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Oxford University Department of Psychiatry, Warneford Hospital, Oxford
Institute of Neurology, University College London
Rampton Hospital, Nottinghamshire
Arnold Lodge (RSU), Leicester
Department of Psychological Medicine, Imperial College, London
Oxford University Department of Psychiatry, Warnford Hospital, Oxford, UK
Correspondence: Dr Robert D. Rogers, University Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK. Email: robert.rogers{at}psychiatry.oxford.ac.uk
Funding detailed in Acknowledgements.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Aims To explore mnemonic impairments in prisoners undergoing personality assessment as part of the dangerous and severe personality disorder initiative or detained in a medium secure facility.
Method We investigated memory function in 18 prisoners with borderline personality disorder and 18 prisoners with other personality disorders.
Results Prisoners with borderline personality disorder exhibited a pattern of multi-modal impairments in the immediate and delayed recall of verbal and visual information, with some association with affective instability. These deficits were not associated with the severity of personality disturbance.
Conclusions These data suggest that memory deficits have some specificity in relation to the constituent traits of borderline personality disorder and indicate that neuropsychological assessment may be a source of useful adjunctive information for distinguishing between the cognitive and psychological difficulties of individual prisoners.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Other evidence suggests that borderline personality disorder is mediated by disturbances within neural (Driessen et al, 2000; Donegan et al, 2003) and neurochemical systems (Hollander et al, 1994; Soloff et al, 2000) that support cognitive and emotional functions, although the specificity of these phenomena remains uncertain. Neuropsychological investigations suggest that borderline personality disorder is associated with memory disturbances, including difficulties in the encoding and retrieval of complex multi-modal information (O'Leary et al, 1991; Burgess 1992; Judd & Ruff, 1993; Kurtz & Morey, 1999). However, to date positive results have been demonstrated only in comparisons of patients with borderline personality disorder and non-clinical healthy controls, again raising the question as to whether such impairments tell us anything about the disorder itself or are merely indicative of the non-specific consequences of psychological distress. Similarly, there have been no studies of memory function in prisoners with borderline as compared with other personality disorders.
In this study, we used traditional pencil-and-paper neuropsychological instruments to investigate visual and verbal memory function in prisoners undergoing assessment for DSPD. All prisoners were screened for neurological illness, learning disability, current mood disorder, and current or previous psychoses. We sought to compare the performance of prisoners with DSM–IV borderline personality disorder with that of prisoners with other DSM–IV personality disorders.
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Clinical assessment
Participants underwent a full psychiatric assessment of DSM–IV Axis I
and Axis II disorders. Axis I disorders were assessed using the Structured
Clinical Interview for DSM–IV Axis I Disorders (SCID–I;
First et al, 1996).
One participant from the borderline group and 4 from the non-borderline group
were screened for Axis I disorders using the Schedule of Affective Disorders
and Schizophrenia (Endicott & Spitzer,
1979). Exclusion criteria were as follows: previous or current
neurological illness or injury; previous or current psychotic illness
(including schizoaffective disorder and bipolar I or II disorder); current
unipolar depression; any evidence of learning disability. Of the 18
participants with borderline personality disorder, 1 received a comorbid
diagnosis of gender identity dysphoria, 1 had an adjustment disorder, 1 had a
history of attention-deficit hyperactivity disorder (ADHD) and 1 had alcohol
dependency. Of the non-borderline participants, 1 was diagnosed with ADHD, and
1 with polydrug misuse and generalised anxiety disorder. Significant previous
alcohol or substance misuse was reported by 3 men with borderline and 1 with
other personality disorders. The number of participants who had been dependent
upon alcohol, stimulants (i.e. amphetamine) or opiates was 4 and 3
respectively.
Personality disorders
Personality disorder was assessed with the International Personality
Disorder Examination (IPDE; Loranger
et al, 1994), which is a semi-structured interview that
provides diagnostic information about DSM–IV personality disorders and
indicates both `definite' and `probable' diagnoses within the personality
disorders specified in Axis II. The participants with borderline personality
disorder had more definite diagnoses of personality disorder than the
non-borderline participants (2.06±0.29 v. 1.33±0.27;
F (1, 34)=3.40, P=0.074). The distribution of `definite' and
`probable' diagnoses is shown in Table
1.
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Each participant was also rated for severity of personality disturbance according to the procedure described by Tyrer & Johnson (1996) in which the number of diagnoses within and between DSM–IV clusters is transformed into four levels of severity: no personality disorder, personality difficulty, simple personality disorder and diffuse personality disorder (Psychiatric Assessment Schedule (PAS)). The PAS has been used to specify the presence, cluster type and severity of personality disorders in a variety of clinical settings (Cuesta et al, 2001; Seivewright et al, 2002). It has been shown to have adequate interrater and test–retest reliability (Tyrer & Alexander, 1979; Tyrer et al, 1983; Hill et al, 2000) and to predict treatment outcome (Tyrer & Seivewright, 1988). The participants with borderline personality disorder were rated as having a significantly greater breadth of personality disturbance than the non-borderline participants (2.56±0.12 v. 2.00±0.20); F (1, 34)=5.743, P<0.05). Specifically, in the non-borderline group, 1 participant was classified as having no personality disorder but had a total score on the Psychopathy Checklist–Revised (PCL–R; Hare, 1991; Hart et al, 1992) of 32.6, indicating a very high degree of psychopathy, 3 were classified as having a personality disturbance, 9 as having a simple personality disorder and 5 as having a diffuse personality disturbance. Eight participants in the borderline group were classified by the PAS as having a simple personality disorder and 10 as having a diffuse personality disorder.
Participants were also assessed using the PCL–R which is a 20-item checklist that measures the personality traits and behaviours characteristic of psychopathy. All items are scored on the basis of a file review and semi-structured interview. Notwithstanding recent controversy surrounding the psychometric structure of the PCL–R (Cooke & Michie, 2001; Cooke et al, 2004; Neumann et al, 2005), total scores on the PCL–R in this study were taken to represent the composite of just 2 factors: Factor 1 relates to interpersonal and emotional deficits characteristic of psychopathy whereas Factor 2 relates to a history of criminality and a propensity towards an antisocial lifestyle. Generally, participants PCL–R scores were rated in the high range but were matched between the borderline and non-borderline groups (26.34±1.23 v. 24.96±2.06; F<1.00). There were 11 participants from the non-borderline group and 10 from the borderline group with a PCL–R of 27 or above. The two groups were comparable for Factor 1 (9.62±0.70 v. 10.06±1.22; F<1.00) and Factor 2 scores (12.91± 0.69 v. 11.84±0.81; F<1.10).
Medication
Twelve participants in the non-borderline group were unmedicated; 2 were
prescribed atypical antipsychotics; 2 selective serotonin reuptake inhibitors
(SSRI) antidepressants, 1 a tricyclic antidepressant, 3 mood stabilisers, 1
beta-blockers, 1 hypnotics and 1 a stimulant. Six participants from the
borderline group were not being prescribed any medication; 1 was being
prescribed a standard antipsychotic, 6 atypical antipsychotics, 2 SSRI
anti-depressants, 8 tricyclic antidepressants, 4 mood stabilisers, 3
beta-blockers and 2 hypnotics. Significantly more participants with borderline
personality disorder were receiving antidepressants (
2=5.9,
d.f.=1, P=<0.05) and there was a tendency for a greater proportion
to be prescribed antipsychotics (2= 3.704, d.f.=1,
P=0.054). However, the two groups were well-matched in terms of mood
stabilisers (2=0.177, d.f.=1, P=0.674), beta-blockers
(2=1.125, d.f.=1, P=0.289), hypnotics
(2=0.364, d.f.=1, P=0.546), and stimulants
(2=1.029, d.f.=1, P=0.31).
Psychometric assessments and self-report measures of mood and impulsivity
All participants were assessed for general cognitive ability using the
Wechsler Abbreviated Scale of Intelligence (WASI;
Wechsler, 1999). They also
completed the Welsh Anxiety Scale (WAS;
Welsh, 1956), which is a
measure of anxiety/negative affect and is derived from the Minnesota
Multiphasic Personality Inventory (MMPI;
Hathaway & McKinley,
1943). High scores on the WAS are thought to relate to a dysthymic
and dysphoric nature in which anxiety is a prominent feature. Depressive
symptoms were assessed using the short form of the Beck's Depression Inventory
(BDI; Beck et al,
1961). Impulsivity was assessed using the Barratt Impulsiveness
Scale (Version 11) (BIS–11; Patton
et al, 1995). The BIS–11 has been used to
distinguish between violent and non-violent parolees
(Cherek et al, 1997),
and has been reported to be a reliable measure of impulsivity in inmate
populations (Patton et al,
1995).
Neuropsychological instruments
Verbal memory
Logical Memory and Word Lists sub-tests of the Wechsler Memory
Scale–III (Wechsler,
1998) were administered to assess retention of verbal material
under immediate and delayed conditions.
Visual memory/Rey–Osterrieth Complex Figure Test
The Complex Figure Test (CFT;
Osterrieth, 1944) was used to
assess visual memory. Participants were scored according to the strict marking
scheme described by Bennett-Levy
(1984) on the quality of their
copy, immediate recall (3 min after copy) and delayed recall (25–30 min
after copy). Additional measures of the participants' recall of features with
good continuation and symmetry were also derived. Previous results have found
that recall deficits in the non-verbal tasks, such as the CFT, have been
associated with right-sided temporal damage
(Lezak, 1983).
Statistical analysis
Age, WASI scores, WAS, BDI, BIS–11 and WMS–III subtest scores
were analysed using one-way ANOVA with the between-participant factor of group
(borderline and non-borderline). Scaled WMS–III scores were derived from
the raw scores adjusted for age according to published norms
(Wechsler, 1998). Scores on
CFT were analysed by repeated-measures ANOVA with the between-participant
factor of group and the within-participant factor of trial (copy, immediate
and delayed recall score).
To investigate which criteria had the largest impact on neuropsychological test performance, we performed backward regression analyses, including both variables expected to influence memory performance – age (except where the dependent measure was scaled), full WASI score and current mood (BDI score) – and other personality-related variables such as the breadth of personality disorder (PAS score), Factor 1 score of the PCL–R and IPDE ratings of impulsiveness and affective instability (scored as absent, present at a sub-criteria level and present at full criteria level). There were no significant differences between the ages, full WASI scores and current mood ratings for participants rated with the IPDE for different levels of trait impulsivity (all F (2, 35), s<1.8) or for different levels of trait affective instability (F (2, 35) s<1.90). Correlations between ratings of impulsiveness and affective instability and other regressors included in the models were, in the main, modest (-0.10 to -0.19 and 0.01 to 0.28). However, affective instability was significantly correlated with the Factor 2 score of the PCL–R, so the latter was dropped. We report only regressors retained in the final model for the dependent measures.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Participants with borderline personality disorder reported significantly greater levels of anxiety on the WAS (F (1, 34)=19.612, P<0.001) and depressive/anxious symptoms on the BDI compared with participants without borderline personality disorder (F (1, 34)=6.987, P<0.05) (Table 2). Different aspects of impulsiveness were also increased, as reflected in higher scores on the attentional (F (1, 34)=6.183, P<0.05), motor (F (1, 34)= 9.201, P<0.01) and planning impulsiveness scores of the BIS–11 (F (1, 34)= 14.357, P<0.01) The total impulsiveness score of the BIS–11 was also increased (F (1, 34)=12.668, P<0.01).
Verbal memory/logical memory
Participants with borderline personality disorder recalled significantly
fewer story elements when recalling the stories immediately compared with
participants without borderline personality disorder (F (1, 33)=
4.54, P<0.05) (Table
3). This was particularly evident when recalling the stories for
the very first time (F (1, 33)=10.21, P<0.005). They also
performed significantly worse when recalling thematic elements of the test,
both immediately (F (1, 33)=9.65, P<0.005) and after a
delay of 25–35 min (F (1, 33)=6.03, P<0.05). There
were no significant differences between groups in the improvement in immediate
recall when hearing the stories for the second time compared with the first
time (F<1.00), in the total number of story elements recalled
after 25–30 min (F (1, 33)=1.57), or the proportion of
information retained in delayed recall (F<1.00). However, the
participants with borderline personality disorder showed significantly poorer
recognition of story elements (F (1, 32)=6.21,
P<0.05).
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Backward regression indicated that both clinical ratings of breadth of personality disorder (PAS score) and affective instability (IPDE criterion score) were significant or near-significant predictors of poor immediate story recall (R2=0.28; standardised ß=-0.32, t=-2.03, P=0.05 and standardised ß=-0.37, t=-2.37, P<0.05, respectively). Affective instability alone was a significant predictor of poor immediate recall after hearing the stories for the first time (R2=0.29; standardised ß=-0.54, t=-3.53, P<0.001; see Fig. 1), immediate thematic recall (R2=0.41; standardised ß=-0.64, t=-4.56, P<0.001; see Fig. 1) and recognition of story items (R2= 0.20; standardised ß=-0.44, t=-2.77, P<0.01). Cognitive ability (WASI full IQ) predicted better delayed thematic recall scores (R2=0.44; standardised ß=-0.49, t=-3.51, P<0.005) whereas higher Factor 1 scores from the PCL–R and affective instability both predicted worse delayed thematic scores (standardised ß=0.32, t=-2.21, P<0.05 and standardised ß= 0.35, t=-3.51, P<0.05 respectively; see Fig. 1).
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Cognitive ability and current mood (BDI score) showed significant but opposing relationships with the number of words recalled after the first learning trial (R2= 0.46; standardised ß=0.45, t=3.337, P<0.005; standardised ß=-0.42, t=-3.05, P<0.01, respectively). Current mood alone predicted poorer list recall after the fourth learning trial (R2=0.14; standardised ß=-0.37, t=-2.27, P<0.05).
Visual memory/Rey–Osterrieth Complex Figure Test
Participants with borderline personality disorder obtained significantly
lower scores on all aspects of performance compared with participants without
borderline personality disorder (F (1,33)=8.11, P<0.01;
see Fig. 2). Planned
comparisons indicated significantly lower scores on the copy component of the
CFT (F (1,33)= 6.86, P<0.05). Specifically, the copies of
the two groups showed comparable evidence of good continuation
(12.00±0.84 v. 11.22±0.86; F<1) but those
with borderline personality disorder tended to show poorer reproduction of the
symmetrical components of the CFT (9.61±0.87 v.
12.06±0.82; F (1,35)=4.29, P<0.05). In addition,
they produced lower scores on the immediate recall (F (1,33)=5.93,
P<0.05) and delayed recall measures (F (1,33)=5.52,
P<0.05).
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Cognitive ability and affective instability were significant predictors of good and poor copy scores (R2=0.52; standardised ß=0.40, t=3.19, P<0.005; standardised ß=-0.47, t=-3.59, P<0.005; see Fig. 1). Breadth of personality also tended to show some association with poorer copy scores (standardised ß=-0.22, t=-1.73, P<0.10). However, affective instability was the single best predictor of poor immediate recall score of the CFT (R2=0.13; standardised ß=-0.36, t=-2.18, P<0.05; Fig. 1).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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We acknowledge that our two groups of prisoners were inevitably different in ways that may have influenced cognitive function. First, the participants with borderline personality disorder scored significantly higher on the BDI; therefore, their greater ratings of depressive symptomology may account for some of the deficits observed here. However, although BDI scores predicted poorer recall of items from the word lists test on the first and fourth presentations across the entire sample, there was no indication of state mood effects in the case of the logical memory or the Rey–Osterrieth CFT tests. Rather, these impairments seemed most closely tied to the presence or otherwise of a diagnosis of borderline personality disorder and the presence of trait affective instability scored as part of the IPDE assessment. Second, we also note that participants with borderline pesonality disorder were receiving more antipsychotic and antidepressant medication. Previous studies have shown that such medications tend to have mixed effects on cognitive measures (Markovitz & Wagner, 1995), depending upon participants' baseline performance, their dose and the treated psychopathology. However, in the present study, the differences in drug regimens between the two groups were relatively modest and unlikely to account for the pattern of our observations.
Finally, participants with borderline personality disorder had a higher number of `definite' and `probable' comorbid personality disorders so that the increased multiplicity of personality disorders associated with borderline personality disorder (Becker et al, 2000) might also account for the observed memory impairments. However, our analyses indicated that breadth of personality disorder – as measured by the PAS (Tyrer & Johnson, 1996) – accounted for only a very modest amount of the variance of memory performance, being a significant predictor only of the immediate recall scores of the logical memory test. We did not find that individuals with a diffuse pattern of personality disorder scored consistently worse than those with a simple personality disorder. Finally, it is unlikely that gross differences in clinical ratings of psychopathy can explain our results as these were comparable between our two groups. Instead, the data indicate that poor recall was more closely associated with the presence of borderline personality disorder and its diagnostic features.
Verbal and visuospatial mnemonic function
Prisoners with borderline personality disorder demonstrated significant
reductions in the total recall, the first recall and the immediate and delayed
thematic recall measures of the WMS–III Logical Memory test, and on the
copy, immediate and delayed recall of Rey–Osterrieth CFT. Performance of
the WMS–III Word Lists test was more equivocal, showing statistically
unreliable impairments in immediate and delayed recall but a significant
reduction in the delayed recall of words successfully reproduced at immediate
recall. This pattern is broadly similar to those reported previously in
community samples, and is consistent with the proposal that the memory
impairment in borderline personality disorder is most strongly expressed in
the recall of complex material (O'Leary
et al, 1991). Extensive evidence indicates that
declarative memory is supported by functionally dissociable sub-systems
supported by overlapping neural substrates
(Schacter, 1996). The present
data suggest that borderline personality disorder in individuals with
significant histories of antisocial behaviour is associated with relatively
generalised memory impairments, perhaps reflecting dysfunction in some of
these sub-systems.
These data do not tell us too much about whether memory problems relate primarily to the encoding of information, the consolidation or the recall of already sampled information. On the one hand, deficits were most marked in the immediate story recall of the Logical Memory and Rey–Osterrieth CFT tests and there was little sign that these differences were increased at delayed recall (the single exception being the poorer retention of previously remembered items of word lists). This indicates that the prisoners with borderline personality disorder did not show greater forgetting of material that has been successfully recalled earlier, at least over relatively brief intervals. Similarly, there were no significant between-group differences in the improvement seen in performance over the successive learning trials of the WMS–III Word Lists test. However, the participants with borderline personality disorder did show evidence of greater susceptibility to interference while recalling word lists, indicating that the retrieval of verbal information might also be compromised (see Della Rocchetta & Milner, 1993).
Further information about the nature of the mnemonic deficits is provided by the observation that participants with borderline personality disorder were most clearly impaired on the thematic elements of the Logical Memory test. These relate to the ability to remember the gist of the stories, which is more general than the specific and literal information required by other components of the test. This finding may have real consequences for assessment and treatment in centres such as those in the DSPD initiative. In these and other forensic settings, treatment intervention might involve exposure to sets of concepts, organised around one single theme, relevant to a particular treatment target (e.g. stop-and-think in cognitive skills training). The present results suggest that some prisoners may find it difficult to assimilate even such general ideas when delivered in a verbal format. Treatment development might involve assessing memory for both the themes and the details of treatment programmes over the short and longer-term to optimise delivery in different individuals.
In addition, it was notable that the participants with borderline personality disorder were impaired in the copy component of the Rey–Osterrieth CFT. Previous results involving patients with borderline personality disorder have been equivocal, with two studies reporting that community patients were impaired relative to non-clinical controls (Judd & Ruff, 1993; Dinn et al, 2004) but three reporting no differences (O'Leary et al, 1991; Driessen et al, 2000; Sprock et al, 2000). Given that the participants with borderline personality disorder in the present study also reproduced significantly fewer symmetrical elements of the CFT, further investigations in antisocial populations should at least explore the possibility that memory impairments are accompanied by more basic deficits in visuospatial construction, as well as using tailored tasks to probe the cognitive mechanisms that underlie problems in mnemonic function related to borderline personality disorder.
Our analyses sought to provide a preliminary test of the extent to which state or trait factors were most closely associated with memory dysfunction. We found only limited effects of current mood or trait impulsiveness but more consistent evidence for the involvement of affective instability in poor memory performance. Thus, these data suggest an association between failing regulation of emotion and generalised multi-modal memory deficits in prisoners with a diagnosis of DSM–IV borderline personality disorder. This is consistent with the findings of a complementary study – conducted in an overlapping sample of prisoners assessed for DSPD – demonstrating that affective instability was associated with reduced attention towards emotional cues while making risky choices (Kirkpatrick et al, 2007). This, and the present study, utilised clinical ratings of affective instability – scored across a relatively restricted range – but future studies should exploit more recently developed and multi-faceted structured clinical measures of emotional regulation (Koenigsberg et al, 2002) to examine its influence upon altered cognition in borderline personality disorder.
Finally, the selection of neuropsychological instruments provides only poor information about dysfunction within underlying neural systems. However, the pattern of memory impairments observed is broadly consistent with the proposal that borderline personality disorder involves dysfunction of bilateral frontotemporal systems. The Logical Memory test and Rey–Osterrieth CFT are sensitive to anterior left-sided anterior temporal lobe damage (Trenerry et al, 1996; Griffith et al, 2004) and right-sided hippocampal and association cortex damage (Bohbot et al, 1998) respectively. Recent research has also suggested that the amygdala plays a significant role in memory for themes or gist, particularly for emotionally salient information (Adolphs et al, 2001). This is consistent with the finding that higher Factor 1 scores, indicative of more marked interpersonal and affective deficits in psychopathy, were associated with impaired thematic memory on the Logical Memory test. Intriguingly, Donegan et al (2003) have demonstrated altered neuronal activity within the amygdala in response to emotional facial expressions in individuals with borderline personality disorder. Therefore, the observed memory impairment might be mediated by dysfunction within association cortices that subserve learning, memory and visuospatial capabilities, and limbic circuits that route emotional information into other forms of cognitive processing.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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—) and 18
with non-borderline personality disorders (—•—). Delayed
recall is at 25-20 min.