Braz J Psychiatry.

2020 Sep-Oct;42(5):503-509
doi:10.1590/1516-4446-2019-0752
Brazilian Psychiatric Association
0 0 0 0 -0 02-7316-1 85

ORIGINAL ARTICLE

The association between neurocognitive functioning and

clinical features of borderline personality disorder
Bahar Kaplan,1 Medine Yazici Gulec,2 Sakir Gica,30 0 -0 0 -0 0 -0 0 Huseyin Gulec2
1
Department of Psychiatry, Sivas Numune Hospital, Sivas Provincial Health Directorate, Sivas, Turkey. 2Department of Psychiatry, University
of Health Sciences Turkey, Erenkoy Mental Health and Neurological Disease Education and Research Hospital, Istanbul, Turkey. 3Department
of Psychiatry, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.

Objective: To investigate the relationship between neurocognitive profiles and clinical manifestations
of borderline personality disorder (BPD).
Methods: Forty-five patients diagnosed with BPD and 35 healthy volunteers were included in the study.
The BPD group was evaluated with the Borderline Personality Inventory for dissociative, impulsivity and
suicidal dimensions. The Verbal Memory Processes Test and the Cambridge Neurophysiological
Assessment Battery were administered to both the BPD and healthy control groups.
Results: BPD patients differed from controls in sustained attention, facial emotion recognition, and
deteriorated verbal memory function. A model consisting of the Dissociative Experiences Scale –
Taxon (DES-T), motor impulsivity and Scale for Suicidal Behavior scores explained 52% of the
variance in Borderline Personality Inventory scores. It was detected that motor impulsivity, decision-
making and recognizing sadness may significantly predict DES-T scores, and response inhibition and
facial emotion recognition scores may significantly predict impulsivity.
Conclusion: Our findings demonstrate that the disassociation, impulsivity, and suicidality dimensions
are sufficient to represent the clinical manifestations of BPD, that they are related to neurocognitive
differences, and that they interact with clinical features.
Keywords: Emotion recognition; suicidality; dissociation; impulsivity; decision-making

Introduction prefrontal cortex and other brain regions,6,7 and that

changes in executive function can be seen as an endo-
Borderline personality disorder (BPD) is characterized by phenotypic trait.8 Although the clinical features of BPD
a troublesome pattern of instability in affect regulation, are thought to be the result of neurodevelopmental
self-image, impulse control, and interpersonal relation- neurocognitive functions, they are not considered a
ships, which leads to emotional dysregulation, impulsive neurocognitive disorder. In addition, impaired neurocog-
aggression, repetitive self-harm/suicidal tendencies, and nitive function is associated with clinical functioning,8,9
clinical symptoms.1,2 BPD is a complex multidimensional general functioning10 and continuation of treatment.8
disorder with a wide range of symptoms and cognitive Social cognition, a prominent neurocognitive function, is
deficits that is frequently accompanied by other psychia- involved in the frequent interpersonal problems and affec-
tric disorders.3 BPD diagnosis is impeded by overlapping tive dysregulation in BPD.11 In interpersonal relationships,
disorders and lack of a biological profile or specific family the correct interpretation of emotions (e.g., the accurate
history.4 To ameliorate the diagnosis problem, the DSM-5 recognition of facial emotions) is an important cognitive
offers a hybrid evaluation model that includes a dimen- component of intact social functioning.12 Disturbed emo-
sional approach. Dissociative symptoms (1001, 1002), tion recognition has been shown in BPD.
impulsivity, and suicidality (1003) are seen as common The aim of the present study was to further investigate
dimensions in BPD and play an important role in clinical the relationship between neurocognitive profiles and clinical
presentation, according to recent studies investigating manifestations by correlating the Verbal Memory Processes
the dimensional aspect (DSM-5) of the disorder, whose Test (VMPT) and a computerized version of the Cambridge
importance is now receiving more attention. Borderline Neurophysiological Assessment Battery (CANTAB). We
personality disorder has been shown to be a result of think that the dissociation, impulsivity and suicidality
neurobiological detriment, primarily executive function, dimensions should be discussed as representative of BPD
due to complicated neuronal connections,5 mainly in the and that they may contribute to the problem of ongoing

Correspondence: Sakir Gica, Necmettin Erbakan University, Meram How to cite this article: Kaplan B, Yazici Gulec M, Gica S, Gulec H.
Medical Faculty, Yunus Emre Mah. Beys¸ehir Cad. No: 281, Konya, The association between neurocognitive functioning and clinical
Turkey. features of borderline personality disorder. Braz J Psychiatry.
E-mail: [email protected] 2020;42:502-509. http://dx.doi.org/10.1590/1516-4446-2019-0752
Submitted Oct 15 2019, accepted Jan 14 2020, Epub Apr 17 2020.
504 B Kaplan et al.

diagnostic validity in this disorder. As a preliminary stage of implementation skills), a paired-associate learning test
the investigation, the diagnostic validity of these dimensions (to assess visual memory and learning), the Stop-Signal
will be tested by considering whether a model including Task (to assess the motor response inhibition), a Rapid
dissociation, impulsivity and suicidal behaviors can suffi- Visual Processing task (to assess sustained attention),
ciently represent the disorder. Adding cognitive deficits the Intra-Extra Dimensional Set Shifting Test (to assess
to the most common aspects of the clinical presentation rule learning, reverse learning and attention set shifting),
could provide a different approach to assessing BPD. and the Emotional Recognition Task (ERT – to assess
Our hypotheses were that the BPD group would have emotion recognition through facial expressions).
a different neurocognitive profile than healthy controls
and that this profile would be related to the impulsivity, Statistical analysis of the data
suicidal behavior, dissociation dimensions.
In SPSS version 16.0, descriptive statistical methods
Methods (mean, standard deviation, frequency, percentage) were
used to analyze the study data. The compatibility of non-
Participants normal distributions were visually (histogram and prob-
ability graphics) and analytically (Kolmogorov-Smirnov and
This was a case-control study with a prospective nature. Shapiro-Wilk tests) examined. An independent Student’s
The sample included 45 patients who were admitted t-test was also used to compare cognitive, sociodemo-
to the University of Health Sciences Turkey, Erenkoy graphic, parametric and quantitative data between groups,
Mental Health and Neurological Disease Education and while the chi-square test was used to compare categorical
Research Hospital between September 2015 and May data. Multivariate linear regression analysis was used
2016 and were diagnosed as having BPD according to to evaluate the effect of clinical features, such as
DSM-5 criteria. Each patient was informed about the dissociative findings, suicidality and impulsivity in BPI
study and agreed to participate. The control group con- scores. Separate multivariate linear stepwise regression
sisted of 35 healthy individuals who were matched with models were created to investigate the effects of cog-
the BPD group on the basis of age, sex, and education nitive data on clinical features. The data are presented
level. The Structured Clinical Interview for DSM-IV Axis I as means and 95% confidence intervals, with a sig-
Disorders (SCID-I) and the Structured Clinical Interview nificance level of p o 0.05.
for DSM-III-R Personality Disorders (SCID-II) were According to calculations performed in G*Power 3.1.9.2
applied to all participants. Patients under 18 or over (effect size: 0.8, significant tail: 2), the study power was
65 years of age, those with a lack of education that might 0.93.13,14
hinder compliance with the instructions, those with a
comorbid psychiatric disorder, those who had noticeable Ethics statement
mental retardation or cognitive decline in the psychiatric
examination, those who were diagnosed through the This study was approved by the clinical research ethics
interview as having a serious general medical condition, committee of the Erenkoy Mental Health and Neurological
and those who were diagnosed with alcohol/substance Disease Education and Research Hospital.
use disorder were excluded from the study.
Results
Procedure
The study included 45 patients, aged between 18 and
BPD patients were assessed with the Borderline Person- 47 years, who were being followed up after BPD diag-
ality Inventory (BPI) dissociative, impulsivity and suicidal nosis. Thirty-five healthy individuals aged 20-36 years
behavior dimensions, as well as for other comorbid psy- were recruited as the control group. The sociodemo-
chiatric conditions. The VMPT and CANTAB were graphic information and the comparisons between the
administered to both the BPD and control groups; no groups are presented in Table 1.
other clinical evaluation scales were used. The neuro- In the BPD group, 33 patients had attempted suicide
cognitive tests were applied in a silent room. Brief and 21 had a history of hospitalization.
instructions were provided before each test battery. The The neurocognitive test scores of the BPD and control
individuals were accompanied by a researcher, who groups were compared, and the results are shown in
also administered the tests. The tests took approximately Table 2.
1 hour 45 minutes to complete. A model was developed including impulsivity, suicidal
ideation, and dissociative symptoms, which cause great
Data collection tools problems, are difficult to manage, and require substantial
follow-up in the clinical course of BPD. Suicidal ideation
Data was collected through the following instruments: scale scores, total Barratt Impulsivity Scale scores and
a sociodemographic data collection form, the BPI, the sub-scores (inability to plan, motor impulsivity and impul-
SCID-I and SCID-II, the Dissociative Experiences Scale – sivity in attention), and DES-T scores were approached
Taxon (DES-T), the Barratt Impulsivity Scale, the Scale as independent variables, and their representation in BPI
for Suicidal Behavior (SSB), the VMPT, the CANTAB, the scores was examined in Table 3 using stepwise multi-
Cambridge Gambling Task (CGT- to assess decision variate regression analysis. According to the results,

Braz J Psychiatry. 2020;42(5)

 Cognitive functions in borderline personality disorder 505

Table 1 Comparison of sociodemographic characteristics in the borderline personality disorder and control groups
BPD (n=45) Control (n=35) t*/w2 p-value
Gender 1.270 0.260
Female 42 (93.3) 30 (85.7)
Male 3 (6.7) 5 (14.3)

Age, mean 6 SD 27.366.3 27.564.3 2.798 0.848

Education (years), mean 6 SD 11.762.6 12.762.5 0.225 0.089

Marital status 6.960 0.031*

Single 33 (73.3) 23 (65.7)
Married 7 (15.6) 12 (34.3)
Divorced 5 (11.1) -

Occupation 20.226 o 0.001*

Employee 19 (42.2) 29 (82.9)
Unemployed 19 (42.2) -
Student 7 (15.6) 6 (17.1)
Data presented as n (%), unless otherwise specified.
BPD = borderline personality disorder; SD = standard deviation.
* p o 0.05; chi-square and Student’s t-test were performed.

Table 2 Comparison of neurocognitive test scores in borderline personality disorder and control groups
Test/Outcome parameter BPD (n=45) Control (n=35) t/w2 p-value
PAL
Total errors (adjusted) 25.1624.7 18.2616.3 1.566 0.160

RVP
Ability to determine target directory 0.8660.5 0.8960.5 0.379 0.041*

IED
Total errors (adjusted) 26.2620.9 20.2618.6 2.463 0.190

VMPT
Immediate memory 6.161.7 6.761.5 0.126 0.100
Complete learning points 115.6615.4 129.569.3 8.937 o 0.001*
Access to criteria 32 (71.1%) 32 (91.4%) 5.079 0.024*
Highest learning point 14.261.3 14.860.5 35.925 0.009*
Long-term recall scores 12.0261.8 13.461.1 6.829 o 0.001*

ERT
Correct disgust (%) 27.2612.8 26.268.8 4.052 0.699
Correct sadness (%) 34.6612.6 35.8614.1 0.589 0.699
Correct fear (%) 22.768.6 26.867.3 5.530 0.253
Correct anger (%) 22.768.6 21.664.3 4.238 0.511
Correct surprise (%) 32.06611.4 32767.4 4.084 0.771
Correct happiness (%) 33.8610.8 36.7610.3 0.023 0.229
Total correct (%) 62.5611.8 67.566.9 5.726 0.030*

SST
Proportion of successful stops (%) 0.56 0.1 0.56 0.1 0.005 0.478

CGT
Deliberation time 2,670.661,135.2 2,600.76966.5 0.323 0.772
Quality of decision-making 0.760.2 0.860.1 2.292 0.190
Bet proportion – ascending 0.462.3 0.460.2 0.365 0.775
Bet proportion – descending 0.660.1 0.660.2 2.926 0.116
Overall bet proportion 0.560.1 0.560.1 0.228 0.601
Bet proportion at 6:4 0.560.2 0.560.2 0.187 0.912
Bet proportion at 9:1 0.660.2 0.660.2 0.094 0.409
BPD = borderline personality disorder; CGT = Cambridge Gambling Task; ERT = Emotional Recognition Task; IED = Intra-Extra Dimensional
Set Shifting Test; PAL = Paired-Associate Learning Test; RVP = Rapid Visual Processing; SST = Stop-Signal Task; VMPT = Verbal Memory
Processes Test.
* p o 0.05.

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506 B Kaplan et al.

a model consisting of DES-T, motor impulsivity, and SSB We detected that dissociation, impulsivity, and suicidality
scores could significantly represent BPI scores (adjusted varied from normality in BPD and that these dimensions
Rs = 0.519, F = 16.815, p p 0.001). could significantly explain the clinical manifestation of BPD.
The stepwise multivariate regression analysis results Although no model that included these dimensions together
for the effects of dissociative experiences are shown in could be found in the literature, there was independent
Table 4, the results for the effects of motor impulsivity are discussion of impulsivity,15 dissociation16-19 and suicidal
shown in Table 5, and the results for the effects of suicidal behavior20 playing important roles in BPD.
behavior are shown in Table 6.

Comparison of neurocognitive functions in the patient and

Discussion control groups

The DSM-5 emphasizes the validity problem in the BPD In harmony with other studies, our BPD group showed a
diagnosis process and suggests the use of hybrid models disturbance in sustained attention and all parts of verbal
(including dimensional structures) to resolve it. Our study memory except for immediate memory, but there was no
thus focused on whether the dissociation, impulsivity, and variation in visual memory/learning performance. A meta-
suicidality dimensions were foregrounded in the clinical analysis found that though both memory types showed
manifestation of the disorder and whether they were deterioration, visual memory was affected more than
sufficient to explain it. However, we aimed to evaluate verbal memory.6 Despite the differing cognitive flexibility
neurocognitive functions present in the disorder (including results in BPD patients, it is accepted that they frequently
hot cognition, which we believe to better represent social experience disturbances. We detected no variation bet-
relations and significantly affects the deterioration of inter- ween the BPD and healthy control groups in terms of
personal relationships in BDP) to allow a different approach cognitive flexibility skills. A study using the Intra/Extra
than previous categorical assessments, as well as to con- Dimensional Set Shifting Test found no variations in
tribute to diagnosis validity (available in the DSM-5). BPD.21 In a facial emotion recognition study, it was

Table 3 The effects of a model featuring important clinical manifestations of borderline personality disorder
Borderline Personality Inventory Scores
Independent variables b coefficient 95%CI for b coefficient SE t p-value
DES-T 0.190 0.080-0.30 0.054 3.488 0.001*
Motor impulsivity 0.792 0.090-1.49 0.348 2.278 0.028*
SSB 0.636 0.036-1.24 0.297 2.141 0.038*
Constant 8.398 1.125-15.670 3.601 2.332 0.025*
DES-T = Dissociative Experiences Scale – Taxon; SE = standard error; SSB = Scale for Suicidal Behavior.
* p o 0.05; stepwise multivariate regression analyses were performed.

Table 4 Investigation of the effect of model for clinical features and cognitive functions related to pathological dissociative
experiences
DES-T
Independent variables b coefficient 95%CI for b coefficient SE t p-value
Motor Impulsivity 3.911 2.383-5.438 0.756 5.175 o 0.001*
ERT (correct sadness) 0.409 0.035-0.784 0.185 2.211 0.033*
CGT (decision-making quality) 24.607 1.007-48.207 11.677 2.107 0.041*
IED (PreED errors) 0.382 -0.344-1.108 0.359 1.064 0.294
Constant -50.590 -81.694-19.486 15.390 -3.287 0.02*
CGT = Cambridge Gambling Task; DES-T = Dissociative Experiences Scale – Taxon; ERT = Emotion Recognition Task; IED = Intra-Extra
Dimensional Set Shifting Test; SE = standard error.
* p o 0.05; stepwise multivariate regression analyses were performed; adjusted Rs = 0.420, F = 8.950, p p 0.001.

Table 5 Investigation of the effect of model for clinical features and cognitive functions related to motor impulsivity
Motor impulsivity
Independent variables b coefficient 95%CI for b coefficient SE t p-value
SST (proportion of successful stops) 11.390 4.710-18.071 3.310 3.441 0.001*
ERT (total correct) -0.072 -0.144- 0.00 0.035 -2.031 0.049*
Constant 10.340 4.722-15.957 2.784 3.714 0.001*
ERT = Emotional Recognition Task; SE = standard error; SST = Stop-Signal Task.
* p o 0.05; stepwise multivariate regression analyses were performed; Adjusted Rs = 0.233, F = 7.674, p = 0.001.

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 Cognitive functions in borderline personality disorder 507

Table 6 Investigation of the effect model for clinical features and cognitive functions related to suicidal behavior
SSB scores
Independent variables b coefficient 95%CI for b coefficient SE t p-value
CGT bet proportion – descending 10.484 5.730-15.238 2.298 4.562 p 0.001*
CGT bet proportion %50 probability -5.628 -9.252-2.004 1.752 -3.213 0.004*
VMPT (immediate memory) 0.657 0.195-1.119 0.223 2.944 0.007*
Constant -2.874 -7.026-1.278 2.007 -1.432 0.166
CGT = Cambridge Gambling Test; SE = standard error; SSB = Scale for Suicidal Behavior; VMPT = Verbal Memory Processes Test.
* p o 0.05; stepwise multivariate regression analyses were performed; Adjusted Rs = 0.506, F = 9.893 p p 0.001.

observed that emotion recognition skills were generally pathological dissociation could be a clinical variable that
decreased in BPD.22 We found that separate recognition differentiates BPD patients in terms of cognitive function-
of the six basic facial expressions did not significantly vary ing. These authors found a negative relationship between
in BPD, although patient performance for total emotion DES-T scores, attention, and verbal memory, and they
recognition was lower. The Iowa Gambling Task, which found no relationship between decision implementation,
assesses decision implementation and impulsivity pro- cognitive flexibility, and visual memory.30 Although they
cesses on a cognitive level and in a manner integrated found that both cognitive areas were associated with
with emotion, has frequently been used in studies assess- dissociative symptoms and their comparison with healthy
ing decision implementation skills.23 In the present study, individuals resulted in different features than the current
we used the CGT, which is reported to be less affected study, it should be pointed out that their sample size
by working memory and learning status than the Iowa was very small.30 Thus, these findings may not reach
Gambling Task. We detected no variation in decision- significance in comparison and correlation tests.
making skills between the BPD and control groups. In our
study, there was no significant difference in Stop-Signal Neurocognitive profile in the impulsivity dimension
Task scores between the BPD and control groups. The
results of other studies involving the Stop-Signal Task It was observed that the basal metabolic rate of the
harmonize with ours.24,25 orbitofrontal cortex area decreased in BPD.9 The orbito-
The BPD group had lower sustained attention, facial frontal cortex is involved in executive functions that
emotion recognition, and verbal memory functions in their regulate decision implementation31 and impulsive beha-
neurocognitive profile than healthy controls. No variation viors. Functioning along with the orbitofrontal cortex in
was observed in cognitive flexibility, visual learning/memory, decision implementation,32 the amygdala also enables
response inhibition, or decision-making skills between the correct recognition of emotions.33 Impulsivity is a beha-
groups. vioral characteristic of BPD.
We detected that response inhibition and facial emo-
Neurocognitive profile in the dissociation dimension tion recognition might significantly predict impulsivity.
The association between impulsivity and response inhibi-
In cases of intense stress exposure, temporary dissocia- tion has been examined in other psychiatric disorders,
tive symptoms can be seen in patients with borderline and it was concluded that impulsivity and response
personality disorder.26 It has been reported that the inhibition probably occurred through the same biological
dissociative symptoms in BPD are related to variation in mechanisms in the prefrontal cortex.34 A study on the
the parietal cortex27 and are mostly caused by difficulties relationship between impulsivity and facial emotion
in autobiographical memory recall.28 In another study, no recognition in ADHD and ASD patients emphasized that
relation was observed between dissociation scores, visual ADHD symptoms had an effect on emotion recognition.35
perception, and working memory.29 We believe that BPD The same study also reported that impulsivity and
patients are a heterogeneous group and that the non- emotion recognition had an inverse interaction. Although
standardized test material has led to conflicting research research on this topic is very limited, our findings support
results. Our study found that motor impulsivity, decision those of previous studies.
implementation (choosing the appropriate response) and
emotion recognition significantly predicted the pathologi- Neurocognitive profile in the suicidality dimension
cal indicators observed in BPD. Haaland et al.30 com-
pared healthy controls and BPD patients with and without Suicide threats and attempts are an important diagnostic
dissociative symptoms, including an examination of cog- criterion in BPD.36 BPD has a high mortality due to
nitive areas such as attention, working memory, verbal suicide. In the present study, cognitive functions, such
memory, visual memory, and executive function. The as decision-making and immediate memory, were found
authors reported that BPD patients with dissociative to have an effect on suicidality. In a study by Bazanis
symptoms performed worse than healthy subjects in all et al.,37 42 BPD patients with self-injurious behavior were
cognitive domains. They emphasized that patients with compared with healthy controls, and the only differences
dissociative symptoms performed worse than those with- found between the two groups were disruptions in deci-
out dissociative symptoms in executive function, working sion making and planning. BPD patients took longer to
memory, and verbal memory areas, concluding that decide, selected the most unlikely outcomes, and placed

Braz J Psychiatry. 2020;42(5)

508 B Kaplan et al.

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Disclosure
24 Legris J, Links PS, van Reekum R, Tannock R, Toplak M. Executive
function and suicidal risk in women with borderline personality dis-
The authors report no conflicts of interest. order. Psychiatry Res. 2012;196:101-8.
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