In Review

The Neuropsychological Correlates of Borderline

Personality Disorder and Suicidal Behaviour

Jeannette LeGris, BN, MHSc, PhD Candidate1, Rob van Reekum, MD, FRCPC2

Objective: In subjects with borderline personality disorder (BPD), compared with subjects who attempted suicide, to
review neuropsychological (NP) function that may predispose to suicidal behaviour along a continuum of high and low
lethality.
Method: We undertook electronic searches of MEDLINE, PsycINFO, EMBASE, Biosos Reviews, and Cinhal. The
searches were restricted to English-language publications from 1985 onward. The search terms borderline personality
disorder, suicide, suicide attempt, self-harm behaviour, neuropsychological, executive function (EF), neurocognitive, and
neuropsychological function produced 29 neuropsychology studies involving BPD and 7 neuropsychology studies of
suicide attempters, regardless of psychiatric diagnosis.
Results: Of the BPD studies, 83% found NP impairment in one or more cognitive domains, irrespective of depression,
involving specific or generalized deficits linked to the dorsolateral prefrontal and orbitofrontal regions. The functions
most frequently reported (in 71% to 86% of BPD studies) are response-inhibitory processes affecting executive function
performance that requires speeded attention and visuomotor skills. Decision making and visual memory impairment are
also most frequently affected; 60% to 67% of BPD studies report attentional impairment, verbal memory impairment, and
visuospatial organizational impairment. Least affected processes in BPD appear to involve spatial working memory,
planning, and possibly, IQ. The similarities in NP deficits found in BPD and suicide-attempt studies involve decision
making and Trails performances. BPD studies, however, reflect more frequent impairment on the Stroop Test and
Wisconsin Card Sort Test performance than the suicide-attempt studies, whereas verbal fluency appears to be more
frequently impaired in those attempting suicide.
Conclusions: Impaired EF and disinhibitory processes, as indicated by verbal fluency, Trails, and Stroop performance,
primarily associated with dorsolateral prefrontal cortical regions may represent a dominant executive pathway to suicide
attempt. A primary motivational inhibitory pathway involving conflictual, affective, and reflexive decision-making
processes associated with orbitofrontal brain regions, in combination with significant cognitive rigidity, may influence the
repetitive expression of self-harm or low-lethality suicidal behaviour. The hypothesis of a specific trait-like cognitive
vulnerability for suicidal behaviour involving dysregulatory, disinhibiting pathways awaits confirmation.
(Can J Psychiatry 2006;51:131–142)
Information on funding and support and author affiliations appears at the end of the article.

Clinical Implications

· Deliberate and automatic neural processes, in combination with other risks, may yield unique pathways to suicide attempt and
self-harm.
· The notion of willful, deliberate self-harm behaviour in some patients may have to be reconsidered.
· Greater clinical recognition and accommodation of neurocognitive impairments in paitents with BPD warranted.

Limitations

· The paucity of comprehenisve NP studies of suicide makes comparisons with other populations preliminary and exploratory.
· The clinical significance of NP findings in suicidal patients awaits further clarification.
· The influence of ADHD–LD comorbidity on the NP performance of suicidal patients requires further understanding.

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The Canadian Journal of Psychiatry—In Review

Key Words: neuropsychological, suicide attempt, borderline connections. Recent investigations combining NP perfor-
personality, executive function mance with structural and functional neuroimaging have
localized the underlying neural pathways and biological
he NP study of suicide remains in its infancy. A growing mechanisms involved (9–17). While extensive NP research
T interest is emerging, however, in the neuropsychology of
BPD. BPD is associated with suicidal behaviour, and hence,
has been conducted on schizophrenia and ADHD, the role of
cognitive dysfunction in the causation of BPD, and suicidal
an understanding of the neuropsychology of BPD may lead to behaviour more generally, remains unclear (18,19).
a greater understanding of the neuropsychology of suicidal One in 10 patients with BPD will complete suicide; 75% will
behaviour. NP studies to date have provided inconsistent engage in self-injurious behaviour, a known risk factor for
results and (or) results that overlap with other clinical disor- suicide attempt (20–23). Because the clinical distinctions
ders. These developments raise questions about the specificity between self-harm and suicidal behaviour remain ambigu-
and stability of these NP deficits and lead one to wonder ous (24,25), the role of cognitive impairment as a potential
whether they are the causal organic antecedents to psychiatric risk factor for suicidal behaviour remains largely unknown.
disturbance (1,2), the result of environmental vulnerabili- Currently, few investigations exist examining the associa-
ties (3–5), some complex combination (6–8), or the result of tions between cognitive impairment and suicidal behaviour,
the illness itself. Longitudinal studies, as yet unavailable, may defined as self-directed injuries with at least some intent to
provide more definitive answers to these important causal die (26). Could dissociable cognitive processes associated
with self-harm and suicidal behaviour provide clinicians with
additional information to more reliably predict and manage
these behaviours? This review of NP function in BPD and in
suicide attempts regardless of psychiatric diagnosis examines
Abbreviations used in this article the role of cognitive dysfunction in the causation of suicidal
ADHD attention-deficit hyperactivity disorder and self-harm behaviour.
ANT Attention Network Test
An examination of cognitive dysfunction in BPD, regardless
BDI Beck Depression Inventory
of the lethality of suicidal behaviour, and its comparison with
BPD borderline personality disorder cognitive dysfunction in suicide attempters in general, may
BWM backward masking yield distinct patterns of NP impairment. A greater under-
CD conduct disorder standing of suicidal and self-harm behaviour can inform sub-
COWAT Controlled Oral Word Association Test sequent research and clinical practice.
CPT Continuous Performance Test
EF executive function Search Methods and Results
fMRI functional magnetic resonance imaging We searched MEDLINE, PsycINFO, EMBASE, Cinhal, and
GNAT Go/No-go Association Task
Biosis Reviews for articles published in English from 1985
onward. Search terms were borderline personality disorder,
ID/ED Intra/Extra-Dimensional Set-Shift Task
neuropsychological, suicide, executive function,
IGT Iowa Gambling Task
neurocognitive assessment, neuropsychological function, and
LD learning disability
suicide attempt. Studies were included if they involved any
NART National Adult Reading Test number of commonly used standardized NP tests or batteries
NP neuropsychological in samples of BPD and suicidal populations. Manual searches
PFC prefrontal cortical of the authors’ reference lists produced additional relevant lit-
PPVT Peabody Picture Vocabulary Test erature. The search produced 29 NP investigations involving
PTSD posttraumatic stress disorder BPD as a primary or secondary comorbid disorder. Only 7
ROFC Rey Osterrieth Complex Figure test
published studies of NP function in suicide attempters were
located (27–33).
SD standard deviation
STROOP The Stroop Colour and Word Test
Overview of NP Studies of BPD
TBI traumatic brain injury
NP studies of BPD suffer from the methodological challenges
WAIS Wechsler Adult Intelligence Scale
related to controlling for past or current alcohol or substance
WAIS-R WAIS-Revised abuse, comorbid anxiety, depression, ADHD, LD, and medi-
WCST Wisconsin Card Sort Test cation effects—all known to potentially affect neurocognitive
test performance (34). Generalized and domain-specific

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 The Neuropsychological Correlates of Borderline Personality Disorder and Suicidal Behaviour
deficits were affirmed in 24 of 29 published studies located in
this review, despite the wide variation in samples studied (see
Note). Studies primarily included convenience samples of
women aged 18 to 50 years, with mixed-sex samples repre-
sented in 7 studies and all-male subjects represented in only 3
investigations. To date, slightly more inpatients are repre-
sented than outpatients, with some investigators including
both. The controlled studies were matched for age, education,
sex, and less frequently, IQ—all believed to affect NP func-
tion. Only 5 investigators (19,35–38) failed to find significant
NP impairment in BPD.
First-Generation Studies: NP and BPD
Psychopathology Correlates
First-generation studies were exploratory for the presence or
absence of NP abnormalities in BPD (35,39–44) associated
with personality and psychopathology measures. These
important studies made use of comprehensive NP batteries,
but they were characterized by very small samples with no
current Axis I comorbidities. These early studies ranged from
those without a control group (35,42) to others with carefully
matched healthy control subjects (40,41,43,44). Only
Burgess (39) and van Reekum (43) made use of psychiatric
comparisons. Reports of general intelligence, attention, mem-
ory, and motor deficits were documented by some investiga-
tors (39,41,43,44). EF was described as abstract thinking,
problem solving, and complex visual or verbal information
processing.
Second-Generation Studies: Biological
Correlates of EF in BPD
Building on first-generation findings, incorporating data
drawn from populations having brain lesions and from
healthy populations, and using modern neuroimaging tech-
nology, second-generation investigators focused on selective
attentional and (or) EF tests with known localizing value to
specific brain regions. These recent technological advances
are strengthening support for the view that biological under-
pinnings are implicated in the disorder (4,19,37,45). Greater
conformity to standardized research diagnosis; use of healthy,
psychiatric, and comorbid control subjects; larger samples;
use of convergent computerized and manual NP tests; and
greater attention to relevant confounds generally characterize
these investigations (3,18,36,38,46–57). However, the inclu-
sion or exclusion of subjects with mild neurologic
comorbidity (that is, with TBI, ADHD, LD, or epilepsy) con-
tinues to vary across studies (5,19,37) and detracts from the
comparisons among samples. To date, few investigators have
attempted to disentangle this significant confound (3,
5,18,43,47,51,58), which is related to both BPD diagnosis and
EF dysfunction.
Can J Psychiatry, Vol 51, No 3, March 2006 W
In 1 of 2 reviews, O’Leary (59) reports on 4 comprehensive
studies, including her own, that found impairment in simple
and logical verbal memory and visuospatial organization (40,
41,44,60). All 4 confirm deficits in complex visual memory,
with 2 of the 4 also identifying lowered IQ (41,44). Because
studying IQ in general remains controversial (61), many
investigators have not measured or reported on it. In a review
of 14 studies, Monarch and others note a lack of comprehen-
sive NP investigations of BPD (42); these often involve a sin-
gle domain, with attentional tests appearing to lose favour to
specific EF measures. More refined hypotheses and tests with
greater localizing value may have led to these trends. As well,
many attentional processes are believed to underly EF func-
tion (62). Findings of impulsivity, verbal memory, and
visuospatial EF impairment were evident in Monarch’s
review. She subsequently found WAIS Digit Symbol scores
(a measure of visuomotor speed, attention, and intelligence)
to be 3 to 5 SDs below historical comparison-group scores in
her own study. Recent investigations demonstrate variable
exclusion of subjects with current Axis I and II comorbidity;
however, representativeness is questionable because it is
unlikely that a “pure” BPD condition exists (8,63). The exclu-
sion criteria may explain the small samples studied.
NP Findings in BPD
BPD and General Intellectual Function
The WAIS-R is the most comprehensive test of general intel-
lect, whereas the NART (64) is widely used as a verbal esti-
mate of premorbid intellectual ability. The Digit Symbol,
Block Design, or Picture Arrangement subtests of the WAIS
also represent intelligence estimates. Three comprehensive
WAIS assessments found subjects with BPD to be more intel-
lectually compromised than were control subjects (40,41,44);
normal findings were reported by Cornelius, who had no con-
trol group (35); and Driessen, who, after controlling for
depression with BDI scores, did not find any difference in
IQ (19). Using 4 WAIS subtests, Irle and others found signifi-
cant impairment in verbal IQ, and more severe performance
impairment on the Block Design (4). Using IQ estimates,
Burgess (39) and Bergvall (56) also endorsed lowered verbal
IQ in subjects with BPD. However, normal IQ in BPD was
also reported (3,19,36,37,48,50,51). These inconsistencies
suggest that the full-scale WAIS may be more sensitive or that
the negative findings associated with IQ estimates may reflect
the classic heterogeneity of BPD. Overall, performance IQ
seems to be more consistently affected than verbal IQ, which
may reflect the visuospatial impairment found in individuals
with BPD. Overall, 54% of studies found lower IQ in subjects
with BPD, suggesting impaired premorbid functioning. Many
researchers set an IQ level in their inclusion criteria and thus
might have erroneously eliminated those most affected.
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The Canadian Journal of Psychiatry—In Review

Attention and BPD subgroup but no visual or verbal memory differences among
Although lacking a clear definition, 2 aspects of attention— subjects in either organic and nonorganice groups (18). These
that is, automatic or reflexive processes and voluntary con- findings suggest that organicity does not account for all
trolled processes—are well established. Sustained attention, observed NP deficits. Depression and anxiety also had little
such as occurs in vigilance, and the notion of a time- effect on the test results. Attention and verbal fluency scores
limited capacity to remain vigilant are known to be affected by correctly predicted 71.3% of group membership.
depression, fatigue, ageing, and brain damage (34). Selective
Of 15 studies, 9 (60%) identified significant, sustained, selec-
attention or concentration involves focusing on relevant stim-
tive, or highly specific attentional impairment in BPD. Do
uli while ignoring irrelevant stimuli. Slowed processing
attentional difficulties further reflect the presence of
underlies many attentional disorders, which can have broad
dissociative phenomena commonly experienced by some
effects on all aspects of attention. Fifteen studies examined
patients during acts of self-injury? Parallel visuospatial and
selective and sustained attention by means of the CPT, ANT,
spatial reasoning, figural memory, immediate verbal memory,
computerized BWM test, or Digit Symbol modalities; of the
and selective and sustained attentional deficits have recently
15 studies, 60% found general or specific impairment (3,4,18,
been confirmed in a study of subjects suffering from deper-
40,42,47,49,53,54), with negative results also reported (19,
sonalization (66). However, these subjects performed nor-
38,41,44,45,65).
mally on the WCST, Trails Tests, IQ tests, and Stroop tests
Posner and others compared negative affect and effortful con- and thus mirrored only some of the NP deficits associated
trol in BPD patients and healthy and temperamentally with BPD.
matched control subjects, using a reaction-time task assessing
3 attentional networks (alerting, orienting, and conflict reso- Verbal Memory in BPD
lution) (53). Only effortful control was related to ANT con-
Memory impairment is not unique to BPD and, when seen in
flict scores, indicating a specific abnormality in BPD,
BPD, is often attributed to comorbid depression. Of 12 studies
irrespective of temperament, in the area of conflict resolution
reviewed, 8 (67%) found verbal learning and memory impair-
and, more generally, cognitive control. The conflict network
ment in comparisons with healthy (40,42,44,49) and psychiat-
is associated with the subcortical anterior cingulate gyrus,
ric (4,18,39,46) control subjects. To clarify the influence on
which normally develops between ages 2 and 7 years, a time
verbal memory of comorbid BPD in clinical depression, Kurtz
when many BPD patients report periods of abuse or neglect.
and Morey tested 20 patients with depression and comorbid
Paris and colleagues reported sustained attentional impair-
BPD, 20 patients with depression only, and 20 healthy control
ment in 41 school-aged children with similar symptoms
subjects (46). Despite similar depression severity, patients
(described by the authors as “borderline pathology of child-
with comorbid BPD showed poorer verbal recall and recogni-
hood”), compared with psychiatric control subjects (3). After
tion memory than did depression-only patients and healthy
controlling for ADHD and other comorbidities, children with
control subjects, suggesting that BPD is associated with cog-
BPD demonstrated poorer orientation to task, slower reaction
nitive deficits beyond those caused by depression. However,
time, inconsistent responses, and greater risk-taking.
in a similar 3-group comparison with patients having schizo-
Zelkowitz and others further compared the predictive effects
phrenia and comorbid BPD, Lysaker and others did not find
of attentional and EF deficits with histories of sexual abuse
any relation between comorbid borderline traits and neuro-
and violence in predicting BPD diagnosis (4). These authors
cognitive function (65). O’Leary’s analysis of medication-
found that environmental trauma explained 25% of the diag-
free BPD patients indicated significant impairment in imme-
nostic variance and that attention and abstract thinking defi-
diate, delayed, and distorted verbal recall, but memory
cits contributed 33%. Attentional impairment on Digit
improved with cueing (44). Monarch and others also vali-
Symbol and Digit Span tests, a measure of gross attention (4,
dated significant verbal memory impairment, using historical
39–42,44), has also been reported in BPD. In 30 women with
control subjects (42). Burgess used 6 subtests of memory in a
BPD and severe histories of sexual and physical abuse, Irle
sample of 27 BPD patients who were compared with control
and colleagues found marked selective attention to be
subjects having schizophrenia and control subjects with
associated with reduced hippocampal volume and exposure to
depression and found an association between deficits in atten-
traumatic stress (4).
tion and memory and self-injury in the BPD group (39). This
Travers and King studied a sample of 80 subjects with BPD, association was not found within the comparative schizophre-
of whom 66% were confirmed with organic impairments (that nia group who self-harmed. Subjects with BPD had more
is, a history of significant head injury, encephalitis, epilepsy, delayed and omission memory errors than either the schizo-
ADHD, or LD). They found greater attentional and EF prob- phrenia or depression groups. Depression was not correlated
lems and substance abuse histories in the BPD organic to self-harm in any of the clinical group comparisons. Irle and

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 The Neuropsychological Correlates of Borderline Personality Disorder and Suicidal Behaviour
other also found logical verbal memory to be impaired (4), but
stringent control for the effects of depression was not possi-
ble. In most of the studies reviewed, verbal memory deficits in
BPD appear to exist beyond those attributed to depression.
These impairments may be secondary to executive dysfunc-
tion such as difficulties with attention, working memory,
strategy formulation, and the inhibition of competing
recollections (62,67–69).
Visual Memory in BPD
Visual memory impairment is reported in 71% (10 of 14) of
BPD studies reviewed (4,18,40–44,49,52,60). In addition to
being more prevalent than verbal memory impairment, right
hemispheric visual memory appears to be more markedly
impaired in these samples (49). The ROFC requires subjects
to reproduce 18 elements of a complex geometric figure from
memory, without warning and after a 1- and 30-minute delay.
The Rey Copy portion of the ROFC measures figural detail
and the Recall component involves spatial memory for loca-
tion. Seven studies found impairment in both Copy and Recall
conditions (4,18,40,42,43,49,52), with Recall-only difficul-
ties reported by O’Leary (44).
Irle and others (4) found that 30 abused women who suffered
from BPD with Axis I and II comorbidity had 11% smaller
right parietal cortex and 17% smaller hippocampal volumes,
compared with control subjects. Greater trauma and marked
deficits in immediate visual memory and visuospatial cogni-
tion were associated with reduced hippocampal size.
Comorbid anorexia, current or past alcohol abuse, and depres-
sion did not predict NP impairment or volumetric change.
While not differing on brain volumes, subjects with BPD and
comorbid PTSD performed more poorly on NP measures.
There was no difference in brain volumes of subjects on anti-
depressants, benzodiazepines, or neuroleptics, compared with
subjects not on these medications. Because 26 of the Irle
study’s 30 subjects met criteria for depression, the effects of
this comorbidity cannot be discounted; however, she suggests
that BPD is a neurodevelopmental deficit of the right hemi-
sphere with subtle NP impairment. This study lends support to
Driessen’s earlier findings of hippocampal reductions in BPD
irrespective of PTSD comorbidity (13). Dinn and others
administered an extensive NP battery to 9 female medicated
in p atien ts w ith self-h arm, su icid e attemp t, an d
schizoaffective and PTSD comorbidity (49). The same tests
were administered to a second sample of 139 university stu-
dents with BPD features. The students exhibited the same NP
impairment as the patients, although the deficits were less pro-
nounced. Contrary to Dinn’s initial hypotheses, nonverbal
memory, nonverbal EF, and visuospatial ability associated
with prefrontal regions were more strikingly implicated than
the expected orbitofrontal functions measuring impulsivity,
Can J Psychiatry, Vol 51, No 3, March 2006 W
social awareness, and response inhibition. Dinn argued that
medication should not have contributed so selectively to non-
verbal skills while sparing verbal skills. Separate analyses
controlling for depression, substance and alcohol abuse, and
anxiety did not alter the findings. Immediate and delayed
visual recall was also supported in a study of a small unmedi-
cated sample (41); however, BPD patients had greater learn-
ing disability, developmental delay, and lower full-scale IQ
than control subjects, despite similar years of education. In
summary, visual memory impairment reported in these and
other studies seems consistent with the clinical observations
of BPD patients’ perceptual distortions in many aspects of
daily living. Reduced hippocampal volumes in BPD (4,19)
may contribute to greater visual memory impairment.
Visuospatial Processing
Visuospatial integrity has been tested in 17 BPD investiga-
tions, of which 11 (65%) implicate impairment as measured
by the Rey Copy, Block Design, Corsi, Embedded Figures,
Digit Symbol, and Picture Arrangement tests. Efficient Rey
Copy depends on organization, intact visual information pro-
cessing, and visual memory (61). Deficits for processing
visual information on the Rey Copy have been strongly asso-
ciated with BPD (18,40–44,49,52) and confirmed by other
tests of visuospatial impairment (4,54,55). Visuospatial scan-
ning deficits, may affect the timed performance on tests of
EF (70).
EF and BPD
Perhaps not surprisingly, as many as 86% (12 of 14) of
reviewed studies confirm a degree of EF impairment in BPD.
EF involves insight, self-awareness, reflection, initiation,
evaluation, and control of thought and behaviour. Interpreta-
tions of abnormal EF findings are challenging because these
tests frequently involve multidimensional components of
attention, memory, response inhibition–suppression, and
visuospatial ability. EF impairment is most frequently associ-
ated with, but not limited to, dorsolateral PFC localization.
While the interrelated functions of the frontal lobes associated
with EF remain poorly understood, visual performance abili-
ties, most frequently affected in BPD samples, seem to be
well-supported to the frontal regions (67).
EF: Tests of Speeded Visual-Motor Skills. Digit Symbol Cod-
ing and Trail Making Test Parts A and B are widely used, non-
specific, timed measures of psychomotor speed, attention,
mental flexibility, visual conceptual, and visuomotor tracking
and are considered highly vulnerable to brain injury (61). Of
7 BPD studies, 5 (71%) employing Trails tests, indicate
impairment (18,42,43,49,50). Lezak suggests that slow Trails
performances at any age on one or both of Parts A and B does
not differentiate whether the problem is one of motor slowing,
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The Canadian Journal of Psychiatry—In Review
coordination, visual scanning, poor motivation, or conceptual
confusion (61). While Trails performance can be affected by
visuospatial impairment (71), the time to complete makes it
sensitive to attentional and psychomotor difficulties, as also
measured by the Digit Symbol test. Digit Symbol impairment,
also evident in 7 BPD investigations (35,40–42,47,59,60), is
believed to be unaffected by intellect, memory, or learning.
Motor persistence, sustained attention, response speed, and
visuomotor coordination play important roles in a person’s
normal Digit Symbol performance (34). Poor EF may be the
result of significantly slowed psychomotor speed in
combination with impaired attention (72).
EF: Tests of Decision Making and Planning. Impaired antici-
patory planning in BPD has been confirmed in some stud-
ies (18,48,49,51) but not in others (36,37,56). We located
only 2 studies of decision making in BPD (48,51). In both,
decision making and planning impairment were implicated.
Only 3 of 6 studies examining spatial working memory,
believed to affect decision making, found impairment in BPD
(49,51,54). Similarly, planning deficits have been inconsis-
tently reported in only 57% of the BPD samples reviewed.
Bazanis hypothesized that self-damaging behaviour may
reflect an impairment in decision making and planning (48).
He tested 42 selfharming BPD patients who were without
TBI, substance or alcohol abuse, or depression, nor were they
receiving medication exceeding 300 mg chlorpromazine
equivalents. Of the sample, 98% were engaged in self-harm
and suicide attempt. This group was compared with 42
matched nonclinical control subjects. Visual recognition
memory and aggression measures were also administered.
Only impairments in decision making and planning were
noted. BPD patients took longer to decide, selected the most
unlikely outcomes, and placed earlier bets on whether their
choices were correct, demonstrating disinhibited responses.
Planning deficits indicated longer deliberation times, more
attempts, and longer latency for first solution attempt. Bazanis
described these deficits as localized to the orbitofrontal and
dorsolateral frontal brain regions and speculated that a general
aversion to delay might be an important feature of BPD.
Dowson and others confirmed longer deliberation times on a
similar computerized decision task (73).
EF: Abstraction and Cognitive Flexibility. The WCST (74)
assesses the ability to form abstract concepts and to shift and
maintain cognitive set. It also measures perseveration and
learning efficiency. Of 13 BPD studies, 8 (62%) reported
impairment on either the WCST (3,5,43,45,49,50) or the
ID/ED (54,56). Lenzenweger and others tested 24 women
with BPD on sustained attention, spatial working memory,
and EF—together known as “controlled information process-
ing” (45). Personality, anxiety, depression, and a computer-
ized spatial working memory test, as well as the WCST, were
136
administered. Three of the 4 WCST subtests were impaired,
with no differences in spatial working memory shown
between subjects and control subjects. Medication, emotional
affect, depression, and anxiety did not alter the results.
In a rare antecedent NP study of BPD, Paris and others stud-
ied 94 school-aged children in psychiatric day treatment; 41
demonstrated similar symptoms (described as “borderline
pathology of childhood”) (3). No sex differences were found
on any NP measures. IQ was in the normal range, and subjects
did not differ from control subjects on neurologic soft signs or
the ROFC Copy or Recall tests. Significant differences on all
scales of the WCST were found in children with BPD symp-
toms, who required more trials to complete and demonstrated
more perseverative responses and errors and fewer conceptu-
alizations, compared with their psychiatric peers. Owing to
high CD comorbidity, CD was entered as covariate but did not
alter the findings. Paris suggests that NP impairment in chil-
dren with BPD symptoms mirrors that of adults with BPD.
Preservative errors and delay in shift set on the WCST are
associated with dorsolateral PFC function (5,75).
EF: Response Inhibition. Of 14 BPD studies, 12 (86%) impli-
cate dysregulated control (stop–start) mechanisms involving
motor, attentional, and other impulsive cognitive pro-
cesses (36–38,41,43,45,47,48,51,54–56). Investigators who
found no other NP impairment (36–38) discovered
dysregulation on the timed Stroop, which requires both atten-
tion and impulse control. The Stroop (76) measures the ease
with which a person can shift his or her perceptual set to con-
form to changing demands and suppress a habitual response in
favour of an unusual one. A markedly slowed naming
response when a colour word is printed in a different colour
has been attributed to a slowed conflict response, a failure of
response inhibition, impaired selective attention and (or) a
difficulty in ignoring distraction (61). Only 2 investigators
report intact response-inhibition behaviours on the
GNAT (38,49). Verbal fluency, a measure of response initia-
tion, has been infrequently tested in only 5 BPD studies, with
3 (60%) reporting impairment (18,49,59). While more flu-
ency studies in BPD are warranted, fluency deficits may con-
tribute to a lack of initiative and self-direction, impaired
problem solving, and the excessive interpersonal dependency
commonly observed in patients with this disorder. Some BPD
patients’ psychomotor regulation difficulties may further pre-
vent them from acting on any newly acquired insight. These
dysregulated arousal and (or) inhibition responses may
explain the commonly experienced “disconnect” between
knowing what is right to do and yet not being able to follow
through, despite intentions. Impulsive personality traits,
known to be high in BPD samples, do not consistently
correlate with laboratory measures of response inhibition or
attentional impulsivity (38,45,54,55).
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 The Neuropsychological Correlates of Borderline Personality Disorder and Suicidal Behaviour
EF: Spatial Working Memory. Only 3 of 6 BPD studies
endorse difficulties with spatial working memory. Slower
visual stimulus perception and working memory impairment
were observed by Stevens in 22 women with BPD, in whom
impulsivity, dissociation, and negative affect did not influ-
ence working memory performance (54). No NP scores were
associated with depression. After controlling for depression
and substance abuse, Dinn and others endorsed striking defi-
cits in visual working memory, as well as slowed planning and
set shifting typically associated with the prefrontal regions of
the brain (49). Surprisingly, omission-only errors on the
GNAT suggested no orbitofrontal involvement. In contrast,
Berlin and Rolls found intact spatial working memory perfor-
mance but deficient time perception in 19 self-harming
women with BPD, in whom a faster subjective sense of time
was related to behavioural impulsivity (55). Dowson and oth-
ers also compared spatial working memory and decision mak-
ing in 19 adults with ADHD, 19 subjects with BPD, and 19
nonclinical control subjects (51). Subjects with BPD demon-
strated longer decision–deliberation times than both groups.
No differences in spatial working memory were evident
among the groups. Since comorbidity as well as any shared
etiology between ADHD and BPD would have reduced the
differences in neurocognitive performance, Dowson con-
cluded that the results were substantial and significant. The
dysfunction of working memory in BPD, while not exten-
sively studied, may be the result of reduced PFC metabol-
ism (11,14), but this requires further study.
In the only NP study comparing the 3 clusters with personality
disorder on the basis of their EF, Besteiro-González and oth-
ers found that cluster B personalities had better overall scores
on all measures except the Stroop (38). The cluster A group
performed most poorly on attention and concept formation,
whereas reaction times on the Stroop were slower for the clus-
ter B group. There were no differences among the clusters on
any pathophysiological or personality measures, adding fur-
ther weight to the observations of dysregulated control pro-
cesses in BPD. Overall, 5 of 6 (83%) BPD samples showed
impairment on the Stroop.
Summary of NP Correlates in BPD
A range of cognitive deficits in BPD appear to exist beyond
the influence of depression, prescribed medication, and possi-
bly, substance abuse. Unfortunately, only 5 of 29 studies strin-
gently controlled for the presence of learning disability and
ADHD (3,18,43,47,48). The most frequently compromised
cognitive processes, as reported in up to 86% of BPD studies,
involved dysregulated control mechanisms; these were fol-
lowed by other EFs involving speeded attention, flexibility,
and visuotracking abilities, as found in 71% of studies. Visual
memory impairment was also evident in 71% of the BPD stud-
ies reviewed. Moderately compromised functions, evident in
Can J Psychiatry, Vol 51, No 3, March 2006 W
60% to 67% of studies, appeared to involve visuospatial pro-
cessing, verbal memory, abstraction, cognitive flexibility, and
verbal fluency. The NP functions least affected in BPD appear
to involve spatial working memory, planning, and possibly,
IQ. Could lower IQ and smaller hippocampi compromise
overall adaptation and coping and result in greater risk for the
development of BPD, as has been suggested in individuals
with PTSD (77,78)? Decision-making and planning functions
may involve distinct processes, as inconsistent planning and
consistent decision-making impairment was evident, albeit in
few BPD studies to date. Several investigators have implied a
level of discrete dysfunction in keeping with frontal function
known not to dramatically disrupt NP performance (34).
While NP tests do not necessarily affirm localized brain dys-
function, examining relations among several related tasks
with established sensitivity for a particular brain region pro-
vides evidence of the probable involvement of those struc-
tures (79). This impairment in NP function may be clinically
significant, involving minimally one-half of all BPD samples
reviewed. With as many as 86% of BPD samples demonstrat-
ing a range of EF impairment, more thorough cognitive
assessments are needed when planning for effective treatment
and recovery.
NP Findings in Suicide Attempters
EF Correlates of Suicide Attempt
Early investigators hypothesized that cognitively rigid indi-
viduals were more prone to suicidal behaviour (80,81) and
poor interpersonal problem solving (82,83). This led investi-
gators to selectively administer fluency and WCST measures.
Surprisingly, we located only 7 NP studies of adult suicide
attempters (see Note). However, learning disabilities in ado-
lescents, involving psychomotor and visuospatial organiza-
tion impairments that affect interpersonal relationships, have
been associated with an increased risk of suicidal
behaviour (84,85).
Suicide and EF: Verbal Fluency
Strong support exists for verbal fluency scores as an indicator
of frontal lobe dysfunction (86,87). Verbal fluency reflects
initiating processes and is reduced in patients suffering from
depression and suicidality despite the challenge, due to the
depressive state, of separating a willed lack of effort from an
unwilled reduced capacity to make an effort. In 9 inpatient
men with affective and adjustment disorder, Bartfai and oth-
ers found reduced intellectual reasoning and verbal and
design fluency 3 weeks following a suicide attempt, but they
found no impairment in problem solving, planning, or cogni-
tive flexibility (28). Fast inspection on the Porteus Maze plan-
ning task for the suicide-attempt group implicated
impulsivity. Abilities to generate alternative problem
137
The Canadian Journal of Psychiatry—In Review
solutions and new ideas were decreased in suicidal patients,
independent of diagnoses and alcohol abuse.
In an fMRI study of verbal fluency in unmedicated suicide
attempers suffering from depression, Audenaert and others
found reduced blood perfusion in anatomically specific areas
of the prefrontal cortex during letter and category fluency
tests, along with poorer overall word production (32). More
recently, low serotonin receptor binding was found in recent
suicide attempters, but interestingly, serotonin was even
lower in patients who had deliberately self-harmed (88). In a
comprehensive comparison by Keilp and others of high- and
low-lethality suicide attempters (27), high-lethality subjects
performed more poorly on all tests of EF than did clinical and
control groups; moreover, they were the only group to per-
form more poorly than healthy control subjects on tests of
intellect, attention, and memory. High-lethality attempters
were differentiated by their EF, whereas depression patients
differed from the healthy control subjects on attention and
memory. This suggests that executive impairment in suicide
attempters exists beyond depression or depression severity.
High-lethality attempters were specifically discriminated by
letter fluency, selective reminding test, WCST failure to
maintain set, and Trail A reaction time scores, suggestive of
significant EF impairment. This study added to the evidence
of fluency impairment associated with suicidal behaviour.
Keilp argues that diffuse brain damage resulting from a lethal
attempt does not appear to be a confounder, as tests
representing diffuse brain injury did not show selective
impairment (27).
Cognitive rigidity and other NP functions were comprehen-
sively evaluated by King in a sample of 57 elderly medicated
inpatients suffering from depression with and without suicide
attempts (31). The only difference between attempters and
nonattempters was that time and sequencing errors on Trail B
showed an increase among attempters that appeared to worsen
with age. Trails tests additionally assessed speed, visual scan-
ning, new learning, mental flexibility, sequencing, and con-
centration (41). Ellis and others also report no differences
between 20 suicide attempters, and 27 psychiatric
nonattempters, with both groups scoring in the impaired range
of standardized scores on several tests, despite similar depres-
sion severity (29). Thirty-five percent of the suicide attempt-
ers and 44% of the nonattempters in this study functioned well
below normal on the PPVT, WCST, Trail making, and finger
tapping tests. In contrast to most BPD studies, King’s
finding (31), and those of Ellis and others (29), support the
influence of psychopathology on the NP results, independent
of suicidal behaviour. Using a modified emotional Stroop test,
Becker compared 31 recent suicide attempters with 31 control
subjects who suffered from anxiety and depression but who
had not attempted suicide (30). Suicide attempters were
138
unaffected by negative, positive, or neutral words; however, a
longer time to name the colour of suicide-related words indi-
cated a highly specific attentional bias toward suicide stimuli.
Severity of suicidal intent was positively correlated to this
attentional bias after control for depression, anxiety, and
hopelessness.
Suicide Attempt and Decision Making
Using the IGT, Jollant and others examined decision making
in violent and nonviolent suicide attempters, a control group
of normal subjects, and a control group of formerly
nonsuicidal subjects with depression (33). All subjects were
free of current Axis 1 disorder when tested. Both groups of
suicide attempters scored lower than healthy control subjects
on decision making, whereas violent suicide attempters per-
formed more poorly than control subjects with nonsuicidal
depression. Lack of other differences between the 2 groups of
attempters, or between the 2 control groups, suggested that
decision-making impairment in high-lethality attempters was
independent of affective disorder and possibly represented a
cognitive vulnerability for suicide. When substance abusers
in both suicide-attempter groups and those on prescribed
medication were removed from the analysis, similar findings
prevailed. Decision-making scores were unrelated to age,
education, intelligence, age at first attempt, number of
attempts, or severity of intent. Decision making for all suicide
attempters was positively correlated to affective lability (89),
whereas decision making in nonviolent suicide attempters
was associated with anger expression and hostility.
Comparison of NP Function in BPD and
Suicide Attempters (Table 1)
In a comparison of NP findings among BPD and suicide
attempter samples, verbal fluency was more frequently found
to be compromised in suicide attempters than in subjects with
BPD, while impairments in psychomotor performance (that
is, Trails A and B), and decision making were found equally in
both populations. Surprisingly, measures of abstract thinking
and cognitive flexibility were relatively intact in suicide
attempters (25%), whereas 62% of BPD studies indicated
impairment according to the WCST. Subjects with BPD,
however, were more frequently found to be impaired on the
Stroop test, a measure of attention and response inhibition
with frequent reports of slowed reaction or response times.
While one must not assume that BPD samples encompass
only those with self-harming behaviour, these divergent find-
ings in the 2 populations may reflect unique cognitive pro-
cesses distinguished by performance on the COWAT, WCST,
ROFC, GNAT, and Stroop, as well as other inhibitory control
processes that may be differentially engaged among those
with and without a conscious intent to die. Behavioural
dysregulation, implicated in 86% of BPD samples, involves a
W Can J Psychiatry, Vol 51, No 3, March 2006
 The Neuropsychological Correlates of Borderline Personality Disorder and Suicidal Behaviour
Table 1 Overlap of EF impairment in BPD and suicide attempters
BPD studies
2/2 Decision making (100%)
5/6 Stroop (83%)
5/7 Trails (71%)
3/5 Verbal fluency (60%)
8/13 WCST (62%)
disruption of cognitive control associated with a general fail-
ure to modify action, thought, and feeling needed to conform
to the social and intellectual requirements of a situation (90).
These inhibitory EF deficits may act as important cognitive
precursors to the self-harm behaviours seen frequently in
BPD. Coolidge further suggests that these processes may be
manifestations of genetically determined EF (91).
It appears that NP performance and suicidal behaviour may be
independent of clinical depression, as reflected in most, but
not all suicide-attempt studies, consistent with the trends in
the BPD literature. The NP inconsistencies among high- and
low-lethality attempters may mirror the clinical ambiguity so
often associated with self-harm and suicidal behaviour. Deci-
sion making, found to be impaired in all suicide-attempt and
BPD studies (33,47,48,73), may represent a shared inhibitory
pathway leading to suicidal behaviour, but this requires
additional study.
Implications
Three models have been proposed to explain dysregulated
behaviour, distinguished by the degree of anxiety or arousal
involved and by the temporal quality of the incentive (imme-
diate or distal) (92–95). Behavioural control also depends on
the positive or negative nature of the incentive. Briefly, the
first model is an arousal model of disinhibition that involves
reflexive or automatic alerting and attention needed to under-
stand new information; underarousal leads to slowed informa-
tion processing. A second model of executive inhibition
requires a deliberate, thoughtful suppression of a previously
learned inappropriate response to achieve a future goal. An
action is suppressed and intentionally held in working mem-
ory (executive) as new information is received. Anxiety or
fear is typically not activated in this case. The third, or motiva-
tional inhibition, model (96,97) proposes a “reactive” process
to emotionally salient incentives, involving immediate pun-
ishment or reward to avoid high anxiety. Hypersensitivity to
immediate rewards with an aversion to more distal future
rewards, as well as an active avoidance of delay (anxiety),
drive these motivational processes. Motivation, believed to be
Can J Psychiatry, Vol 51, No 3, March 2006 W
Suicide-attempt studies
1/1 Decision making (100%)
2/3 Stroop (67%)
3/4 Trails (75%)
3/4 Verbal fluency (75%)
1/4 WCST (25%)
modulated by the hippocampus and amygdala, may involve
slowed or variable motor responses and difficulties in motor
control. Understandably, the integration of executive and
motivational inhibition is closely linked to real-life
behaviour (93).
These inhibitory models, activated by different regions of the
brain, can guide an understanding of the predominant path-
ways that may lead to suicidal behaviour. One pathway to sui-
cidal behaviour involving suicide attempt with intent may
involve both arousal and executive inhibition deficits. These
deficits are evidenced by low verbal fluency, slower informa-
tion processing on Trails and Stroop tests, and conflict scores
on decision tasks. A greater risk of acting on suicidal thoughts
may be the result of inabilities to express and repress an inap-
propriate choice. Suicidal patients may demonstrate primarily
arousal and executive inhibitory control deficits through
perseverative nonsuppression of deliberate thought and
action to end their lives. A compromised ability to generate
and verbalize more creative problem-oriented solutions may
lead to feelings of entrapment. Paradoxically, the decision to
take one’s life may reduce anxiety.
Conversely, self-harm behaviour involving ambivalent or a
lack of deliberate intent or forethought may involve another
pathway of motivational inhibition associated with an imme-
diate delay aversion to intense negative affect. Inability to
endure a temporary, albeit intense, emotional state may reflect
a propensity for immediate rewards and avoidance of anxiety
with little regard for future consequences, irrespective of the
number of past occurrences. Reflexive and repetitive
self-harm behaviour, which for some provides a form of
immediate emotional relief, may reflect these deficient
reward–punishment signals. This motivational dysregulation
may represent an important delay aversion pathway to
self-harm. In BPD samples, impaired decision making involv-
ing temporal rewards or punishments on risky, uncertain out-
comes, combined with executive inhibition deficits (indicated
by higher Stroop and WCST scores), may interact to produce
even greater behavioural and emotional dysregulation, result-
ing in reactive, avoidant self-harm behaviour. The potential
139
The Canadian Journal of Psychiatry—In Review
involvement of this motivational pathway, believed to local-
ize to the orbitofrontal regions with connections to the
amydala and hippocampus (99–101), may challenge the
notion of deliberate self-harm behaviour in BPD. These
hypotheses examining causal pathways to suicidal behaviour
require further examination and analysis but may provide a
conceptual framework for subsequent study.
Conclusions
Cognitive impairment predominantly associated with, but not
restricted to, the right frontal hemisphere (visual dominance)
exists in BPD. The specific source, severity, and outcome of
this impairment, however, remain unclear. Contrary to popu-
lar belief, these deficits, particularly in BPD, do not appear to
be primarily the result of comorbid depression or of its sever-
ity. Whether BPD contributes to impairment beyond unrecog-
nized comorbid ADHD or LD awaits further validation. One
cannot ignore the consistency of this impairment across multi-
ple domains, as understood by both first- and second-
generation investigators. However, reports of clinical
significance are noticeably lacking in the studies to date. Fur-
ther research is therefore needed to clarify the extent of NP
impairment that may contribute to the unique behavioural
manifestations of BPD or the dimensional nature of suicidal
behaviour. While cognitive impairment in BPD has been
associated with the growing evidence of biological dysfunc-
tion, the direction of causation remains inconclusive. Perhaps
most important, the outcome of this impairment on everyday
function awaits confirmation.
It is evident from this review that not all individuals with BPD
suffer from impaired cognitive and behavioural EF, which
challenges the notion of a single causal pathway model. Nigg
suggests that causal models do not have explanatory power
unless they capture the broad essence of the disorder as it is
manifested by the individual patient (98). Self-harm behav-
iour, considered unique to BPD, warrants further understand-
ing within an NP or cognitive framework. No matter how one
interprets these findings, one cannot ignore the converging
patterns of NP impairment associated with BPD that may rep-
resent a cognitive vulnerability for the development of the dis-
order and the manifestation of suicidal behaviour. A trait-like
vulnerability for suicide involving dysregulatory,
disinhibiting processes is suggested by the available data but
awaits clarification and confirmation.
Note
A detailed list of studies investigating neuropsychology in BPD is
available from the author.
Funding and Support
This review was supported by a Canadian Institutes of Health
Research fellowship as part of the clinical trial “Hope for the
140
Chronically Suicidal Patient: Evaluating the Clinical and Health
Services Impact of Dialectical Behaviour Therapy in Individuals
With Borderline Personality Disorder” with the Arthur Sommer
Rotenberg Chair in Suicide Studies, St Michael’s Hospital,
Toronto, Ontario.
Acknowledgements
We acknowledge the contributions of Paul Links, Arthur Sommer
Rotenberg Chair in Suicide Studies, and Professor, Dept of
Psychiatry, University of Toronto; and Rosemary Tannock, Senior
Scientist, Brain and Behaviour Program, The Hospital for Sick
Children, and Associate Professor of Psychiatry, University of
Toronto.
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Manuscript received and accepted November 2005.
1
Fellow, The Arthur Sommer Rotenberg Chair in Suicide Studies, St
Michael’s Hospital, Toronto, Ontario; Assistant Professor, Faculty of
Health Sciences, School of Nursing, McMaster University, Hamilton,
Ontario.
2
Assistant Professor, Department of Psychiatry, University of Toronto,
Toronto, Ontario; Baycrest Centre for Geriatric Care, Toronto Ontario.
Address for correspondence: J LeGris, Faculty of Health Sciences, Rm
2J12, McMaster University, 120 Main street West, Hamilton, ON L8N 3Z5
legrisj@smh.toronto.on.ca; legrisj@mcmaster.ca

Résumé : Les corrélats neuropsychologiques du trouble de la personnalité limite et du comportement

suicidaire
Objectif : Chez des sujets souffrant du trouble de la personnalité limite (TPL) comparés à des sujets ayant tenté de se
suicider, examiner la fonction neuropsychologique (NP) qui peut prédisposer au comportement suicidaire sur un
continuum de létalité élevée et faible.
Méthode : Nous avons effectué des recherches électroniques dans MEDLINE, PsycINFO, EMBASE, Biosos Reviews
et Cinhal. Les recherches étaient limitées aux publications en anglais de 1985 à aujourd’hui. Les termes de recherche
trouble de la personnalité limite, tentative de suicide, neuropsychologique, fonction exécutive, neurocognitif, et fonction
neuropsychologique ont produit 29 études neuropsychologiques incluant le TPL, et 7 études neuropsychologiques de
personnes ayant tenté de se suicider, sans égard au diagnostic psychiatrique.
Résultats : Sur les études du TPL, 83 % constataient une déficience NP dans un ou plusieurs domaines cognitifs,
indépendamment de la dépression, faisant appel à des déficits spécifiques ou généralisés liés aux régions préfrontale
dorsolatérale et orbitofrontale. Les fonctions les plus fréquemment déclarées (dans 71 % à 86 % des études du TPL) sont
les processus inhibiteurs de réponse affectant le rendement de la fonction exécutive qui exige une attention accélérée, la
souplesse cognitive, le traitement visuospatial, et le processus décisionnel; 60 % à 66 % des études du TPL rapportent
une déficience de l’attention, une déficience verbale et une déficience de la mémoire non verbale. Les processus les
moins affectés par le TPL semblent être la mémoire de travail spatiale, la planification et possiblement, le QI. Les
similitudes des déficits NP dans les études du TPL et des tentatives de suicide sont le processus décisionnel et les
rendements au Trail Making Test (TMT). Les résultats de la fluidité verbale, du test Stroop et du test Wisconsin
nécessitent d’autres comparaisons.
Conclusions : Les fonctions exécutives partagées, et les processus désinhibiteurs d’éveil qu’elles apportent, ainsi que la
fluidité verbale, les rendements au TMT et possiblement au Stroop associés aux régions du cortex préfrontal dorsolatéral
peuvent représenter une voie commune vers la tentative de suicide. Une voie inhibitrice motivationnelle prédominante
impliquant les processus décisionnels associés aux régions orbitofrontales peut influencer l’expression d’actes
autodestructeurs ou un comportement suicidaire de faible létalité. L’hypothèse d’une vulnérabilité cognitive semblable à
un trait pour un comportement suicidaire impliquant des voies dysrégulatrices, désinhibitrices n’est pas confirmée.

142 W Can J Psychiatry, Vol 51, No 3, March 2006