Neurocognitive impairment in dramatic personalities: Histrionic, narcissistic, borderline, and antisocial disorders

Neurocognitive impairment in dramatic personalities: Histrionic, narcissistic, borderline, and antisocial disorders

283 Psychiatry Research. 42:283-290 Elsevier Neurocognitive Impairment in Dramatic Personalities: Histrionic, Narcissistic, Borderline, and Antisoc...

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283

Psychiatry Research. 42:283-290

Elsevier

Neurocognitive Impairment in Dramatic Personalities: Histrionic, Narcissistic, Borderline, and Antisocial Disorders J. Wesley

Burgess

Received August 31, 1990; first revised version received February version received January 9, 1992; accepted May 10, 1992.

4, 1991: second revised

Abstract. Thirty-seven patients with personalities in the dramatic cluster (DSMIII-R histrionic, narcissistic, borderline, and antisocial) and 40 controls matched for age and gender were evaluated on 16 neurocognitive variables. The evaluation screened for deficits in functions of attention, memory, language, abstraction, and behavior planning/sequencing. Analysis of variance revealed significant deficits in neurocognitive performance among patients with dramatic personalities, particularly in subtests requiring multi-step, multi-element associative operations. Key Words. Personality ing, neuropsychology.

disorder,

development,

cognition,

information

process-

deficiencies in information processing have been implicated in schizophrenia, major depression, and other serious psychiatric disorders, neurocognitive problems have not been considered important in dramatic personality, even in the presence of severe symptoms such as chronic depression, anxiety, and impulsivity (Burgess, 1991~). Traditional psychological tests have generally found that persons with dramatic personalities make no more errors in thinking than the general population (Cornelius et al., 1989). However, recent articles have reported a variety of mild cognitive errors in persons with borderline personality (Burgess, 1990, 19914 1991~; O’Leary et al., 1991; Burgess and Zarcone, 1992). The strength and generalizability of this finding to other populations and types of personality disorder is currently unknown. As defined by DSM-III-R (American Psychiatric Association, 1987), the dramatic personalities encompass a collection of interrelated personality characteristics (cluster B) that can be subdivided into histrionic, narcissistic, borderline, and antisocial personalities. Patients with these diagnoses may experience clinical symptoms that include extreme vulnerability to stress; chronic and persistent affective symptoms including depression, anxiety, and anger; recurring problems in interpersonal relationships; and a tendency toward impulsive, maladaptive beAlthough

At the time this work was done, J. Wesley Burgess, Ph.D., M.D., was a Fellow in Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Stanford University Medical Center and Palo Alto Department of Veterans Affairs Medical Center. Dr. Burgess is now Director, Adolescent Division, Los Angeles Center for Mood Disorders. (Reprint requests to Dr. J.W. Burgess, Adolescent Division, Los Angeles Center for Mood Disorders, 1990 S. Bundy Dr., Ste. 790, Los Angeles, CA 90025, USA.) 0165-1781/92/$05:00

@ 1992 Elsevier Scientific

Publishers

Ireland

Ltd.

284

haviors. Such patterns may suggest the presence of underlying problems in the registration and interpretation of internal and external stimuli, perhaps beginning in early development (e.g., Vaillant and Perry, 1985; Vaillant, 1987). Because of these suggestions in the literature, we decided to examine neurocognitive functions in persons with dramatic personalities. Methods Subjects. Seventy-seven adults participated in the study. All were evaluated for alertness and ability to attend to events in the environment; none showed detectable impairment. All denied drug abuse in the week before the evaluation. The personality-disordered group contained 37 persons (mean age = 34.3 years, SD = 8.6; 46% female). These subjects were prospectively drawn from a population of persons who consecutively presented for routine psychiatric evaluation at the Stanford and Palo Alto V.A.

Medical Centers. Inclusion in the personality-disordered diagnosis by at least two recent psychiatric evaluations

group required

agreement

on

that were carried out without knowledge of the patient’s neurocognitive performance; these assessments were based on all available information, including recent clinical examination, past history, and clinical records. Further diagnostic material was obtained from structured clinical interviews and self-report measures (Burgess, 1991b). All diagnoses were made by DSM-III-R criteria (American Psychiatric Association, 1987). The diagnostic breakdown was as follows: histrionic (n = 5) narcissistic (n = I), borderline (n = 15), antisocial (n = I), histrionic/ borderline (n = 4) narcissistic/ borderline (n = 6) and borderline/antisocial (n = 5) personalities. The control group (n = 40; mean age = 34.3 years, SD= 8:O; 50% female) was matched for age and gender to the personality-disordered subjects, and was drawn from clinical and associated mental health personnel without a history of psychiatric diagnosis or treatment. Neurocognitive Examination. Subjects received a 16-item neuropsychiatric battery based on the published examinations of Strub and Black (1987) and Luria (1973, 1980). The examination required approximately 20 minutes to complete. Sixteen subtests, each scored from 0 to 8 points, were administered. The specific items and their presumed functional significance are outlined below: Attention is associated with the function of reticulocortical, thalamic, and brainstem areas (Magoun, 1963; Watson and Heilman, 1979, Watson et al., 1981; Ferro and Kertesz, 1984). We initially screened for level of consciousness and vigilance to the environment/evaluator: these functions were not impaired in any subjects and were not evaluated further. We then tested orientation (to date, day, month, and year). Memory is associated with the functions of the hippocampus, dorsomedial thalamic nuclei, mammillary bodies, and language cortex (Milner, 1968; Scoville and Mimer, 1957; Kandel and Schwartz, 1985). We tested immediate memory spun (for 7 spoken numbers) and cued delayed memory (for 3 objects after 10 minutes). Language functions are associated with the functions of temporal, parietotemporal, and subcortical brain areas (Mohr, 1976; Goodglass and Kaplan, 1983). Verbal repetition is specifically linked to the language cortex surrounding the Sylvian fissure (Geschwind et al., 1968) focal object naming has been linked with lesions of the second and third temporal gyri (Geschwind, 1967) and subcortical lesions have been associated with mild anomia and comprehension errors (Mohr, 1976). We tested repetition of common words (red, ball, blue, car, city, and Chicago) and naming of visually presented objects and their parts (pen: point, cap, clip; watch: band, crystal, winder/ stem). Abstract operations are linked to cortical association areas (Critchley, 1953; Teuber, 1964; Black and Strub, 1976; Anderson, 1987), particularly posterior areas at the intersection of the temporal, parietal, and occipital lobes (the PTO association area of Kandel and Schwartz, 1985). Abstract tasks, which emphasized simultaneous comparison of multiple elements,

285 included similarity comparisons (e.g., truth vs. justice, poverty vs. misery, and daisy vs. flower: Wechsler 1981; Strub and Black, 1987) dependence comparisons (e.g., son of the father and daughter of the mother: Luria, 1973) and proverb interpretation (e.g., “don’t cry over spilt milk”and “let sleeping dogs lie”; scored according to Gorham, 1956). The subtraction of serial sevens emphasized both simultaneous comparative operations and sequential planning. The planning/sequencing of behavioral programs is also linked to cortical association areas, particularly those in the frontal and prefrontal cortex (Luria, 1973; Das et al., 1979; Kandel and Schwartz, 1985; Strub and Black, 1987). Tasks that emphasize the sequential planning and execution of successive steps include the reproduction of nonverbally presented Luria movements (fist-palm-thumb/forefinger ring: Luria, 1973, 1980) and nonverbally presented rhythm reproduction (of hard [T] and soft [t] taps: TTTtttTTT, tttTTTttt, ttTTtt; Luria, 1973, 1980). The following errors of planning and sequencing were also scored: slowing (of responses > 5 sec),perseverution (of previous responses), inversion (of material within a response), addition (of irrelevant material to a response), and omission (of relevant material from a response). Statistical Analysis. Between-group comparisons of neuropsychiatric performance were made by analysis of variance and F tests for nonrepeated, between-subjects effects (Winer, 1971; Snedecor and Cochran, 1980). Within-group comparisons of performance between subtests were made with multifactoral analysis of variance and Hotelling-Lawley tests for repeated effects (Bock, 1975; Morrison, 1976). Tukey’s all-pairs test was used for multiple between-group comparisons of performance on individual subtests (Games, 1978). Programs from the Statistical Analysis Systems were used throughout (SAS Institute, 1988).

Results Levels of overall cognitive performance differed significantly between groups (F = 19.67; df = 1, 75; p < 0.0001; Table 1). A significant overall difference in performance across subtests was found within groups (Hotelling-Lawley T = 3.34;

Table 1. Cognitive performance in dramatic personality and control subjects Dramatic personality Subtest

Control subjects

Mean

SD

Mean

SD

1. Orientation

2. 3. 4. 5. 6. 7. 8. 9.

7.78

0.79

7.80

0.76

Memory

span

7.51

0.77

7.45

0.68

Delayed

memory

6.89

1.31

7.62

0.67

7.78

0.63

7.95

0.32

7.37

1.16

7.90

0.38

6.92

2.14

7.80

0.99

7.46

1.39

8.00

0.00

6.38

1.74

7.78

0.48

Repetition Naming Similarity

comparisons

Dependence Proverb

comparisons

interpretation

Serial sevens

10. Luria movements 11. Rhythm reproduction 12. Slowing errors

6.84

1.40

7.85

0.43

6.38

2.09

7.20

1.09

3.81

3.34

6.95

1.82

3.89

4.05

4.60

4.00

13. Perseveration

4.76

3.98

6.60

3.08

14. Inversion errors 15. Addition errors

4.1 1

4.60

4.00

5.62

4.05 3.71

5.40

3.79

16. Omission

4.32

4.04

6.40

3.24

errors

Significance lTukev test1

p < 0.05 p p p p p p p

< < < < < < <

0.05 0.05 0.05 0.05 0.05 0.05 0.05

p < 0.05

p < 0.05

286 df= 15, 61; p < O.OOOl), and a significant interaction effect revealed group differences in subtest performance (Hotelling-Lawley T = 0.93; df = 15, 6 1; p < 0.000 1). When performance on individual subtests was compared between groups, persons with dramatic personalities made significantly more errors than control subjects on the following measures: delayed memory, naming, similarity comparisons, dependence comparisons, proverb interpretation, serial sevens, Luria movements, rhythm reproduction, perseveration, and omission errors (Tukey test, p < 0.05; Table 1). Discussion The current study indicates that persons with dramatic personalities (histrionic, narcissistic, borderline, and antisocial types) show significant impairment in their performance on tests of cognition and information processing, particularly on subtests requiring multi-step, multi-element associative operations. Cognitive Information Processing in Dramatic Personalities. Recent studies have demonstrated significant levels of cognitive impairment in persons with borderline personality, particularly in tests of planning/ sequencing cognitive functions (Burgess, 1990, 1991a, 1991~; O’Leary et al., 1991; Burgess and Zarcone, 1992). Similar types of cognitive deficits have also been found in persons with major depression (Glass et al., 1981; Shipley et al., 1981; Weingartner et al., 1981; Gruzelier et al., 1988; Cassens et al., 1990; Burgess, 1991a, 1991~). This relationship between depression and cognitive impairment is further strengthened by findings that depressive symptoms are correlated with the severity of cognitive impairment (in planning/ sequencing tasks) in both major depression and dramatic personality disorders (Burgess, 199 la, 199 1c). Different patterns of cognitive information processing are found in schizophrenia (Neale and Oltmanns, 1980; Asarnow and MacCrimmon, 1982; Nuechterlein and Dawson, 1984), mental retardation (Farnham-Diggory, 1976; Burgess, 1981, 1989; Burgess and McMurphy, 1982; Burgess and Fordyce, 1989), and normal controls (Corcoran, 1971; Butler, 1978; Burgess and Spoor, 198 1). Cognitive deficits may point to biologic etiologies in dramatic personality disorders. Current theories relate dramatic personality disorders to psychologically stressful experiences during childhood (Vaillant and Perry, 1985; Vaillant, 1987), but it has been suggested that physical stressors that affect brain development may play a role as well (Burgess, 1990). Physical stressors could include gestational complications, childhood injuries, malnutrition, and illnesses that occur spontaneously or as a result of parental abuse and neglect (Lewis et al., 1979; Soloff and Millard, 1983; Burgess, 1990). A relationship between physical stressors and dramatic personality disorders is supported by numerous past studies that have demonstrated excessive amounts of childhood head trauma, encephalitis, epilepsy, hyperactivity, abnormal electroencephalographic and auditory evoked potential findings, and aberrant sleepcycle architecture in persons with dramatic personalities (Akiskal et al., 1980; Andrulonis et al., 1981, 1982; Bell et al., 1983; McNamara et al., 1984; Cowdry et al., 1985; Reynolds et al., 1985; Kutcher et al., 1987).

287 Implications for Clinical Treatment. Our results encourage the use of neurocognitive testing in the assessment of persons with dramatic personalities. Such testing provides information about thinking style and limitations that may also be related to mood symptoms and behavioral impulsivity (Burgess, 1991a, 1991~). The tests presented here are well suited for such use because they are easily administered in the context of a brief clinical interview and their relevance in this population has been demonstrated. Our findings also support the use of both psychological and biological treatments of mood disorders in dramatic personalities (Brinkley et al., 1979; Leone, 1982; Serban and Siegel, 1984; Gardner and Cowdry, 1986; Goldberg et al., 1986; Soloff et al., 1986; Berger, 1987; Cowdry and Gardner, 1988; Kaplan and Sadock, 1989; Beck and Freeman, 1990). We hope that an increased awareness of different patterns of information processing will aid in our understanding of and communication with patients with dramatic personalities, Acknowledgments. The author thanks Drs. Herbert Leiderman, James Moses, Jr., Brant Wenograt, Vincent P. Zarcone, Jr., and Robert Zeiss for their help and suggestions.

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