words as well.


The effect of examiner on the dependent measures was examined using 2 (examin-er) 3 3 (group) ANCOVAs. The only significant finding was an interaction betweendiagnostic group and examiner for WMS-R Logical Memory II delayed recall (i.e., BPDpatients recalled more idea units for the female examiner while depressed patients recalledmore for the male examiner). While ANCOVAs examining site and group revealed sig-nificant interactions for several of the memory variables, it is important to note that theexaminers did not test an equal number of participants from each site or group, therebylimiting interpretation of these findings.

Table 3Part II. Results of ANCOVA (Using IQ and Education as Covariates)Comparing the Performance of the Three Groups on the Memory Tasks

Participant Groups

Task BPD Depressed Normal F a Differencesa

Wechsler Memory RevisedLogical Memory I 26.7 26.8 26.0 .07Logical Memory II 24.3 21.7 25.6 2.31Figural Memory 7.2 7.1 7.8 1.91Digit Span:

Forward 9.1 9.5 8.3 1.73Backward 7.7 7.3 6.8 2.11Total 16.8 16.8 15.1 2.32

Rey-Osterreithb

Copy:Time 142.8 155.0 132.1 .82Quality 32.3 31.5 33.1 .62

Immediate 20.5 18.5 23.4 3.31*Delayed 19.6 18.3 20.5 .68

Word Recallc

Interference:Emotional 6.5 5.9 7.0 2.60Neutral 6.8 6.4 6.4 .72

Story Recalld

Idea Units:Immediate 48.9 33.5 53.3 7.20** D , B, D , NDelayed 45.6 29.8 46.1 6.89** D , B, D , N

Positive Elements:Immediate .45 .25 .47 11.73*** D , B, D , NDelayed .41 .22 .41 8.46*** D , B, D , N

Negative Elements:Immediate .67 .58 .73 6.06**Delayed .68 .50 .70 4.45* D , B, D , N

Neutral Elements:Immediate .54 .41 .69 3.10 D , NDelayed .42 .41 .65 5.29** B , N, D , N

aLevel of significance: *p , .05; **p , .01; *** p , .001. Significant differences between groups (usingt-tests) are designatedin the last column.B 5 BPD, D 5 Depressed,N 5 Normal.bTime is recorded for the copy phase only; quality of the reproduction is scored (using Lezak’s system) for all conditions.cNumber of words recalled under two interference conditions.dNumber of idea units recalled and percent of elements recalled.


Discussion

Little support was found for the neurobehavioral hypothesis of BPD when there was acareful attempt to diagnose subjects and delineate groups. While the BPD group demon-strated impaired performance compared to normals on two tasks, the findings were notvery compelling. Thus, there was little evidence of frontal- or temporal-lobe dysfunctionin patients with BPD. Additionally, the cognitive functioning of patients with BPD wasnot impaired by emotional stimuli.

These results failed to replicate previous findings with regard to the Stroop (Carpenteret al., 1993; Swirsky-Sacchetti et al., 1993) or Trails B (Carpenter et al., 1993; vanReekum et al., 1993) for BPD. However, copy and recall of the complex figure and storyrecall has varied across studies. Results are consistent with O’Leary et al.’s (1991) failureto find impaired performance on copying the figure, Swirsky-Sacchetti et al.’s lack ofsignificant findings for recall of the figure, and both Swirsky-Sacchetti et al.’s and Carpenteret al.’s findings of normal performance on story recall.

The one expected finding was that depressed patients demonstrated psychomotorslowing compared to the other groups (although only one of the differences was signifi-cant using covariates) and generally poorer performance on story recall. However, theperformance of depressives was not impacted by emotional stimuli.

These results generally are consistent with previous findings of psychomotor slow-ing (e.g., Sabbe, Hulstijn, Van Hoof, & Zitman, 1996) and memory deficits (e.g., Brown,Scott, Bench, & Dolan, 1994; Elliot, Sahakian, McKay, & Herrod, 1996) with majordepressive disorder, which may have a basis in structural or functional brain disorder(Heller & Nitschke, 1997; Rogers, 1993). However, the deficits found in this study werenot as severe or pervasive as those found in other research (i.e., Brown et al., 1994; Elliotet al., 1996), and some studies have failed to find significant psychomotor slowing ormemory impairment (e.g., Miller, Faustman, Moses, & Csernansky, 1991; Purcell, Maruff,Kyrios, & Pantelis, 1997). One reason for the variable results may relate to major depres-sive subtype (Basso & Bornstein, 1999). While this study did not assign major depressivespecifiers, cognitive deficits may be most evident in patients with psychotic (Basso &Bornstein, 1999) or melancholic (Austin et al., 1999) features, and there may be a neuro-biological basis for the increased cognitive deficits in patients with melancholia (Austinet al., 1999; Austin & Mitchell, 1995).

Another explanation for the findings in this study is that the measures lacked sensi-tivity. For example, the failure to replicate findings on the Stroop for depressed patients(i.e., Bentall & Thompson, 1990) may suggest the sadness words were not sufficientlydepressinogenic or the short form of the Stroop was not of adequate length. Also, thesmall sample size may not have allowed for sufficient statistical power if the effect sizewas small (i.e., the performance of the BPD group often fell between that of the depres-sives and the normals).

Another possibility is that there is considerable heterogeneity in the cognitive func-tioning of patients with BPD. Post-hoc analysis suggested that there was a small subset ofBPD patients (n5 6) whose performance on the memory tasks was more poor; however,their performance did not differ significantly from the other BPD patients. Nevertheless,if cognitive functioning is variable, samples smaller in size will be greatly influenced bythe composition of the group. Moreover, small samples limit the ability to detect a sub-group of patients who may have deficits.

Also, if cognitive deficits associated with BPD are due to a brain disorder [i.e., vanReekum et al. (1993) found a history of neurological insult in 88% of BPD patientswhich correlated with BPD symptomatology), those individuals with a neurological basis


for cognitive dysfunction would not have been included in this study due to the exclusioncriteria. Further, BPD patients referred for the study were high functioning (based oneducation, WAIS-R scores) and most were over 30, an age at which there may be adecline in florid symptomatology.

Two important potential confounds are psychotropic medications and comorbid diag-noses. Most BPD participants also had a depressive disorder (13 major depression,5 dysthymia) and were clinically depressed on the CES-D. Most BPD patients (and nearlyall depressed patients) were taking antidepressants. Although findings have been variable(Hartmann, 1988; Heaton & Crowley, 1981), antidepressants may improve cognitive andpsychomotor functioning and may even have a direct effect on BPD symptomatology(Markovitz & Wagner, 1995).

Despite their dual diagnoses, BPD patients generally outperformed the depressivegroup. One explanation is that there is a qualitative difference in the nature of depres-sion experienced by individuals with BPD and those with only depression. Winokur(1991) and Akiskal (1983, 1990) have differentiated between depression associated withpersonality disorders and “pure” depression based on symptoms, family history, course,and treatment response. Borderline depression may be distinct from nonborderline de-pression and characterized by a different constellation of symptoms (Gunderson & Phil-lips, 1991; Lecic-Tosevski & Divac-Jovanovic, 1995; Rogers, Widiger, & Krupp, 1995).Borderline depression may be more chronic (Burgess, 1991), have an earlier onset, andmay be accompanied by more axis I and axis II comorbid diagnoses (Sullivan, Joyce, &Mulder, 1994). Further, compared to borderline depression, individuals with nonborder-line depression may have more symptoms of melancholia (Bellodi et al., 1992), whichis associated with higher levels of cognitive dysfunction (Austin et al., 1999). Finally,neuroanatomical differences have been found in individuals with borderline versus non-borderline depression (De la Fuente & Mendlewicz, 1996; Southwick, Yehuda, Giller,& Perry, 1990). Thus, there is considerable evidence that the type of depression expe-rienced with BPD may be distinct from uncomplicated unipolar depression and maydiffer in neurophysiology, providing an explanation for the observed differences on thecognitive measures.

The major limitation of this study is the generalizability of results due to the smallsample size and inclusion of only women. The finding of examiner effects, and the factthat the examiners were not blind to participants’ diagnoses, are potential threats to theinternal validity of the study. Also, comorbid diagnoses and antidepressant medicationmay have influenced the results.

In conclusion, this study failed to find significant cognitive deficits in a group ofpatients with BPD who were carefully diagnosed with structured interviews and screenedfor organic or substance use disorders. However, there may exist a subset of patients withBPD who exhibit significant cognitive impairment, perhaps directly associated with BPDor secondary to neurological insult. Replication of the research with larger samples, aswell as use of more sensitive cognitive measures, may help detect more subtle deficitsand identify which patients with BPD exhibit cognitive dysfunction and under whatconditions.

The influence of emotional arousal on the cognitive functioning of patients withBPD may be explored more fully using stronger experimental manipulations. Invokingaffective experiences that have more personalized meaning for BPD patients (e.g., usingvignettes portraying affectively charged interpersonal situations) and then assessing aspectsof cognitive functioning (e.g., problem solving, drawing conclusions, or recalling detailsfrom the vignette) might bring to light the nature of cognitive errors made by patientswith BPD when emotionally aroused.


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Neuropsychological functioning in patients with borderline personality disorder