اختلال در هر عملکردهای دیداری و تناقض عصب روانشناختی در اختلال شخصیت مرزی

Abstract For Borderline Personality Disorder (BPD) cognitive and perceptual impairments were reported in some but not all studies. The aim of the present study was to analyze the neuropsychological performance of BPD patients in different domains. Predominant impairments of visual functions and an increased intra-individual variation of test performances within neuropsychological domains were expected. We investigated 22 patients with BPD and a matched sample of 22 healthy control subjects. A comprehensive clinical and neuropsychological test battery was administered. Effect sizes indicate primarily deficits of visual functions such as visual memory (Wechsler Memory Scale-Revised, WMS-R: Visual pair associates and visual reproduction, Complex Figure Test: Recall) and visuo-spatial abilities (Leistungspruefsystem, LPS 9 and 10: Spatial imagination and embedded figures), but also of executive functions (Tower of Hanoi, Trail Making Test-B, semantic and figural fluency, LPS 4: Reasoning). In addition, the intra-individual ranges of neuropsychological test results in BPD patients were increased compared to those of healthy subjects. This finding might be due to a high degree of temporary stress that interferes with effective cognitive processing. Further research is needed to confirm the present results and to control for stress during the test procedure

1. Introduction Patients with Borderline Personality Disorder (BPD) show a pervasive pattern of instability in their interpersonal relationships, self-image, and affective states, a reduced ability to inhibit impulsive behavior, self-harm, and a wide range of comorbid psychiatric disorders (Zimmerman and Mattia, 1999). The majority of these patients reports to be victim of abuse of different kinds (Driessen et al., 2002 and Golier et al., 2003). Clinical reports characterized BPD patients as temporarily suffering from psychotic and dissociative symptoms, with disturbances of perception and of cognition, including abnormalities of language, memory, attention, and executive functions (Zanarini et al., 1990, Sternbach et al., 1992 and Kernberg et al., 2000). Although these reports suggest neuropsychological deficits in BPD, the number of controlled neuropsychological studies is few, and these demonstrate heterogeneous results: Whereas some authors found deficits in most neuropsychological functions (Judd and Ruff, 1993, Swirsky-Sacchetti et al., 1993 and van Reekum et al., 1996), others reported performance similar to that of healthy subjects (Cornelius et al., 1989, Sprock et al., 2000 and Kunert et al., 2003). Characterizing the neuropsychological profile, O’Leary et al. (1991) found salient deficits of memory and of visual perceptual tasks; Bazanis et al. (2002) reported executive dysfunctions. Dinn et al. (2004) observed deficits of nonverbal memory and nonverbal executive functions. Stevens et al. (2004) reported perceptual and visual working-memory deficits. Interestingly, working-memory deficits did not extend with increasing cognitive load. Furthermore, deficits in attentional functions were also found (Judd and Ruff, 1993 and Swirsky-Sacchetti et al., 1993). Recently, Posner et al. (2002) specified that these deficits primarily affect conflict resolution, rather than other attentional functions such as alertness. In a meta-analysis Ruocco (2005) stated that BPD patients demonstrate deficits across a wide range of neurocognitive domains, but also concluded that nonverbal functions are predominantly affected. The reasons for these rather diffuse, and in part inconsistent, findings still remain unclear, but some factors might be of special importance. BPD is known for its complexity and wide range of comorbid symptoms and disorders. For example, many patients additionally suffer from posttraumatic stress disorder (PTSD) or depression (Zimmerman and Mattia, 1999), each of which is accompanied by neuropsychological deficits (Veiel, 1997 and Golier and Yehuda, 2002). Berg (1983) noted that patients with BPD show a temporary decline in cognitive efficiency, which also may contribute to the heterogeneity of findings. The present study was conducted to analyze the neuropsychological performance of BPD patients with a comprehensive neuropsychological and clinical test battery. We expected nonverbal functions to be primarily impaired. In addition, based on clinical experience and the remark by Berg (1983), we hypothesized a decreased intra-individual consistency of test performance within neuropsychological domains (memory, executive functions, attention, visuo-spatial abilities).

. Results 3.1. Demographic and clinical data The mean age of both groups, patients and controls, was 32 years (S.D. = 7.9), years of education were 11.2 (S.D. = 1.6) for the patients and 11.7 (S.D. = 1.6) for the healthy subjects (n.s.). All subjects were female. Table 1 reports the clinical data of BPD patients and control subjects. As expected, the BPD patients showed a wide range of comorbid disorders, 11 of them (50%) had a comorbid PTSD. Moreover, some patients also showed anxiety as well as affective disorders. Clinical rating scales indicated a significant burden of general psychopathology, depression, dissociation and PTSD symptoms in the patients, while the mean scores of the control group were extremely lower. None of the healthy subjects fulfilled the criteria for any Axis I or Axis II DSM IV disorder. The majority of BPD patients (77%) suffered from at least one trauma experience according to DSM IV (PTSD criterion A), and 14 patients (64%) reported self-harm. None of the healthy patients reported these clinical features. Table 1. Clinical characteristics of patients with Borderline Personality Disorder and matched healthy control subjects BPD patients (n = 22) Controls (n = 22) Comorbidity n n Major depression 6 0 Dysthymia 3 0 Substance abuse 2a 0 Panic disorder 5 0 Phobia 4 0 Obsessive compulsive disorder 2 0 Generalized anxiety disorder 2 0 Posttraumatic stress disorder 11 0 Eating disorder 4 0 Somatization 2 0 Rating scales — totals M (S.D.) M (S.D.) P b Symptom Checklist (SCL 90-R) 117.0 (49) 19.4 (28.1) < 0.001 Beck Depression Inventory (BDI) 25.8 (11.5) 2.7 (4.7) < 0.001 Hamilton Depression Rating Scale (HDRS) 16.7 (8.2) 2.4 (4.6) < 0.001 Dissociative Experience Scale (DES) 20.6 (10.2) 3.6 (2.6) < 0.001 Impact of Event Scale-Revised (IES-R) 63.9 (31.9) 4.5 (11.3) < 0.001 a Alcohol, sedatives. b T-tests (matched pairs, df = 21). Table options Some patients had received psychotropic drugs with possible cognitive side effects on the days before testing. (Five patients took neuroleptics [four of them, typical neuroleptics], two of these five also took benzodiazepines, two of these five also selective serotonin reuptake inhibitors (SSRI) and another two of these five received additional mood stabilizers.) However, the major results reported in the result section (increased intra-individual ranges of test results, and deficits in visual memory, executive functions, and visuo-spatial functions) remained stable after exclusion of these five patients from data analysis, despite the decrease of sample size. Of the 17 remaining patients, two received a beta-antagonist, another a tricyclic antidepressant drug, and three took SSRIs on the days before testing. The control subjects were free of psychotropic drugs. 3.2. Neuropsychological data Neuropsychological data are presented in Table 2. Strong group effects (ε > 0.6, Bortz, 2005) with a superior performance by the control subjects were found in the domains of visual memory (WMS-R: visual reproduction I & II, visual pair associates I & II, Complex Figure Test), attention (spatial span forward, TMT-A), executive functions (Tower of Hanoi, TMT-B, Five Point Test, Animals, LPS 4: Reasoning), and visuo-spatial functions (LPS 9: Spatial imagination, LPS 10: Embedded Figures). With the exception of a few tests (visual pair associates II, attentional performance, animals), all of these parameters reached significance on both parametric (t-tests, see Table 2) and non-parametric (Wilcoxon) evaluation. Thus, it appears that primarily visual functions, in particular visual memory and visuo-spatial abilities, as well as executive functions were impaired in BPD patients. Table 2. Neuropsychological data of patients with Borderline Personality Disorder and matched healthy control subjects (t-tests, matched pairs) BPD patients (n = 22) Controls (n = 22) T (df) P ε Memory M (S.D.) M (S.D.) Figural Memory (WMS-R) 7.3 (1.8) 7.5 (1.6) 0.5 (21) ns 0.1 Logical Memory I (WMS-R) 30.8 (9.1) 32.1 (6.4) 0.5 (21) ns 0.2 Logical Memory II (WMS-R) 26 (10.4) 28.5 (6.2) 0.9 (21) ns 0.3 Visual Paired Associates I (WMS-R) 13.3 (4.9) 16.1 (1.9) 2.6 (21) 0.016 0.8 Visual Paired Associates II (WMS-R) 5.1 (1.8) 5.8 (0.5) 1.7 (21) ns 0.6 Verbal Paired Associates I (WMS-R) 21.6 (3.7) 21.9 (2.2) 0.3 (21) ns 0.1 Verbal Paired Associates II (WMS-R) 7.7 (0.6) 7.8 (0.6) 0.2 (21) ns 0.2 Visual Reproduction I (WMS-R) 36.4 (3.8) 38.5 (2.8) 2.8 (21) 0.011 0.6 Visual Reproduction II (WMS-R) 33.8 (5.6) 37.6 (4.7) 3.1 (21) 0.005 0.8 Complex Figure Test (recall) 16.4 (8.1) 21 (5.9) 2.3 (21) 0.034 0.8 AVLT (totals) 58 (11.5) 60.7 (6.1) 1.2 (20) ns 0.3 AVLT (delayed recall) 13.3 (2.3) 13.9 (1.2) 1.3 (20) ns 0.3 AVLT (recognition) 14.6 (0.7) 14.3 (1) − 1.4 (20) ns 0.3 Attention Digit Span Forward (WMS-R) 7.1 (1.6) 7.8 (1.7) 1.5 (21) ns 0.4 Digit Span Backward (WMS-R) 6 (1.6) 6.9 (2) 1.7 (21) ns 0.5 Spatial Span Forward (WMS-R) 8.3 (1.6) 9.2 (1.4) 1.8 (21) ns 0.6 Spatial Span Backward (WMS-R) 7.9 (2.4) 8.8 (1.7) 1.6 (21) ns 0.4 Trail Making Test (A, sec) 35.5 (14.9) 28.7 (9.3) 1.7 (21) ns 0.6 TAP-Alertness (sec) 267 (36) 262 (33) 0.9 (21) ns 0.1 TAP-Divided Attention (sec) 692 (61) 683 (76) 0.3 (19) ns 0.1 Executive Functions Trail Making Test (B, sec) 70.9 (23.1) 57.2 (16.8) 2.2 (21) 0.039 0.7 Tower of Hanoi, 4 plates (moves) 27.7 (12.7) 22.5 (9.0) 1.4 (21) ns 0.5 Tower of Hanoi, 4 plates (sec) 125 (70.6) 62 (38.5) 3.4 (21) 0.003 1.2 FAS-Test (verbal fluency, lexical) 32.9 (8.9) 36.9 (9.9) 1.5 (21) ns 0.4 Animals (verbal fluency, semantic) 22.3 (5.7) 26.4 (5.9) 1.9 (20) ns 0.7 Five-Point-Test (figural fluency) 31.8 (8.1) 38.2 (7.5) 2.4 (21) 0.026 0.8 LPS 4 (reasoning) 26.8 (4.9) 29.7 (4) 2.2 (21) 0.036 0.7 Visuo-spatial abilities Complex Figure Test (copy) 33.2 (3.2) 34.5 (1.7) 1.6 (21) ns 0.4 LPS 9 (spatial imagination) 21.6 (8.1) 27.4 (5.7) 2.6 (21) 0.015 0.8 LPS 10 (embedded figures) 24.6 (7.2) 29.6 (6.9) 2.4 (21) 0.024 0.7 Table options To control for PTSD as the most prominent comorbid disorder, we compared healthy controls with BPD patients without PTSD (n = 11) regarding those performances that were impaired in the patient group. The exclusion of PTSD patients was relevant for visual reproduction I (ε = 0.2), as well as for TMT-A and -B (ε = 0.2), leaving only small effects in the comparison between healthy controls vs. BPD patients without PTSD. For all other tests, effects were still moderate to strong (ε = 0.4–0.9), indicating no substantial influence of PTSD. In a second step, the ranges of individual testing results within the neuropsychological domains (memory, attention, executive functions, visuo-spatial abilities) were defined. The intra-individual ranges of neuropsychological performance reflected by the range of z-scores (see above) were significantly increased in the patient group in the domains of memory (t = 2.5, df = 21, P = 0.019; ε = 0.7), executive functions (t = 2.1, df = 21, P = 0.045; ε = 0.6), and visuo-spatial abilities (t = 3.9, df = 21, P = 0.001; ε = 0.9) compared to the group of healthy controls. The groups did not differ with regard to attentional performance (ε = 0, Fig. 1). These results were confirmed by means of non-parametric statistics (Wilcoxon). Effect sizes indicate strong effects for the consistency of memory, executive and visuo-spatial performance when patients were compared to healthy controls. Mean intra-individual ranges of test performance on memory, executive functions, ... Fig. 1. Mean intra-individual ranges of test performance on memory, executive functions, visuo-spatial abilities, and attention in BPD patients and matched healthy control subjects. Figure options To control for PTSD, we again compared healthy controls to BPD patients without PTSD (n = 11) regarding the ranges of memory, executive functions, and visuo-spatial abilities. The exclusion of PTSD patients was relevant for the ranges of memory and visuo-spatial abilities, leaving only small effects for the comparison between healthy controls vs. BPD patients without PTSD (ε = 0.2 and ε = 0.3). With regard to the ranges of executive functions, the moderate effect (ε = 0.5) indicates no substantial influence of PTSD. In sum, the results indicate primarily visual deficits: With impairments of visual memory, visuo-spatial abilities and of executive functions in BPD patients, and, also in accordance with the hypothesis, the intra-individual variation of test performance was increased with regard to memory, executive functions, and visuo-spatial abilities. The results were in part related to comorbid PTSD.