The document presents an overview of cognitive functioning and functional abilities in individuals with borderline personality disorder (BPD), highlighting key cognitive deficits such as attention, memory, and executive functions. It emphasizes the variability of cognitive abilities among individuals with BPD and their relatives, as well as the impact of these deficits on daily living and treatment outcomes. Additionally, it suggests that cognitive difficulties may relate to higher levels of functional disability in both patients and their families.

1. Cognitive
Functioning
and
Functional
Abilities
in
Borderline
Personality
Disorder
Anthony
C.
Ruocco,
Ph.D.
Department
of
Psychology,
University
of
Toronto
1

2. Topics
In
This
Presentation:
1. What
Is
Cognition?
2. Examples
Of
Cognitive
Tests
Used
By
Neuropsychologists
3. Why
Evaluate
Cognition
In
BPD?
4. Cognitive
Functions
In
BPD
5. Functional
Abilities
In
People
With
BPD
And
Their
Relatives
6. Summary
and
Future
Directions
2

3. What
Is
Cognition?
§ The
term
cognition
refers
to
thinking
abilities
(e.g.,
attention,
concentration,
memory,
and
problem-­‐solving
skills).
§ Neuropsychologists
are
trained
to
assess
cognition
in
people
with
mental
and
neurological
disorders.
They
use
carefully
designed
instruments,
which
have
been
validated
on
very
large
groups
of
individuals,
to
measure
various
types
of
thinking
abilities.
3

4. Cognitive
Functions
Often
Evaluated
By
Neuropsychologists
4

5. Examples
of
Cognitive
Tests
Used
By
Neuropsychologists
5

6. Attention
And
Concentration
§ Brief
attention
can
be
tested
by
asking
examinees
to
repeat
a
series
of
digits.
For
example:
Say these digits back to me in the same order: 6-4-1-9-3.
§ Concentration
may
be
evaluated
using
computerized
tests
that
ask
examinees
to
pay
attention
to
letters
presented
on
a
computer
monitor
and
press
a
key
only
when
they
see
a
certain
letter
For
example:
Press the space bar every time you see the letter “A”. Don’t press any button
when you see any other letter.
6

7. Working
Memory
§ Working
memory
is
the
ability
to
maintain
and
manipulate
information
“online”
for
brief
periods
of
time.
For
example:
Remember these three words—apple, table, and mouse. Now count
backward by five from the number 76. [Time 10 seconds.] Tell me the three
words that I asked you to remember.
7

8. Verbal
and
Visual
Memory
§ Verbal
and
visual
memory
reflect
the
ability
to
learn
and
recall
different
types
of
information.
For
example,
verbal
memory
can
be
tested
in
this
way:
Remember this list of 10 words. [Read examinee the list of words.] After 20
minutes, I’m going to ask you to repeat the same list of words.
For
example,
visual
memory
can
be
tested
in
this
way:
I’d like you to remember these 10 designs. [Show examinee a page with
10 designs.] After 20 minutes, I’m going to ask you to draw each of these
designs from memory.
8

9. Executive
Functions
§ Executive
functions
refer
to
higher-­‐order
thinking
abilities,
such
as
planning,
problem-­‐solving
and
impulse
control.
For
example:
Make your board look like the target board
using as few moves as possible.
Ruocco
et
al.
(2014)
9

10. How
Is
Neuropsychological
Testing
Used
in
Clinical
Practice?
§ To
aid
in
making
a
diagnosis
(for
example,
diagnosing
ADHD,
a
learning
disorder,
or
dementia).
§ To
assist
in
treatment
planning
(for
example,
identifying
a
need
for
memory
aids
during
psychotherapy
or
to
remember
to
take
medications).
10

11. Why
Evaluate
Cognition
in
Borderline
Personality
Disorder?
11

12. Why
Evaluate
Cognition
in
BPD?
§ Historically,
clinicians
have
described
a
variety
of
cognitive
deficits
which
seemed
to
interfere
with
the
treatment
of
some
individuals
with
BPD
(Kroll,
1988).
§ Difficulties
with
cognitive
functioning
have
been
strongly
associated
with
high
levels
of
inpatient
psychiatric
hospitalization
in
BPD
(Comtois
et
al.,
2003)
and
a
greater
likelihood
of
patients
with
BPD
dropping
out
of
psychotherapy
treatment
(Fertuck
et
al.,
2012).
12

13. Poor
Focus
&
Concentration
Memory
Problems
and
Distortions
Impulsive
Behaviours
Difficulties
with
Logical
Reasoning
Kroll
(1988)
13

14. People
With
Childhood
ADHD
Have
A
High
Risk
Of
Developing
BPD
As
Adults
§ Attention-­‐deficit
hyperactivity
disorder
(ADHD)
and
BPD
appear
to
share
several
symptoms,
including
impulsiveness,
emotional
instability,
and
difficulty
controlling
anger.
§ Children
with
ADHD
are
5
times
more
likely
than
children
without
ADHD
to
develop
BPD
later
in
adulthood
(Fischer
et
al.,
2002).
14

15. Cognitive
Function
In
Borderline
Personality
Disorder
15

16. Precautions
When
Interpreting
Results
Of
Cognitive
Functioning
In
BPD
ü Not
all
people
with
BPD
have
cognitive
difficulties.
ü These
results
present
the
averages
of
how
people
with
BPD
perform
on
standardized
tests
of
cognition.
ü Some
people
with
BPD
have
difficulties
with
many
cognitive
abilities,
whereas
others
perform
in
the
average
or
even
superior
range.
ü There
may
be
many
reasons
that
a
person
with
BPD
may
experience
cognitive
difficulties—for
example,
due
to
sedating
medications,
fatigue
caused
by
poor
sleep,
and
other
physical
and
mental
disorders.
ü Understanding
what
might
be
a
significant
or
problematic
weakness
in
cognition
for
any
one
individual
should
be
made
in
consultation
with
a
psychologist
with
expertise
in
neuropsychology.
16

17. People
With
BPD
And
Their
Relatives
Report
Many
Cognitive
Limitations
0
1
2
3
4
Inattention
Hyperactivity
Impulsivity
Self-­‐Concept
Z-­‐
S
CORE
Proband
(n=26)
Relative
(n=17)
Control
(n=31)
Ruocco
et
al.
(2014)
Weakness
17

18. Most
Research
Participants
with
BPD
Put
Forth
Good
Effort
on
Cognitive
Testing
Ruocco
(in
revision)
-­‐1.5
-­‐1.3
-­‐1.1
-­‐0.9
-­‐0.7
-­‐0.5
-­‐0.3
-­‐0.1
0.1
0.3
Verbal
Episodic
Memory
Selective
Attention
Response
Control
Problem-­‐Solving
Processing
Speed
Z-­‐
S
CORE
Compliant
(n=44)
Questionably/Probably
Not
Compliant
(n=6)
*
p
=
0.01
18

19. People
With
BPD
Have
Cognitive
Deficits
Affecting
A
Range
of
Abilities
-­‐1.8
-­‐1.6
-­‐1.4
-­‐1.2
-­‐1
-­‐0.8
-­‐0.6
-­‐0.4
-­‐0.2
0
Cohen’s
d
E
ffect
S
ize
Ruocco
(2005)
Weakness
266
patients
with
BPD
255
healthy
controls
19

20. People
With
BPD
May
Also
Have
Greater
Variability
In
Their
Cognitive
Abilities
§ Some
research
suggests
that
patients
with
BPD
(as
well
as
those
with
schizophrenia
and
depression)
may
show
high
degrees
of
variability
in
how
quickly
they
respond
to
visual
information
(e.g.,
press
a
button
to
a
specific
letter
of
the
alphabet)
(Kaiser
et
al.,
2008).
§ Ruocco
and
Bahl
(2014)
extended
this
research
to
memory
functioning
in
patients
with
BPD.
They
showed
that
patients
showed
larger
than
average
discrepancies
in
their
verbal
and
visual
memory
abilities,
but
neither
one
was
consistently
better
or
worse
than
the
other.
20

21. Poorer
Executive
Functions
May
Be
Associated
with
More
Medically
Lethal
Self-­‐Injurious
Behavior
Williams
et
al.
(in
press)
-­‐0.8
-­‐0.6
-­‐0.4
-­‐0.2
0
0.2
0.4
0.6
Color
Naming
Word
Reading
Inhibition
COHEN'S
D
E
FFECT
S
IZE
Worse
performance
for
high
lethality
patients
(n=18)
vs
low
lethality
patients
(n=40)
21

22. Cognitive
Deficits
May
Run
In
Families
With
BPD
§ We
recently
showed
that
subjective
complaints
of
cognitive
disturbance
run
in
families
with
BPD
and
co-­‐segregate
with
the
disorder
(Ruocco,
Hudson,
Zanarini,
&
Gunderson,
2015).
§ First-­‐degree
relatives
of
patients
with
BPD
may
also
be
at
risk
for
deficits
in
executive
functions,
especially
planning
and
response
inhibition
(i.e.,
impulse
control
ability)
(Gvirts
et
al.,
2012;
Ruocco
et
al.,
2012).
22

23. Functional
Abilities
In
People
With
BPD
And
Their
Relatives
23

24. Many
Ways
To
Measure
Functional
Abilities
In
People
With
Mental
Disorders
Work/
Employment
Interpersonal
Relationships
Family
Household
Responsibility
Academics
Recreation
Physical
Functioning
Vitality
Self-­‐Esteem
Relation
to
Self
Economic
Self-­‐
Sufficiency
Mobility
24

25. Functional
Limitations
Are
Commonly
Reported
By
People
With
BPD
§ Individuals
with
BPD
report
greater
disability
than
people
without
BPD,
even
when
controlling
for
socio-­‐demographic
characteristics,
physical
conditions
and
other
mental
disorders
(Grant
et
al.,
2008).
§ Patients
with
BPD
(and
those
with
schizotypal
PD)
report
more
impairment
at
work,
in
social
relationships,
and
at
leisure
than
other
PD’s
or
patients
with
depressive
and
anxiety
disorders
(Ansell
et
al.,
2007;
Skodol
et
al.,
2002).
§ Functional
impairments
(especially
in
social
relations)
are
relatively
stable
at
multi-­‐year
follow-­‐up
assessments
(Gunderson
et
al.,
2011;
Skodol
et
al.,
2005a;
Zanarini
et
al.,
2009).
25

26. World
Health
Organization
Disability
Assessment
Schedule,
Version
2.0
(WHODAS
2.0)
Understanding
and
communicating
Getting
around
Self-­‐care
Getting
along
with
people
Life
activities
(e.g.,
household,
work/school)
Participation
in
society
26

27. Patients
With
BPD
Report
Extremely
High
Levels
of
Functional
Disability
0
10
20
30
40
50
60
70
80
90
100
WHODAS
Total
Score
for
Patients
with
BPD
(n=43)
Percentile
Note:
Error
bar
represents
95%
confidence
interval.
27

28. How
Might
Cognitive
Deficits
Affect
Someone’s
Life?
§ Difficulties
with
various
aspects
of
cognition
could
impact
a
number
of
functional
abilities.
For
example,
§ Caring
for
oneself
§ Communicating
effectively
with
other
people
§ Carrying
out
one’s
daily
activities
(work,
school,
household
responsibilities)
28

29. Disability
in
Patients
with
BPD,
Non-­‐
Affected
Relatives
and
Controls
0
10
20
30
40
50
60
70
80
90
100
Cognition
Mobility
Self-­‐Care
Social
Life
Activities
Society
SEVERITY
O
F
D
ISABILITY
Control
Relative
BPD
29

30. Problems
With
Attention
And
Memory
Are
Linked
To
Difficulties
With
Activities
Of
Daily
Living
In
BPD
§ After
controlling
for
depressed
mood
in
the
two
weeks
prior
to
assessments,
complaints
of
inattention
and
forgetfulness
were
associated
with
difficulties
carrying
out
activities
of
daily
living
(including
work,
school,
and
household
responsibilities)
in
patients
with
BPD
and
their
non-­‐affected
relatives
(Ruocco
et
al.,
2014).
§ Among
patients
with
BPD
(but
not
relatives),
greater
difficulties
with
social
functioning
were
moderately
associated
with
deficits
on
neuropsychological
measures
of
attention
and
speed
of
information
processing
(r’s
>
.54,
p’s
=
.001).
30

31. Conclusions
And
Future
Directions
31

32. Summary
§ On
average,
people
with
BPD
show
subtle
weaknesses
in
certain
cognitive
functions,
especially
attention/concentration,
memory,
and
executive
functions
(e.g.,
planning,
problem-­‐
solving,
and
impulse
control).
§ In
addition
to
weaknesses
in
specific
cognitive
functions,
when
comparing
different
people
with
BPD,
there
appears
to
be
a
high
degree
of
variability
in
cognitive
abilities
(e.g.,
some
people
have
strong
verbal
memory
but
weak
visual
memory,
and
vice
versa).
This
is
consistent
with
findings
in
other
mental
disorders,
such
as
schizophrenia,
depression,
and
ADHD.
§ More
severe
deficits
in
impulse
control
and
problem-­‐solving
may
underlie
more
severely
lethal
self-­‐injurious
behaviours
in
people
with
BPD.
32

33. Summary
§ Individuals
with
BPD
and
their
relatives
report
elevated
functional
limitations
across
a
wide
range
of
life
areas.
§ Limitations
in
attention
and
memory
may
be
linked
to
difficulties
carrying
out
activities
of
daily
living
(e.g.,
work,
school,
and
household
responsibilities)
in
people
with
BPD
and
their
relatives.
33

34. Implications
for
Treatment
§ To
effectively
engage
in
psychotherapy,
attention,
concentration,
memory
and
executive
functions
(e.g.,
planning,
problem-­‐solving
and
impulse
control)
must
be
intact.
§ Problems
may
arise
when
any
one
of
these
cognitive
functions
are
affected
in
individuals
with
BPD,
and
in
turn,
these
difficulties
could
have
downstream
influences
on
therapy
outcomes
and
functional
abilities.
34

35. How
Can
Mindfulness-­‐Based
Psychotherapy
Improve
Cognition
In
BPD?
Practice
in
mindful
awareness
and
acceptance
Improved
attention,
concentration
and
impulse
control
Better
capacity
to
benefit
from
treatments,
and
improved
functional
abilities
35

36. Future
Directions
Promising
New
Research
Is
Underway
To
Investigate
Many
Compelling
Questions
About
Cognition
And
BPD
• How
and
in
what
ways
do
cognitive
limitations
impact
psychotherapy
outcomes
for
patients
with
BPD?
• Can
we
use
cognitive
deficits
as
potential
biomarkers
to
identify
genetic
factors
involved
in
BPD?
• Are
cognitive
deficits
inherited
in
families
affected
with
BPD?
• How
might
cognitive
limitations
impact
functional
abilities
in
patients
with
BPD
and
their
relatives?
• Do
brain
stimulation
therapies
to
improve
depression
in
BPD
impact
cognitive
abilities?
36

37. Acknowledgements
University
of
Toronto
Clinical
Neurosciences
Laboratory
Western
University
Paul
Links,
M.D.
Centre
for
Addiction
&
Mental
Health
Shelley
McMain,
Ph.D.
McLean
Hospital
John
Gunderson,
M.D.
Mary
Zanarini,
Ed.D.
37