Neuropsychology has had relatively limited impact on the practice of psychiatry and on the evaluation and treatment of personality disorders. Clinicians might be tempted to ask, What use is neuropsychology? What is its value added? This article reviews the existing literature on neuropsychological testing of patients with borderline personality disorder (BPD), comments on how neuropsychological testing research has contributed to the understanding of BPD, and closes with brief observations on how this research might contribute to the assessment and treatment of this group of patients in general.

In research studies focusing on the cause of specific disorders, neuropsychological tools are helpful for the following reasons.

Several systematic neuropsychological samples have been gathered in the population of people with BPD. One challenge in drawing overall conclusions from the results is that a wide variety of testing approaches exist, each of which is comprised of a handful of studies. The contributions of several of these testing approaches are evaluated to determine whether they confirm clinical impressions and whether they offer new insights into the disorder.

Cognition is medically defined as “mental activities associated with thinking, learning, and memory.”<sup>68   Stedman's Medical Dictionary Baltimore: Williams & Wilkins (1995). 

Cliccare qui per andare alla sezione Riferimenti</sup> What kinds of cognitive impairment have been identified in the clinical literature that would lead one to undertake psychological testing to better document and define this impairment? The early emphasis in defining BPD was on the conditions under which these patients displayed disturbed thinking. People with this diagnosis were thought to be so “on the border” of psychosis that, with sufficient stress, they would cross over into psychotic thinking. Following this working hypothesis, several often-quoted early studies used the “structured” Wechsler Adult Intelligence Scale (WAIS) and contrastingly “unstructured” Rorschach inkblot projective test to purportedly show normal scores on the WAIS but psychotic thought processes on the Rorschach.<sup>13 Carr A., Goldstein E., Hunt H. , e al. Psychological tests and borderline patients J Pers Assess 1979 ;  43 : 582-590  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 19 Edell W. Role of structure and disordered thinking in borderline and schizophrenic disorders J Pers Assess 1987 ;  51 : 23-41  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 41 Mercer M., Wright S. Diagnostic testing in a case of latent schizophrenia Journal of Projective Techniques 1950 ;  14 : 287-296

Cliccare qui per andare alla sezione Riferimenti, 52 Rapaport D., Gill M.M., Schafer R. Diagnostic Psychological Testing New York: International Universities Press (1968). 

Cliccare qui per andare alla sezione Riferimenti, 54 Rorschach H.   Psychodiagnostics New York: Grune and Stratton (1975). 

Cliccare qui per andare alla sezione Riferimenti, 58 Schafer R.   The Clinical Application of Psychological Tests New York: International Universities Press (1948). 

Cliccare qui per andare alla sezione Riferimenti, 59 Schafer R.   Psychoanalytic Interpretation in Rorschach Testing New York: Grune and Stratton (1954). 

Cliccare qui per andare alla sezione Riferimenti, 65 Singer M.T. The borderline diagnosis and psychological tests: Review and research Borderline Personality Disorders New York: International Universities Press (1977).  193-212

Cliccare qui per andare alla sezione Riferimenti, 66 Singer M.T., Larson D.G. Borderline personality and the Rorschach test Arch Gen Psychiatry 1981 ;  38 : 693-698

Cliccare qui per andare alla sezione Riferimenti, 81 Weiner I.B.   Psychodiagnosis in Schizophrenia New York: Wiley (1966). 

Cliccare qui per andare alla sezione Riferimenti</sup> Reviewers of the early “normal WAIS/disturbed Rorschach” studies,<sup>46 O'Leary K.M., Cowdry R.W. Neuropsychological Testing Results in Borderline Personality Disorder Biological and Neurobehavioral Studies of Borderline Personality Disorder Washington: American Psychiatric Press (1994). 

Cliccare qui per andare alla sezione Riferimenti, 75 van Reekum R. Neurobehavioral study of borderline personality disorder J Psychiatry Neurosci 1993 ;  18 : 121-129

Cliccare qui per andare alla sezione Riferimenti, 84 Widiger T.A. Psychological tests and the borderline diagnosis J Pers Assess 1982 ;  46 : 227-238  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 86 Zalewski C., Archer R. Assessment of borderline personality disorder J Nerv Ment Dis 1991 ;  179 : 338-345  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> however, have concluded that this construct remains unproven because of several methodologic issues but primarily because of a diagnostic misinterpretation. These studies were done decades before the DSM<sup>1 American Psychiatric Association   Diagnostic and Statistical Manual of Mental Disorders Washington: American Psychiatric Press (1994). 

Cliccare qui per andare alla sezione Riferimenti</sup> formulation of the disorder. The patients on whom this belief is based most likely had schizotypal personality disorder rather than BPD. In addition to more refined diagnostic systems and instruments, a more refined description of the characteristics of quasipsychotic symptoms in this population is now available.<sup>87 Zanarini M., Gunderson J., Frankenburg F. Cognitive features of borderline personality disorder Am J Psychiatry 1990 ;  147 : 57-63

Cliccare qui per andare alla sezione Riferimenti</sup> Newer studies of these symptoms have used projective testing in better-defined populations; these results are examined.

Research assessing in detail the domains of learning and memory functioning in BPD has only been undertaken much more recently. These areas show the clearest empiric evidence of cognitive impairment in BPD and have carefully diagnosed the subjects, re-examined the “normal WAIS” portion of the earlier paradigm, and administered additional batteries with specific tests of problem solving, motor skills, and auditory and visual memory. These results are described in detail.

Standard dictionaries, as opposed to medical dictionaries, also include the concepts of perception and judgment in their definitions of cognition, describing it as “the process of knowing in the broadest sense, including perception, memory, and judgment.”<sup>77   Webster's New World Dictionary, third college edition New York: Simon & Schuster (1988). 

Cliccare qui per andare alla sezione Riferimenti</sup> Visual perceptual issues were examined as part of the tests of visual memory mentioned earlier and raise interesting questions about visual perception in BPD. Broader issues of distorted perception in this population are raised by clinical observations detailing how individuals with BPD misperceive the world, their relationships, and their own role in cause and effect. Given the clinical examples of lapses in judgment arising in part from these misperceptions, one wonders whether a broad impairment of judgment in general or of social judgment in particular could be documented in testing. An effort to quantify and elucidate this area within the context of object relations has been made. A related effort examines the way individuals with BPD process emotion-laden material specifically. One is also led to question and discuss the possible role of depression, affective lability, state-dependent learning, and dissociation in these findings.