Cognitive Information Processing in
Borderline Personality Disorder: A
Neuropsychiatric Hypothesis
J. Wesley Burgess, Ph.D., M.D .
Abstract
Neurocognitive info r mat io n processing was compared in 18 borderl ine
su bjects and 14 controls of simi lar age and gender. An II-item screening
ex am ina tion sig nificantly di ffer en tiated the two groups (P < 0 .001 ). Significa nt
d iffere nces were fou nd on Delayed Me mory, Serial Sevens, Rh ythm Reproduction, an d Perseveratio n su b tests (P < 0.05). The results a re interpreted as
evi dence for mi ld frontotem poral brain deficits. The findi ngs sup po rt a d evelopmenta l model of bo rderli ne disorder where early stress/ injury d u r in g the
childhood period of frontotemporal vulnerability results in fai lu re to negotiate
developmental land mar ks and adult deficits in cognition , emotio n/behavior
modulation, and insight.
I NTRO DUCTIO N
Mu ch of the con temporary in terest in neurophysiological and neuropsychological infor mation processing was influenced b y the work o f Luria ( 1,2), who
co rrelated aberrant patterns of thought and behavior with th e locat io n of
specific brain lesions in hospi ta lized neuropsychiatric patients. T he notion that
t he brain acts as a processor of exogenous information provides o ne theoretical
framework to b r id ge biological, ps ychological and behavioral view points of
b ra in injury a nd m ental illness ( 1,2). Alterations in the processing o f incoming
sensory informatio n are thought to play important roles in schizop h renia,
mental re tardat io n and learning disabilities (e.g ., 3- 17). H ow ever , th e ro le of
bra in information p rocessin g in characte rological d isorders is unclear , and has
received little clinical or research attention .
T here are so me suggestions of an organic component to characterologic
diso r d ers, particul arly in bord erl ine personality disorder , wh ich could p ro vid e a
substrate for altered neurocognitive processing. Adrulonis and co lleagues (18, 19)
The author thanks Drs. Brant Wenegrat and James Moses, Jr. for th eir helpful discu ssions. Support was provided by a Moos Fell o wship in Psychi atry. Ad d ress correspondence
to Dr . Bur gess, Dep ar tme nt of Psychiatry, Stanford University Med ical Center, Stanford,
Ca lifornia 94305 .
34
BORDERLI NE PERSO NALI T Y DISORDER
35
hav e fo u nd a di sp roportionat e percentage of head trau ma , encephal itis, e pilepsy
and learn in g di sabilities in some subgroups including bo rd erl ine d iso rde red
persons, suggest ing th ey may have suffered lesio ns p lacing them at r isk for
neu r ocogni tive d ysfun ctions.
There is also circ u ms tantial evidence suggesting a role of organi c d ysfun ction in th e sim ilarity be tween t he symptoms of borderl ine personality di sorde r
and th e sym p to ms of ac u te, d iffu se b rain inj u ry . T he Diagno stic and Statisti cal
Manual III-Revi sed (DSM-II I R) lists th e foll o wing symptoms of borderline
personality disorder: chronic depression , mood in stabili ty, poor control of
anger , relations hi p ins ta bi lity and im p ulsivity with im pulsive sexual and vio lent
acts (20). In patients with diffuse co r t ical inj ury secondary to clos ed head
trauma , th e most fr equently reported behavioral symp to ms include: chronic
depression, mo od in stability, ir ri ta bil ity with te mper o utbursts, and poor impulse co ntro l with sexua l and aggressive ac ts (2 1-25). Obvio usly there is a str ong
con ve rgence between th e ch r o nic symp to ms of borderline personal ity disorder
a nd the acute symp to ms fo llowing adult fronta l b rain injury. Moreover, re sea rc h
st udies and clinical imp ressions have associate d characteriological dis orders wit h
parental d epri vation and a buse (26) ; conditio ns whi ch co u ld resu lt in pos sib le
ea rly brain injury. Overall , this circums ta n tia l evid ence suggests t hat a theory of
a berrant b rain p rocessing co u ld explain aspects of characterologi c behavio ral
d ysfun cti on occ u rri ng after early neu ropsyc h iatric trauma.
Studies of endogenously d epressed patients have revealed d eficie ncies in
sta ndar d ized tests o f cognition and informa t io n p rocessing , including in form atio n co d ing, ap prehension span, logica l operations, and abstract functi ons (2734). T hese findi ngs have been ex plai ned as a reversible impairment in co rtical
information processin g accompanying affective changes (31) . A lthough borderline perso nali ty d isorder characteristically manifests marked affective cha nges,
th e d e monstr at io n of an equ iva lent neurocognitive de ficit in borderline d isorder
is as yet unkno wn .
Assumptions ofNeu rocognitiue Testing
The d isciplines of neuropsych ology/neuropsychiatry are co ncerned with
the mechanisms and measurement of functiona l brain proce sses (35,36). T ypically, these include asse ssment of integrity of such brain functions as attentio n ,
memory, langu age , abstraction , and motor behavio r (37) . T hese general fu nctional ma y be combined or separated into other derivative functional categories,
depending on the theoretical stance of the author. Confirmation o f loca lizatio n
site can come from anatomical measures such as imaging stud ies, ph ysiological
measures including EEG, evoke d potentials or radioisotopic labeling metabolic
st ud ies . Importantly, certain neuropsychological subtests are thought to asses s
mental function s whi ch localize more or less specifically to area s of th e brain a nd
can ther efore be used as behavioral measures o f organic o r fu nc tio na l impairment (3 7). An o u t line of co m monly presented mental fu nc tio ns, together with
36
JEFFERSO N JO UR NAL O F PSYCHIATRY
their associated brain mechanism s and sub tests which are thought to localize to
them is presented below.
Attention. The control of attention is intimately associated with corticoreticular, reticulocortical and thalamic projections and posterior int ernal capsule
pathways, as well as other brainstem and midbrain str uctu res (38-4 2). It can be
measured by suc h subtests as Double Simultaneous Stimulation (43,44), or
vigilance subtests (37).
Memory. Recen t memory is dependent on intact fu nc tio n ing of limbic
system structures, particularly the bilateral hippocampus, dorsom edia l thalamic
nuclei , and mammalary bodies (45 -48). Memory can be tested b y re petition of
digits (4 , 10, 14 ,49), delayed recall or free recall from a story (2,3 7), or such
batteries as the Wechsler Memory Scale (50).
Language. Functions of language are associated with temporal and parietotemporal cortical and subcortical language areas (51,52). Classical d ysfu nct io ns
include Broca's, Wernicke's, conduction, transcortica l and su bco rtical ap hasias
(52) . Expressive language functions are classicall y associate d with anterior or
Broca 's area (53), whereas receptive language function s are cla ssicall y associate d
with the posterior or Wernicke's area (54). Tests such as th e Boston Naming
Test (55) , the FAS Controlled Oral Word Association Test (54), or th e Animal
Naming Test (56) particularly assess naming processes d eficien t in expressive
ap hasias.
Abstraction. Higher cognitive functions , including abstract operations, are
associated with many areas of the brain, especially the pariet al lobes (57-59).
Operations of abstraction and generalization can be measured by standardized
versions of the proverbs interpretation task (37,61), th e W AIS Sim ilar it ies
subseaIe (62), Rave n Progressive Matrices (64), th e Category T est (63), th e
non verba l half of the Shipley Hartford Sca le (60 ), and other test s.
Computations ma y be disrupted by dominant parietal lesions, as well as
other lesions (57 ,5 5 ,56). Arithmetic operat io ns can be measu r ed by the serial
seve ns ta sk (3 7), the WAIS Arithmetic subseaIe (6 2), and other tas ks.
Constructions. Constructions are nonverbal performance tas ks relying on
abstract , visuo spatia l and motor ope ra tio ns , whi ch a ppear to overlap functions
of abstraction and behavioral seq ue nc ing . T hese fu nc tions can be assessed by
drawing to co m mand , figure reproduction and copyin g tas ks (37,67,68). Unfortunately, th e most widely used co ns truct io n te sts also include th e additiona l
co n fou nd ing dim ension of visuospatial memory, suc h as th e Bender Visua l
Motor Gestalt (69 ,70), the Graham and Kendall Memory fo r Designs Test (71) ,
a nd th e Benton Visu al Retention Test (6 7).
Behavioral Sequence. Organ ization of behaviors, and the abi lity to switch
mo to r ac tiv ities or men ta l se ts is associate d wit h th e frontal cortex (1,2,37).
Pe rseverat ion erro rs are a hallmark o f frontal d amage (72), as are other errors in
o rder ing. Behavioral seque nc ing is important in th e execution of Luria's alternating movement s task ( 1,2), Luria 's rhythm repr oduct io n task ( 1,2), Reitan's
BORDERLINE PERSONALITY DISORDER
37
Trai l Making Test (73 ), or the Proteus Maze Test (74). T he Wisconsin Card
Sorting Test (75 ), provides one measure of ability to switc h mental sets without a
strong loading for motor abi liti es .
Successive and Simultaneous Processing. Based on the wo r k of Luria, Das and
co llegues (76) have taken another approach to function al localizat io n , by proposing that certain tasks represent a specialization in " successive" information
processing operations. According to Das (76) these include W AIS Digit Span
and Digit Symbol subscales (62) , free recall from a sto ry (l ,2,3 7), Re ita n 's Trail
Making Test (73), and other tasks where information is prese nt ed in serial ,
sequentia l fas h ion . Impair me n t in successive processing ta sks is generall y associated wit h d e ficits offrontotemporal neocortical function (76). Conversel y, other
tasks involve more " simultaneous" information processing operations, including
the Graham and Kendall Memory for Designs Test (7 I) , th e Raven Progressive
Matrices (64), an d the Be nd er Visual Motor Gestalt (69,70). Impairment in these
tas ks is generally associated with deficits of parietoccipital neocortical function
(70, 73 ,76).
Research Hypothesis and Experimental Model
We were impr essed by the circumstantial evidence lin king or ganic d ysfu nction and borderline personality disorder, and decided to test thi s relationsh ip
using the neuropsychiatric tools described above. As an initial ste p , we proposed
a testable model of organic dysfunction leading to cognitive infor ma tion p rocessing defects in bo rder line personality disorder. This became t he basis of a
research h ypo thesis wh ich was tested in a clinical population sample.
Developmental Model . We propose that certain developing bra in areas,
particularly frontal and temporal neocortex (which are at risk during early
development (1) sustain injury during childhood trauma in perso ns who will
later be d iagnosed with borderline personality disorder. Although grossly foc al
neuro logical sig ns are absent, a chronic deficit in cognitive information processing loca lizing to the frontotemporal cortex remains. This ea rly, ge neralized,
subclinical insult results in difficulty negotiating developmental landmarks, with
consequent personal and interpersonal problems during lat e child hood and
adulthood. Initial behavioral deficits in childhood are partiall y co mpensated
during personality development, but th ere remains a pattern o f affective instabi lity, relationsh ip dysfunction, and impulsive thought and action in regard to both
self and others. This pattern of behavioral impulsivit y, emo tiona l instability, and
insight impairment ma y appear mild or sever e, depending o n th e individua l and
the degree of stress in the environment.
Experimental Hypothesis. Based on the developmental model above, we
hypothesize that a battery of neurocognitive scr ee ning tests will show measurabl y greater neurocognitive dysfunction in a samp le popula tion of individuals
with borderline personality di sorder than in a comparabl e pop ulation of individ-
38
J EFFERSON JO URN AL O F PSYCH IATRY
uals without this diagnosis. We would expect that the most d e ficie nt tests wou ld
localize to the frontal and temporal regions of the cortex.
METHODS
Subjects
Subjects were drawn from successive presentation fo r psychiatric evaluation, and neurocognitive function was tested in the o verall con te x t ofcomprehensive mental status evaluation. The borderline group was co mprised of 18
patients with an independant diagnosis of borderline perso nality di so rd e r by
DSM-11IR criteria from at least two clinicians. Subject s had no A xis I d iagnosis,
no history of neurological disorders, neurosurgery, or focal brain inj u r y. All
subjects denied the use of drugs for the week preceeding eva luatio n. In this
group, mean age was 32.61 years (S.£. = 2.23), and gender was 33 % fe male
(S.£. = 12.1; the high proportion of males reflects the overall hospital pop ulation).
The control group was comprised of 14 persons with no cu r re nt histor y of
psychiatric hospitalization, Axis I or 11 diagnosis, history of neuro logica l dis orders , neurosurgery, or focal brain injury. The average age was 3 1.36 years
(S.£. = 1.21), and gender was 43 % female (S.£. = 12.8).
II-Item Screening Examination
All patients were given an II-question neurocognitive screeni ng examination (see the Appendix), administered by th e author, wh o was blind to the
diagnosis of borderline personality disorder. Test s were drawn from th e work
cited above, particularl y from th e exam inat io n o f Luria (197 3). Two subtests
were used to evaluate ea ch of the fu nct io na l categori es of memo r y, language,
abstract operations, and behavioral seq uence, and three types of errors of order
and seq ue ncing were scored se pa rate ly. Bec ause all patients p rese nt ed in a
normal wa king state of co nscio us ness, no assessm ent of attention was provided.
The entire examination required less than 10 minutes to admin ister and is
therefore appropriate for clinical scree ning purposes. The exam ination is reproduced verbatim in the Appendix. T he followin g outline descr ibes the tests
administered, and our understanding of the functi ons th ey measure .
Memo ry
I . Digit Span was th e abi lity to repeat 6-7 digi ts in two presentations of
7-di gits ea ch , adapted fr om WAIS Digit Sp an Su btest (4, 10, 14,49,62).
2. Del ayed Memory for 3 objects was th e ability to repeat the 3 asso cia ted
wo r d pairs fir st presented in Question # 3 after 10 minutes of distraction ; our
ve rsion of this su b tes t in co mmon use was adapted from Stru b and Black (37).
BORDERLI NE PERSO NALITY DISORDER
39
Language
3. Immediate Repetition was th e ab ility to repeat th e foll owing 6 associated
wo rd s aft er presentation a t a ra te of o ne per second : " re d ball, blue car , city of
Chicago" (5 1,77) .
4 . Object Nam in g was th e ability to nam e common objects a nd th ei r pa rts
when presented visua lly: pen , ca p , cover , cli p , poin t , watch , ba nd ; (37, 77).
Abstract Operation s
5. Serial Sevens te sted th e ability to serially sub tract 7 fro m 100 five tim es
with minimal help from the invest igator (5 7 ,65 ,66 ,78).
6 . Proverb Interpretation te sted th e ability to interpret the proverb " Do n' t
cry over spilt milk" abstractl y, ac cording to criteria ad ap te d from Gorham
(37,61) .
Behavior Sequen cing
7. Luria Mo vements te sted th e ab ility to reproduce with either hand th e
following three sequential movements after seeing th em per fo r med by th e
investigator: clenched fist ; outstretched palm & fing ers; thumb & forefinger
ring . This task was adapted from Luria (1,2).
8. Rh ythm Reproduction was the ability to reproduce with ei ther hand the
following three rhythms comprised of hard [T] and soft [t] taps present ed at one
per second: TTTtttTTT; tttTTTttt; ttTTtt. This task was also adap ted from
Luria (1 ,2).
General Errors ofOrdering and Sequen cing
9. Slowing Errors were scored when at least one response to a sub tes t was
delayed for 4 seconds or more.
10 . Perseveration Errors were sco red when a t least one respo nse to a sub test
was repeated more than once (37 ,72).
11. Inversion Errors were scored when parts of at lea st o ne sub test response
were reversed in order.
Total Sum ofFailed Subt ests
The total su m of failed subtests, r anging from 0-11 was reco rded for a ll the
su b tests listed above.
Statistical Analysis
Group Comparisons. Neurocognitive measures from the borderl ine and
control subject groups were compared using Multifactoral A na lyses o f Var iance
40
JEFFERSON JO UR NAL OF PSYCHIATRY
(MANOVA: 79 ,80). St ati stical anal ysis was performed with th e Statistical Analysis System (81). The MANOV A was a mixed design with th e fo llowing model:
[Diagnosis x (Measures x Subject sj] , see Winer (82). The between subjects
factor (Diagnosis) had 2 levels (Borderline Personality Disorder, Co ntrol). The
within subjects factor (Measures) had II levels (Digit Span , Delayed Memory,
Immediate Repetition, Object Naming, Serial Sevens, Prove rb Interpre tatio n ,
Luria Movements, Rh ythm Reproduction , Slowing Errors, Perseverati o n Errors
and In version Errors).
The MANOVA generated omnibus comparison (F-tests) for betwee n subjects factors (82 ,83) and multivariate tests (Hotelling Trace) wit h F-Test equivalents for within subjects factors (79,80). Multiple comparisons testin g allowed
statistical comparisons to be made between the subject groups on specific
subtests without violating Type I or Type II error assumptions by repeated
individual tests. Multiple comparisons were made using Tukey's all-pairs test
with appropriate error terms for a posteriori contrasts between borderline and
control for each of the II subtests (84) .
In addition to the above mixed, repeated measures design , o ne-factor
analyses of variance (ANOVAs) were used to compare th e su bject groups for age
and gender distribution. One-factor ANOVAs were also used to co mpare total
sum of test performance between the subject groups (82 ,83).
RESULTS
Subject Groups
The average age of the borderline and control subject groups was not
significantly different, as shown by one-factor ANOVA [Age F(I ,30) = 0 .22;
P = NS). Similarly, gender distribution in the borderline and co nt rol subject
groups was not significantly different [Gender F(I ,30) = 0.29; P = NS )
Neurocognitive Tests
Omnibus Tests. Borderline and control groups showed a significant d ifference in performance across the II subtests of the neurocognit ive screening
examination [Diagnosis F(I,30) = 14.180; P = 0 .0007) . Overall performan ce
differed significantly according to subtest [Measures Hotelling Trace = 3.435;
F(IO,21) = 7.214; P < 0 .0001], and an interaction comparison reveal ed that a
significant component of this resulted from differential performance by the two
subject groups across the II sub tests [Measures x Diagnosis Hotelling
Trace = 1.449; F(10 ,21) = 3.043; P = 0.015) .
Multiple Comparisons. As shown in Table I , multiple comparisons testing
revealed sign ifican t impairment in the borderline group on subtes ts of Delayed
Memory (Tukey test, P < 0.05), Serial Sevens (Tukey test, P < 0.05), Rhyt hm
Reproduction (Tukey test, P < 0.05), and Perseveration Errors (T ukey test ,
I:ll
o
:;r;l
t:l
trl
:;r;l
t:
z
trl
....,
trl
:;r;l
en
oZ
TABLE 1.
>
r-
Neurocognitive Screening Measures in 2 Groups'
Function =
TEST =
BO RDE RLINE GROU P
% Errors =
±S.E. =
CONTROL GROUP
% Errors =
±S.E. =
SIGNIFICANCE =
MEMO RY
LANGUAGE
ABSTRACT
~
BEH AVIO R
GENERAL ERRORS
SPAN
MEM3
REPT
NAME
SER7
PROV
LUR I
RHT M
SLOW
PERS
INVT
5.6
5.9
36.1
10.3
0.0
0.0
16.7
5.6
5.9
61.1
9.6
55 .6
12.8
77.8
10.7
50.0
12.8
27 .8
11.5
50 .0
12.9
0.0
0.0
7.1
7. 1
28 .6
11.7
35.7
12.4
12.4
0.0
0.0
35 .7
6.7
0.0
0.0
35 .7
6.7
0.0
0.0
7. I
6.7
SPAN
**
MEM3
REPT
NAME
**
SER7
PROV
12.5
LU RI
**
RHTM
-<
e
en
o:;r;l
e
SLOW
**
PERS
trl
:;r;l
12.4
INVT
'Differences are significant at P < 0.05 by Tuken's multiple comparisons test, from MAN OVA results. KEY: SPAN = Digit Span ,
MEM3 = Delayed Memory, REPT = Immediate Repetition, NAME = Object Naming, SER7 = Serial Sevens, PROV = Proverb
Interpretation, LURI = Luria Movements, RHTM = Rhythm Reprod uctio n, SLOW = Slowing Errors, PERS = Pers everation
Errors, INVT = Inversion Errors.
,j>,
42
JEFFERSON JO UR NAL O F PSYCHI ATR Y
P < 0.05) . T here was no significant difference between performa nce of the two
groups on su b tes ts of Digit Span, Immediate Repetition , Object Na ming, Proverb Inte rpretat ion, Lu r ia Movements, Slowing Errors, o r In versio n Errors
(P = S).
Total Sum ofFailed Subtests
Across the e n tire screening exam ination, the borderline group had an
average of 3.86 er rors (S.E . = 0.47), whereas the con trol group had a n average
of 1.57 er rors (S.E. = 2 .2 2). T h is difference was significant, as described above
for between subjects co mparisons [Diagnosis F(I ,30) = 14. 180 ; P = 0.0007 ].
DISC USSIO N
In sum marizing th e find ings, it was shown th at groups of borderline and
co n trol su bj ects of eq uivale n t ag e and ge nder co uld be sig nificantly di scriminated b y th e ir per form ance on a screening neurocog nitive examination. Deficit s
were m ost pronounced o n sub tests of Del ayed Memo r y, Serial Sevens, Rh yt hm
Reproducti on , and Per severat ion Errors .
Impli cations ofthe Find ings
T he fin di ng th at borderlines can be d iscr im inated from controls by their
per formance o n a screening neu rocogniti ve exam ination provides e vidence th at
that bo rderline th ought p rocesses d iffe r from nonborderlines on a basi c, measura ble, neuropsych ological level.
These fin d ings su pport o ur research h yp oth esis that borderline individuals
show a sig ni fica n t ne u rocogn iti ve d eficit. T his hypothesis is based on a h ypothet ical d evelopmental model, wh er e stress, ab use or d epri va tio n during vu lne ra ble
stages o f ea rly d evel opmen t res ult in ch ron ic cogn itive information processin g
errors . T hese erro rs impair th e ability to negotia te formative developmental
stages in chi ld hood , a nd in te r fere wit h social/interpersona l relationships
th roughout ad ulthood, co ntr ib u ting to th e cha racteristics diagnosed as borderlin e personality di sorder (see Introduction).
Int erpretation of the Findings
Co n trary to our p redict ions, there was no concentration of deficit s in a
single fu nc tio nal ca tegory . In stead , poor per fo r mance was found in sub tes ts
measuring d ive rse fu nc tio ns of mem ory, abst ract operations, behavioral seq ue ncing and ge nera l e r rors of o rder a nd seq ue nce, overlapping all neurocogni tive
func tions except language. To fin d o u t the natu re of the borderline dysfunct ion ,
we m ust look a t t he pattern of cognitive errors .
BORDERLINE PERSONALITY DISORDER
43
The pattern of deficient subtests a ppear to b est fit the Das (76) model of
d eficient sequential information processing, since deficits we r e fo und in sub tests
of De layed Memory, Serial Sevens, Rh ythm Reproduction , a nd Perseveration
Errors, whi ch all involve information that is presented in serial, sequential
fash ion , and where a str in g of stimuli must be sequent ia lly memorized o r
manipulated. According to the model of Das and collegues (76), e r r o r s in
seq uential information processing suggest involvement of the frontotemporal
pole. Unfortunate ly, we did not have a wa y of formall y testing the significance of
this relationship in our borderline population .
Another wa y of explaining th e findings is to look for simi larities between
the deficient subtests of delayed memory, serial subtraction, rh ythm reproduction and perseveration . All these tests require planning, multipl e o perations, and
th e maintainance of a prolonged response over time; thus, a ll the su b tests are
particularly subje ct to distraction or intrusion from e xogenous or endogenous
stimulation. This is similar to t he pattern of errors whi ch T eube r (5 8) associates
with fronta l brain injury, and is simi lar to the dimension o f " p la n n ing" which
Luria (1 ,2) associates with frontal and prefrontal injuries.
Thus, the results of our study ca n be interpreted as supp o r t ing o ur hypothesis of mild injury to the fronta l and temporal brain regions , whi ch are particularly vu lnerable d u r ing early chi ldhood (1) .
Limitations ofthe Study
The current methodology does not rule out effect s of in cidental variables
like apathy, depression , anxiety or e n vir o n menta l stressors kn o wn to be common in borderline di sordered persons lives. An explanation of o ur results base d
e n tir ely on exogenous stressors cannot account for the magnitude of di ffere nce
between borderline and control performance, nor can it exp la in ho w borderlines could perform well on such diffi cult su b tests as Pro verb Interpr e ta tio n ,
while fa iling sim p le r tasks like Dela yed Memory or Serial Se vens.
However, we suggest that future research e m p loy test s for atten tionalj
motivational variables, if on ly to dispel the notion that subjects we re inattentive
o r unmotivated. Although the l l -itern scr een ing examinatio n is co nven ient to
use , the use o f add itional te sts fo r each neu r oco g n it ive fu nction would provide a
much str o nge r picture of neurocognitive deficits. Power of th e examination
would also be in creased by e xch a ngin g th e current pass/fa il scoring system for
an interval or co n tinuous m ea surement sca le (85). Ad d itiona l tests with standardized, in terva l sco r in g are a vailable (1,2,3 7, 62, 70,73).
CONCLUSIONS
T he present study is a n attempt to p r o vid e a b r oad e r , multidisciplinary
vie wpoint o n borderline personality di sorder b y evalua ti ng cognitive information processing. T h e importance of the findin gs, wh ich support a neur ocog nit ive
44
JEFFERSON JO UR NAL OF PSYCHIATRY
deficit in borderline frontotemporal processes, will d epe nd on the results of
future st ud ies confirming and expanding the cu r rent results.
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J EFFERSO N J O U R N AL O F PSYCHIATRY
APPENDIX
Cognitive Screening Test
MEMORY
I . Digit Span: (Say at rate of one number per second. Record performan ce .)
" I' ll say some numbers and you repeat them whe n I'm done."
"3-2-6-0-9-1 -0 " (Record answers): _-_ -_-_-_ - _ -_ -_ -_ -_ -_
"8-1-5-3-7-2-9" (Record answers): _-_-_-_-_- _-_-_-_-_-_
SCORE: s 5 either trial, score I
(Record slowing/hesitat ion, perseverati on , inversion bel o w.)
2. Verbal Dela yed Memory: (See below).
LANGUAGE
3. Repetition: " I' ll say three things and yo u repeat them wh en I'm don e."
" A red ball, a blue car, and the cit y of Chicago. "
" No w see if you can remember them when I ask yo u ag ain lat er. "
SC ORE: unless repetition is perfect, score I
(Record slowing/hesitation, perseveration, inversion below.)
4. Naming: (Hold up item and point to part. Correct an swers underlin ed .)
record answer) :
_
" What' s this thing?" (point to ~;
record answer):
_
" What' s this thing?" (Point to cap/ cover;
record an swer):
_
" What's this thing?" (Point to~;
" What' s this thing?" (Point to point/tip;
re cord an swer):
_
"What's this th ing?" (Point to watch;
record answ er):
_
"What's this thing?" (Point to ~bracelet ; re cord answer):
_
SCORE: if any errors in naming, score I
(Reco rd slowing/hesitation, perseveration, inversion below.)
ABSTRACTION
5. Serial 7's: (Check if correct or record errors.)
"What's 100 minus 7?" _ _ (93) "And 7 from that?" _ _ (86)
"Keep taking 7 awa y." _ _ (79)
_ _ (72)
_ _ (65)
SCORE: if subject misse s or unable to complete, score I
(Record slowing/hesitation, perseveration , inversion below.)
6. Proverbs: (Record full answer).
" What does it mean to yo u when people say ' Do n't cry over spilt milk ?' "
Score: _ _
Score : _ _
Score : _ _
Score : _ _
Sco re : _ _
SCORE: use scoring key below; unless matches ab stract , score I
(Abstr act: Don't wo r ry about mistakes in the past. When some th ing 's gone, do n't be concerned about it. What's done is done; don't brood. It 's gone, don 't worry. Don 't cry whe n
so meth ing goes wrong.
Concrete: just clean it up. The milk 's gone, you can't use it.)
(Record slowing/hesitation, perseveration, inversion below.)
BEHAVIORAL SEQUENCE
7. Luria Movements: "I'll do something with my hand and yo u try to r ep eat the same thing
when I'm done."
(T a p yo ur right knee 3 times with the right hand in these 3 po sition s):
FIS T : (make a first and strike the kn ee with the heel of th e hand)
PALM: (extend fingers out flat and str ike the knee with th e palm)
RING: (make 'O K' sig n with the thumb and forefinger together in a ring; extend th e o ther
fing ers and strike the knee with th e heel of the hand) "Now you try it."
SCORE: if subj ect cannot reproduce in first trial, sco re I
Sco re : _ _
(Re cord slowing/hesitation, perseveration, inversion bel ow. )
49
BORDERLINE PERSONALITY DI SORDER
APPENDIX (CONTINUED)
Cognitive Screening Test
8 . Rh ythms Reproduction: 'I'll tap a littl e r hyt h m o n my kn ee. Wat ch carefully and try to repeat it when I'm done."
(T ap on right knee wit h r ight hand in fo llowing seq ue nce where (*) eq ua ls a brisk (l-sec) tap
and (-) eq uals a slow (2-sec) tap):
* * * - -- * * * " Now you try." (Reco rd re sponse):
_
"Now try this on e." (Tap out following sequence):
-- - * * * -- - " No w yo u try. " (Record response):
_
" No w try this one. " (Tap out following sequence):
-- * * - - "Now you try." (Record response:
_
SCORE: if subject misses or unable to complete, sco re I
Score : _ _
(Record slowing/hesitation, perseveration, inversion bel ow .)
DELAYED MEMORY
2. Verbal Delayed Memory: (Record full answ er).
"Now tell me the 3 things I asked you to re mem ber earlier. "
(Correct = Red Ball , Blue Car, City of Chi cago)
SCORE: if subject misses an y or unable to complete, sco re I
(Record slo wing/ hesita tio n , perseveration, inversion bel o w.)
9. Slowing/Hesitation: (>3 sec delay on an y question . Record times:
SCORE: if subject hesitates on an y question, score I
10. Perseveration: (Repeats response on an y question . Re co rd times):
SCORE: if subject perseverates on an y question, score I
II . Inversion: (Inverts/reverses response on an y question. Record times):
SCORE: if subject inverts on any question, score I
TOTAL (add together all points from 0-11)
Score: _ _
_
Score: _ _
_
Score: _ _
_
Score: _ _
T OTAL: _ _