Borderline personality disorder (BPD) is considered a chronic and severe mental disorder that could be fatal due to the high prevalence of suicide, self-destructive behavior, affective instability, and impulsivity 1. BPD affects ∼10% of the psychiatric population; females are more likely to be affected with BPD compared with males 2.
BPD is the only disorder in which suicidal behavior is a diagnostic criterion. One in 10 patients with BPD will commit suicide and 75% will engage in chronic self-injurious behavior 3,4. Even with the exclusion of self-destructive behavior, BPD is strongly associated with suicidal behavior beyond what is attributed to clinical depression, substance abuse, or, other personality disorders 5.
Various biopsychosocial factors have been implicated in the pathogenesis of BPD symptoms, especially the suicidal and impulsive behavior, and they have received the majority of attention in several studies. Disruption in the basic neurocognitive process, especially executive dysfunctions, were also found to play a key role in the development of clinical features of BPD. However, studies on underlying cognitive deficits that may constitute a biological vulnerability for suicide and impulsivity risk are too scarce 6.
Executive functions (EFs) are higher-order cognitive functions that involve the abilities to plan, judge, and weigh options; to make complex decisions; and control or inhibit other thoughts or behaviors 7. These EFs rely, in large part, on the integrity of the prefrontal cortex (PFC) and its complex neural interconnections with other brain regions 8,9.
It has been postulated that a high likelihood of neurobiological injury, especially to the PFC in BPD patients, is responsible for the initiation and maintenance of BPD symptoms, mainly impulsive and suicidal behaviors 10–12. Other studies have confirmed a positive correlation between the severity of brain damage and the severity of behavioral disorders among BPD patients 13.
Thus, a proper understanding of the EF processes of individuals with BPD could improve the assessment and treatment of their considerable risk for suicide and impulsivity. As the assessment of these risks in BPD patients is still not completely developed, the role of cognitive impairment may confer additional risk and may constitute a reliable clinical evaluation of suicide and impulsivity risk. Despite that, the role of executive dysfunction as a risk for the disorder and its consequent suicidal and impulsive behaviors remain poorly understood.
Based on the inconsistency and inadequacy of the available data on EFs in BPD and its association with suicidal and impulsivity risk, this study set out to compare a variety of EFs in patients with BPD relative to healthy controls and to describe the associations of these EFs with greater suicide and impulsivity risks among BPD patients. We expected that (i) EFs performance would be more impaired in BPD patients compared with controls and (ii) EF impairment would be more strongly associated with suicidal and impulsive behaviors. We hypothesized that deficits in the Wisconsin Card Sorting Test (WCST) dimensions would be related to the impairment in global psychosocial functioning [Global Assessment of Function (GAF)].
Patients and methods
Site of the study
This cross-sectional, case-controlled study was carried out at the outpatient clinics of the Institute of Psychiatry, Ain Shams University (The Institute of Psychiatry Ain Shams University is an academic and clinical facility representing the Department of Psychiatry in the Faculty of Medicine in Ain Shams University. The institute is one of the largest mental health hospitals in Cairo with a catchment area that includes the eastern region of greater Cairo and the nearby governorates. There are three outpatient clinics that operate four times a week.).
In total, 19 patients diagnosed with BPD according to the Diagnostic and statistical manual of mental disorders, 4th ed., text revision (DSM-IV-TR) were recruited from the outpatient clinics of the Institute of Psychiatry, Ain Shams University. Their ages ranged from 18 to 50 years. To eliminate the effect of confounding factors that might disturb the cognitive functions, patients with any current or past history of medical, neurological disorder or currently taking any medication (as patients should be free at least 4 weeks before enrollment in the study) were excluded from the study. Moreover, patients on any current substance abuse, with any other psychiatric comorbidity, or receiving an electroconvulsive therapy course in the last 3 months were excluded from the study.
A group of 10 female healthy volunteers matched for age, educational level, IQ, and other demographic variables with the patient group served as the control group. They were selected among the employees of the Ain Shams University Hospitals.
Ethical approval for the study was granted by the Ain Shams University Ethical and Research Committee. A written informed consent was taken from patients to whom we explained the full procedure and the aim of the study. The participants were able to withdraw from the study at any stage knowing that their dropping out will not affect their treatment and management plan for their psychiatric case.
Procedure and tools
All participants were subjected to the following:
- A full psychiatric interview following the psychiatric case sheet designed by the Institute of Psychiatry, Ain Shams University (ASUIP).
- Full medical and neurological examination to exclude medical or neurological disorders that may affect cognitive function.
- Structured Clinical Interview for DSM-IV (SCID-II) 14, which is an efficient tool to make standardized, reliable, and accurate diagnosis of the 10 DSM-IV Axis II personality disorders.
- Structured Clinical Interview for DSM-IV (SCID-I) 15, which is a clinician-administered, semistructured interview. It provides a broad coverage of psychiatric diagnoses according to DSM-IV; it is used to assess and exclude psychiatric comorbidities in the study participants.
- Wechsler Adult Intelligence Scale (WAIS) 16 – Arabic version 17 – to test the verbal performance and total IQ of the participants, to determine the general intellectual functions of patients and controls, and to confirm that the two groups were matched in terms of IQ.
- WCST 18, which was used to assess EFs that include the abstraction ability and the ability to shift cognitive strategies in response to changing environmental contingencies, and as a measure of frontal lobe [mainly dorsolateral prefrontal cortex (DLPFC)] EF; it also provides information on several aspects of problem-solving ability and strategic planning.
- Suicidal Behavior Questionnaire (SBQ) 19, which is a self-report assessment for suicidal thoughts and behaviors in adults. The SBQ measures the frequency and intensity of suicidal ideation, past and future suicidal threats, past and future suicide attempts, and nonfatal self-harming behavior. Suggested cutoff scores for a general adult population is more than 7 and more than 8 for adult inpatient psychiatry 19.
- Eysenck Personality Questionnaire (EPQ) 20, which was used to assess the impulsivity, which is a part of unstable extraversion axis.
- GAF 21, which is a numeric scale (1–100) used by mental health clinicians and physicians to rate subjectively the social, occupational, and psychological functioning of adults, and it is Axis V of the internationally accepted DSM-IV-TR.
Data were recorded and analyzed using the statistical package of the social sciences (SPSS, 17th version, 2009; SPSS Inc., Chicago, Illinois, USA). The results were tabulated, grouped, and statistically analyzed using the following tests: mean
, SD for quantitative data, and frequency with percentage for qualitative data. Kolmogorov–Smirnov test was used to study the normality of data distribution. The χ2-test was used for the comparison of categorical variables. Continuous normally distributed variables were compared by using the independent sample t-test. Spearman’s correlation test (r) was used to study the relationship (direction and power) of quantitative variables simultaneously. A statistical level of significance was set at 0.05.
Sociodemographic and clinical data of the study participants
Nineteen patients with BPD and 10 healthy controls were enrolled into this study. All patients and controls were females so as to eliminate the effect of sex difference as a confounding factor. The mean age of the patients was 23.4±3.2 years, whereas it was 23.2±3.5 years for the control group. Patients and controls were well matched as regards age, marital status, education level, and residence. No statistical difference between patients and controls was found as regards all studied demographic variables.
Clinically, there was no significant difference between patients and controls as regards past and family history of psychiatric illness. In terms of suicidal behavior, data revealed a high significant difference (P=0.000) between patients and controls as 89.5% of the patients had positive score on SBQ, whereas none of the controls had a positive score on SBQ. Assessment of impulsivity by using EPQ revealed higher impulsivity scores in patients compared with controls (P=0.000).
Functional assessment for the study participants using the GAF scale revealed that the control group had better functions compared with the patients group (P=0.000). Results are displayed in Table 1.
Assessment of cognitive functions
Assessment of general intellectual abilities
The findings of the WAIS revealed nearly similar mean IQ scores in the patients group compared with the control group, with no statistical significance in the total performance and verbal IQ, as shown in Table 2 (P>0.05).
Assessment of executive functions
On using the WCST, patients with BPD displayed a lower number of completed categories (denoting lower overall executive performance), lower percentage of conceptual-level responses (denoting lower abstraction and problem-solving abilities), higher number of trials to complete the first category (denoting that the initial concept formation was impaired), higher failures to maintain set (denoting inability to continue using successful strategies), and higher learning to learn scores (denoting lower conceptual efficiency). Nevertheless, the difference in the total errors and the number of perseverative errors were not significant between the two groups. Data are presented in Table 2.
Comparison between borderline personality disorder patients with and without past history of psychiatric illness in terms of their cognitive functions
Results of the present study showed that BPD patients with a negative past history of psychiatric illness had better total IQ scores in comparison with patients with positive past history of psychiatric illness. However, there was no significant difference between the two groups in terms of other compared cognitive variables (Table 3).
Correlation between cognitive function in borderline personality disorder patients and different clinical variables
Correlation between Global Assessment of Function scores and Wisconsin Card Sorting Test
Results showed that the patients’ GAF scores were positively correlated with categories completed conceptual response percentage and learning to learn subtests of the WCST. On the contrary, there were significant negative correlations between GAF scores and number of trials completed, numbers of nonperseverative error, failure to maintain set, and numbers of perseverative error subtests of the WCST (Table 4).
Correlation between executive function deficits and suicidal behavior and impulsivity in borderline personality disorder patients
Date revealed no significant correlation between suicidal behavior (as measured by SBQ) and different domains of EFs (subtests of WCST), as presented in Table 4.
Correlation between impulsivity as measured by the EPQ and different WCST subtests revealed that the numbers of categories completed, conceptual response percentages, and learning to learn were negatively correlated with impulsivity behavior of the BPD patients (P=0.006, r=−0.604; P=0.012, r=−0.565; and P=0.02, r=−0.532; respectively).
Whereas there was a significant positive correlation between impulsivity score and number of trials to complete first category (P=0.013, r=0.575), as patients with high impulsivity needed more trials to complete the first category (Table 4).
Early studies that attempted to relate neurocognitive performance to the BPD diagnosis were hampered by methodological limitations and unfocused instrumentation. That is why objectives of this study were to describe EFs in a group of female patients with BPD who were matched with regard to their age, educational level, and IQ. In addition, we aimed to examine the association of executive dysfunction with certain clinical risks of BPD, specifically suicidality and impulsivity.
Comparison between patients and controls regarding sociodemographic data revealed that both groups were well matched as regards their age, educational level, and IQ. Similarly, majority of the literature on BPD focuses on its occurrence in women or does not incorporate sex as a separate variable, therefore not addressing possible sex differences in clinical presentations.
We preferred to include only female cases to minimize the effect of sex as a confounding factor. However, Grilo et al.22 in their study reported that, although BPD is believed to occur more frequently in women, research findings on the prevalence of BPD in men and women are inconsistent. Thus, little is known regarding the potential sex differences in persons with BPD that may impact the manifestation, course, and treatment of BPD in both men and women. Future research is recommended to investigate the effect of sex difference on cognitive functions of this patient group.
Cognitive function in borderline personality disorder patients
IQ in borderline personality disorder
Comparison between the patients and control groups with regard to total performance and verbal IQ scores showed no significant difference between the two groups. While we were enrolling for the patients and control groups, we aimed to get them matched as much as we can. Very few researches in the past specifically investigated intelligence in patients with BPD, and those that did revealed inconsistent results. For example, normal IQ in BPD was also reported in previous studies 10,23,24. Other studies revealed that performance IQ was more negatively affected than was verbal IQ in BPD patients 9. On the other hand, studies such as that by Swirsky-Sacchetti et al.25 found that women with BPD scored significantly lower on only the Picture Arrangement subtest of the WAIS-revised, but there were no significant differences on any other subtests.
Executive function in borderline personality disorder
The first significant difference encountered in the current study between BPD patients and healthy controls was the statistically significant lower performance of patients in the majority of WCST measures.
Impairment in WCST subtests in the current study may indicate deficit in strategic planning, organized searching, utilizing environmental feedback to shift cognitive sets, directing behavior toward achieving a goal, and modulating impulsive responding 26, which was consistent with clinical symptoms of BPD and may explain most of the symptoms. For example, significant impairment in the score of conceptual response percentage indicates the inability to form concepts about abstract and complex situations that are used in planning as well. This may explain instability in goals, aspirations, values, or career plans seen in BPD patients. In addition, impairment in the number of trials to complete first category and learning to learn scores may indicate impairment in attention and the ability to learn 26. Therefore, patients with BPD have difficulty in learning from past experiences. Whereas impairment in nonperseverative error may indicate impairment in the overall executive control, which may explain symptoms like impulsivity and inability to control anger.
This finding was in agreement with previous studies by Lenzenweger et al.27 and Fertuck et al.28, who found that poorer performance on the conflict score of the Attention Network Test was significantly correlated with increased nonperseverative errors and fewer conceptual-level responses on the WCST. Their findings reinforce the association of BPD with executive control impairments.
Similarly, Swirsky-Sacchetti et al.25 in a study of the neuropsychology of BPD matched a group of 10 female patients with BPD to 10 female age-matched and education-matched control participants and studied a number of domains of neuropsychological functioning. As part of their study, they conducted the Stroop Color–Word Test for both groups, and found that participants with BPD scored significantly lower on the Stroop Color–Word Test than did control subjects. They attributed this result to subtle frontal lobe deficits in BPD patients. Thus, even with different tools of assessment, cognitive dysfunction of BPD was clearly demonstrated the impairment involved in decision-making, planning, working memory, and attention.
Other previous studies revealed that BPD patients predominantly demonstrate deficits in the domain of EFs. In particular, processes of inhibitory control and decision-making appear to be most frequently affected 8,9,29.
This corroborates earlier studies that have identified frontal regions as potential neurobiological substrates of the BPD syndrome 10,11. In addition, these findings support the previous hypothesis that patients with BPD could benefit from the application of a specific neuropsychological rehabilitation program directed to every type and grade of the neurocognitive difficulties they have 30. They also encourage the idea that the cognitive improvement could be a contributing factor for the improvement in the clinical symptoms and would thus have a positive impact on the general functioning of the patient 30.
Comparison of IQ and EFs between patients with positive and negative past psychiatric history revealed nonsignificant differences between the two groups of patients except for the scores of total IQ test. Our findings demonstrated that the impact of past history of psychiatric disorder on EF might be very low or even negligible.
Our results support previous preliminary evidence that executive dysfunction in BPD is heritable and represents stable characteristics, temperaments, or predispositions 31. EF deficits were also found in younger children with BPD-like symptoms who were not yet formally diagnosed 32,33. Such findings, similar to ours, would in fact contradict the idea that executive dysfunction in BPD is primarily the result of the disorder or its treatment or comorbid psychiatric disorder, and they might implicate a biological vulnerability for the BPD that precedes the diagnosis.
However, our results still need to be cautiously interpreted as the percentage of patients with past psychiatric history was only 26% of the whole patient sample size.
Borderline personality disorder symptoms and cognitive impairment
Overall, studies of executive functioning in participants with BPD indicate that attention and executive control are areas of difficulty for BPD patients. In particular, participants with BPD appeared to struggle more to maintain their attention and executive control under conflicting conditions or when negative affect interfered with cognition.
Impulsivity and cognitive impairment
In this study, correlation between impulsivity as measured by EPQ and WCST revealed significant negative correlation between impulsivity scores and the numbers of categories completed on the WCST. Impairment in these subtests would affect different cognitive processes, such as planning, working memory, attention, problem-solving, verbal reasoning, inhibition, mental flexibility, and task switching.
On the other hand, there was a significant positive correlation between impulsivity scores on the EPQ and number of nonperseverative error on the WCST as patients with higher impulsivity performed more nonperseverative error and impairment in that test could affect the overall executive control.
This finding was consistent with those obtained in a study by Swirsky-Sacchetti et al.25, who found that participants with BPD scored significantly lower on the Stroop Color–Word Test, which was used for the measurement of EFs, than did controls.
Thus the impairment in EF tasks might be the cause of impulsivity in the study patients as we had hypothesized, or that both impulsivity and cognitive deficits are stemming from the same etiology 34, which may be related to structural pathology in certain brain areas such as prefrontal region. Moreover, Svaldi et al.35 investigated 21 female BPD patients and 29 healthy female controls, and highlighted deficits in decision-making, which were correlated with BPD symptom severity and impulsivity; they concluded that risky decision-making may be a relevant maintenance factor for the disorder.
Suicidality and cognitive impairment
Our study showed no specific correlation between executive dysfunctions and suicidal behavior (either attempt or ideation) as measured with the SBQ. Our results were in agreement with those of other studies, such as that by LeGris et al.7, who found that poor decision-making (measured by using the Iowa Gambling Task) 36 was not associated with any suicide risk, but they found that only Stroop interference control (measured by using the Stroop Task Test) 37 contributed significantly to lifetime suicide intent/attempt beyond depression or BPD severity. They concluded that the Stroop Task appears to be more sensitive to suicide risk than does the Iowa Gambling Task.
However, our findings were inconsistent with the those of a study by Mak and Lam 38, who reported that executive dysfunction in BPD was linked to suicidality and treatment adherence, and may serve as an endophenotype.
The difference in results may be attributed to the fact that different but specific types of EFs were found to be correlated with suicidal behavior among patients with BPD, which are as follows: working memory, inhibitory control, and emotional decision-making 8,9.
Various neuroimaging evidences suggested that the DLPFC, anterior cingulate, and the orbitofrontal cortex (ventro-medial prefrontal cortex) are three functional domains of the PFC that regulate the EFs of working memory, inhibitory control, interference control, and complex decision-making. These specific EFs are compromised in many individuals with BPD 8,9. Each psychometric test is believed to sensitively test a certain area and specific EF.
In our study, we used the WCST, which assess mainly the DLPFC EFs (cognitive flexibility and set shifting, which are parts of inhibitory control). As inhibitory deficits are believed to underlie more the impulsive behavior, this may be another explanation for the correlation of executive dysfunctions with the risk for impulsive behavior in our results. Future studies are needed to examine other types of EFs that are implicated in the risk for suicidal behavior, such as the type of emotional decision-making.
Cognitive impairment and global function in borderline personality disorder
Measuring overall function in BPD patients by using the GAF scale revealed highly significant difference between patients and controls as BPD patients had more impairment in the GAF. At the same time, there were highly significant positive correlations between the GAF and the WCST subtests such as categories completed, conceptual response percent, and learning to learn, which means that higher score on those cognitive tasks associated with better function.
However, there were highly significant negative correlations between GAF and the scores of WCST. Impairment in tasks such as number of trials to complete the first category, numbers of perseverative error, numbers of nonperseverative error, and failure to maintain set associated with less function.
Not surprisingly, our results indicated worsening of the GAF with more impairment in cognitive function.
However, our results are not in agreement with those obtained in a study by Fertuck et al.28, who found that the extent of impairment in attention networks was associated with a greater spectrum of BPD pathology, as indicated by the BPD dimensional score, but not with the level of psychosocial functioning, as assessed by the GAF. That may be due to methodological differences between the two studies.
Other studies suggested that persons with BPD perform more poorly in their psychosocial functioning than do healthy controls 39.
Strength and limitations
Our study was one of only a few, if any, preliminary studies that investigated the cognitive component of BPD and how it was associated with the behavioral component of BPD in a relatively homogeneous sample of adult women with BPD.
The study focused on cognitive domains that show impairment in previous studies together with emphasis on the effect and relation of that impairment on clinical symptoms and functioning in BPD patients. In addition, a healthy control group was employed to improve the internal validity of the study design and sex effects on EFs were controlled as recommended.
However, our study was limited by its sample size and the inclusion of only female sex; thus, caution should be exercised in generalization of the results of this study and more research should be carried out on larger samples and both sexes to replicate these results. Another limitation of our study was that it was cross-sectional in nature, and although it helped identify associations, it was difficult to infer causality in relationships.
BPD psychopathology, especially suicide and impulsive behavior, is considered unique and warrants further understanding within a cognitive framework. Executive dysfunctions in BPD patients are correlated with impulsivity risks, which highlight the importance of early assessment of such deficits and identification of individuals at risk for executive deficits. Ongoing research on the cognitive functions of BPD patients may contribute to a clearer conceptualization of their conflicted interpersonal relationships and life-threatening behaviors, which may eventually result in more targeted treatments for these patients.
Implications for future research
Future researches employing different psychometric tests to examine other types of EFs and their correlation with BPD symptoms need to be taken in considerations.
Conflicts of interest
There are no conflicts of interest.
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