Neuropsychological Deficits in BPD and Implications for Treatment

all right while we were waiting to hit the other slides up I also want to mention we did mention a thank you to our sponsors I didn't specifically our co-sponsors I didn't specifically mention that we're talking about Clearview treatment programs you can meet their director michael roy and other representatives they're also silver Hill hospital where we have Amy Grimaldi you can orient us not sure where we're stuck while we are sorting this out I will mention that our next presenter dr. Anthony roko is an assistant professor of psychology at the University of Toronto where he's the director of the clinical neurosciences laboratory he's an affiliate research scientist with the Toronto Centre for Addiction and Mental Health he's a prolific researcher he is clearly an up-and-coming gonna be a leader of our field particularly with regard to neuropsychological impairment within borderline personality disorder he's already well established with grants and and we are delighted with us [Applause] sorry give me a moment here all right thank you very much sir for the quick delay there it's very nice to be here today and thank you for inviting me so my name is Anthony Rocco and I came in from Toronto last night to be here today to talk about some of the research that were doing in my laboratory at the University of Toronto so I should say at the outside that I am a clinical neuropsychologist it was really nice to see that the theme of this meeting was cognitive disturbances in BPD and this is actually the area that I specialize in as a clinical neuropsychologist so I recognize that many people may not be so familiar with what I mean when I say neuropsychological functioning so I'm gonna review a little bit today about what neuro psychology is and why neuro psychology may be useful for people people with BPD um and then talk a little bit about how this might impact treatment and some of the research that we're doing funded by the American Foundation for Suicide Prevention that helps us potentially understand how cognitive dysfunctions might impact treatment for people with BPD okay so when we talk about BPD there are a lot of different ways and actually Gabrielle did a great job describing the different core symptom dimensions of the disorder um I like to think about the core symptoms as revolving around three domains we can talk about the interpersonal the emotional but I want to highlight impulse control because that is actually one domain of neuropsychological functioning that neuro psychologist like me use when we evaluate a patient so it could be somebody with dementia a traumatic brain injury schizophrenia we use cognitive tests neuropsychological tests actually measure impulse control so you can bet that I'm gonna be talking a little bit about what do people with BPD look like when we're talking about their impulse control on these standardized tests and one thing that I want to point out at the outside is you've probably heard the word cognition before as it relates to BPD you've probably seen it in the DSM 4 that there are difficulties with cognition actually it could be a component of any of the personality disorders but cognition in the DSM 4 is actually referring to something different from what neuropsychologist typically associate with cognition so in the DSM 4 we're normally talking about cognition as a way that people were view the world and themselves and the future this is different from what we mean as neuropsychologist when we talk about cognition so in the DSM for cognition is referring to things in BPD like an unstable self-image idealizing devaluing others paranoia when under stress these are different from what we mean is neuropsychologist so what do I mean well we're talking about thinking abilities broadly speaking in neuropsychology and so we use these very sophisticated instruments neuropsychological tests to evaluate thinking abilities um and I should point out that all of these tests that we use have been standardized so that there should be administer the exact same way every time that the test is actually given to somebody and we actually figure out what's normal for any given individual by giving these tests to hundreds if not thousands of different people to see what's average and what's maybe superior so above average or below average or even a deficit or an impairment and these tests can be used with all kinds of different people people who are you know in adulthood with possibly a neurologic or a mental illness or we could been using these with children to evaluate ADHD for example so what are the different types neuropsychological or cognitive abilities that we typically evaluate as neuropsychologists so I should point out first of all that these are all coming from the brain okay we assume that these are the tests that we give of these different abilities are all correlated with specific parts of the brain and different brain systems are coordinated and involved in a lot of these different abilities so for example one thing we talk about is attention which is hopefully what I've got here today right now is your attention working memory so your ability to actually maintain the information that I'm telling you now in your mind for brief periods of time episodic memory that's your memory for things that you may learn today and then be able to recall them tomorrow you've probably heard of the term executive function and it's actually a complex term that we'll be talking a little bit more about in a moment and it's basically a term that refers to higher-level thinking abilities that rely on a lot of these other functions and this is something that's particularly relevant to BPD so if you hear me talk about this more in a moment we also have visual spatial abilities so if you're able to navigate the streets to get here today then you've probably got intact visual spatial abilities motor abilities like tapping your finger to your fingers to your thumb and then perceptual abilities so being able to perceive things in your environment now some of these things are gonna be more relevant to BPD and some of them will not be as relevant but I want to point out that we usually evaluate all of these domains to try to figure out how they might be impacting somebody's life okay so I had to strike a balance here between actually showing you the test that we use to evaluate these abilities and protecting their confidentiality and privacy because the most of them are copyrighted tests but I want to give you a flavor of what we typically do to evaluate evaluate these domains and I'm gonna go into talking about what do we actually see in people with BPD all right so when we're talking about attention and concentration one test for me here would be seeing you is anybody dozing off hopefully you're not and you're paying close attention to this brief attention is one aspect of attention that we measure this is actually looking at things like asking you to repeat a series of digits so I might say four three nine seven two and then you have to repeat it back to me so this is a measure of brief attention so you may have heard of you know this type of a thing is a measure of short-term memory that's okay to say that many people use that term for this type of a test but we're usually referring to as neuropsychologist this is an attention test or it sustained attention this is obviously the ability to sustain your attention for long periods of time so we often use computerized tests where we ask the person to sit in front of a computer and look at a series of things on the computer screen and we want to see how well they can maintain their attention so for example paying attention to letters presented on a computer monitor you may have guessed that this is actually one of the tests actually the Connors continuous performance test is one of the tests that we use to diagnose as part of the diagnosis for ADHD so if you're gonna see a neuropsychologist for a diagnosis potentially of attention deficit disorder this is one way that we objectively measure attention so I want to show you a quick example of how this test works actually I'll be showing you in a moment it looks like it's not here um okay hopefully if somewhere there um verbal and visual memory another important aspect of neuropsychological functioning so what we have here is first verbal memory test that we usually ask somebody to remember a story or a list of words and then maybe half an hour later remember what the words were or the story visual memory tests as you might imagine require you to reproduce a design for memory so this is something that people really get overwhelmed by a picture here of the actual eye of the actual complexity of trying to reproduce from Maree a complex design it's actually not that easy now another thing that we do is we have something called the executive functions now executive functions as I said are is like it's a complex term we usually call it an umbrella term for a lot of these very high-level cognitive abilities so these are things like planning problem-solving and impulse control so seeing what I say here about executive functions you can probably guess right now that this is one of the cognitive abilities neuropsychological abilities that tends to be impacted in BPD this is the most common one and I'll talk about what these results are in a moment so how might you use a neuropsychological testing so there are lots of different uses you know I've seen people with all types of cognitive dysfunctions so people who you know come in with brain injuries related to playing hockey or soccer I have people coming in to get a more refined diagnosis of dementia so is a dementia associated with Alzheimer's or depression or both um but probably what I see the most when it comes to BPD is people talking about being worked up fried diagnosis of ADHD or a learning disorder so this might bring true for people in the room in terms of having this come up for people with BPD another important piece of this is treatment planning you know it's really important for a clinician to know does somebody have really significant memory problems because if they do then maybe we should be accommodating these by maybe using memory aids in psychotherapy or maybe giving them memory aids to take medications I mean these are important things that we might be kind of ignoring that could be important and impacting somebody's treatment and later I'll be showing you some cases where this definitely seems to be the case that these types of problems are actually impacting people's ability to engage successfully in psychotherapy okay so why do we care about cognition and BPD it's probably a question that many people ask well historically if we look at some of the writing early writings of people with BPD or that we're suspected of having BPD um there was a lot of talk about problems with integrating information and you know that these types of things might interfere with treatment and so recent research actually suggests well first of all that if we look at people with BPD who are being seen on an inpatient basis presenting for you know really in crisis situations that the two strongest predictors of who those people end up being with BPD their that end those two strongest predictors of being seen for inpatient psychiatric hospitalization are suicidality and deficient cognitive functioning and a very recent study showed that neuropsychological functioning so performance on these types of tests actually helps us understand who's going to drop out of treatment so I'll be talking a little bit about that in a moment okay so some of the cognitive difficulties that we've heard talked about in the literature in these kind of descriptions of BPD have been things like poor focus and concentration problems with memory or if they are remembering things okay that maybe they're somewhat distorted I will talk about what this actually looks like in a moment impulsive behaviors have been described not surprisingly and difficulties with logical reasoning so well we talked about cognition and BPD I often get questions from family members especially from parents who have a child who's affected with the disorder asking about the relationship between ADHD and learning disorders and BPD and they do share several features actually so on the surface they share things like impulsiveness emotional instability difficulty controlling anger you know these are things that on the surface look very similar between the two disorders and interestingly children who have ADHD have been found to be five times more likely to develop BPD in adulthood so there are good reasons to suspect that maybe some people BPD have difficulties with some of these cognitive functions now I often get the question as well well do people with BPD what you know what's going on with this relationship with ADHD if you have ADHD or you're more likely to have BPD or if you have BPD I mean are you more likely to have ADHD well the way I like to look at it is that the brain systems that are involved in regulating emotions which we often associate with BPD are very similar on the overlap considerably with a lot of these cognitive functions I just talked about attention concentration problem solving and memory and so this is a recent study that got a lot of media attention where I actually looked at put all these studies together that have been done on BPD and brain imaging and while people are processing negative emotions what I found when it comes to parts of the brain that are under active is that the dorsal lateral prefrontal cortex which you see here in blue the blue little blobs here means there's less activity for people with BPD and then you have something called a subchannel anterior cingulate which is right over here another little blue blob these are toward the front of the brain and tend to be associated with obviously regulating emotions but also with attention and problem-solving and a lot of these executive functions so really these same brain systems are involved so I don't like to see things as ADHD versus BPD but the parts of the brain that tend to be not functioning in the same way as that are in healthy individuals are involved in attention and emotion regulation and it's okay to think of it as ADHD and BPD but I like to encourage the people that I see to think about these all being related to each other okay so we finally get to the slide that I wanted to get to after talking about all of these cognitive functions what actually do we see in people with BPD so one thing that I want to point out here is that this this is the base synthesis of eleven different studies on BPD that looked at neuropsychological functioning but this is remember while people are not emotionally disregulated this is when people are stable and being asked to complete all these different tasks so this doesn't account for what happens when somebody becomes emotionally disregulated so at baseline what we see across the seven different cognitive domains is that first of all I should say that all of these cognitive domains attention processing speed so this is how quickly can you actually process information verbal memory visual memory your visual spatial functioning that I talked about kind of navigating yourself cognitive flexibility the ability to change your mind and planning these are all actually somewhat less efficient and people with BPD as compared to individuals who don't have BPD so all of these you know deficits I like to call them inefficiencies because they're not real deficits they're not strong enough to be deficits are are significant they really do exist in the world but where we see the greatest difficulties believe it or not or with visual memory which surprised a lot of people when this study came out um this has to do with remember drawing something and then remembering maybe 20 minutes later what is it that you just drew and it's amazing to see what people actually do that some people really can't even remember at all that they even drew something previously um and those who do tend to really have distorted images um and again I would show you a little bit more some of these things but they're copyrights Heth uh-huh and then planning is something that wasn't necessarily surprising here that we actually have tests where we have somebody build a tower for example it's called the tower test um and what you do is you ask them to place these blocks and build this tower and we can measure how efficiently they're basically solving this problem and what we found is that they have a hard time really planning out what they're doing so this was the first time that we really see evidence for clear difficulties when somebody is emotionally stable somebody BPD is emotionally stable okay so then the question becomes well how might these types of things affect treatment unfortunately we don't know very much just yet I mean a year from now I'd love to be able to talk to everybody about the results of this study that we're doing in Toronto looking at treatment and how these types of things might affect treatment for people with BPD I do have a little bit of information that I'll tell you about in a moment but if you think about these types of cognitive abilities that I just described if somebody with BPD is going to effectively engage in treatment well it's important that they're able to pay attention right it's important for anybody be able to pay attention if you're gonna engage in something as complex as psychotherapy um to be able to concentrate you should be able to remember what you did in in treatment what happens if somebody comes in and and you as a therapist have just spent you know an hour talking to them and and and processing a number of different important parts of this psychotherapeutic interaction maybe if it's a DBT type of therapy then maybe we're talking about skills that they should be implementing in their daily lives what if they forget everything once they leave your office I mean this is an important thing to consider because it's completely possible that this is what's going on so memory obviously important and executive functions if you're going to use what you learned in psychotherapy and this is assuming that you attended to it and remembered it you have to be able to problem-solve in those particular situations maybe use these these skills you've learned to control your impulses to plan out what you're going to be doing these are all really important and it's kind of surprising we know so little nobody's really looked at this with BPD and a problem can arise when any one of these specific cognitive functions is effective so if you have a problem with attention then you probably can't remember what it is that you were supposed to be paying attention to and that will affect whether you can actually use what you learn in treatment so I want to talk here now about some case examples because we don't have data just yet about how these things affect treatment but what are we talking about are some individuals who were referred to me for neuropsychological testing as part of their work up for DBT at the Centre for Addiction and Mental Health in Toronto so before I go into the details of these individuals I want to refresh people or teach people if you're not familiar with it just yet how we actually gauge how good somebody is doing all these tests versus how not-so-good people are doing on these tests and we call these z-scores or if you're from Canada we call it a Zed score so if I say Zed just you know deal with me so I want to refresh people's minds for those who may have learned this a z-score is a score that we use that helps us understand where an individual person that I have in my office where do they lie with respect to the general population so like I said these tests have been given to hundreds if not thousands of people so we know what's average and we know what's not so good and what's really good so an average score I should say is zero okay a z-score of zero means you're right in the middle 50th percentile as a neuropsychologist unfortunately we're looking for the lower end of things so you know are there certain problems that might be explaining you know why somebody isn't getting better in treatment so we usually look for a Z that's less than one negative one point five do you think of a bell-shaped curve it's kind of on the on the low end of this so as you're looking at the first peoples results I'll be presenting in a moment I want you to look for a Z of negative 1.5 as an indication of we actually would call that a significant deficit for an individual person now anything above that you can see ranges from low average up to average and then even superior so keeping this in mind and you all have it in front of you so you can refer to it I want to first talk about a male that I just saw probably three months ago he was a 25 year old young man a really really sweet guy in his third year of college and he was again referred for DBT because of extensive self-harming behaviors notably cutting and also making suicidal threats to a number of different people so he eventually was hospitalized and he was hospitalized for so long that he decided to drop out of college because things were just too difficult to manage at that time so he came to see me and you know he really presented as very anxious I really wasn't sure whether he wanted treatment it was so hard for him to get treatment that he was at the point where he's like okay I guess I'll kind of give this a trial go through this assessment um and then we'll see where I am and you know maybe I'll commit to treatment but maybe I won't so he talked a lot about you know a history of parental abandonment and his father left his family when he was a young child and he talked unfortunately a lot about extensive physical abuse on which he said was at the hands of his mother and that a lot of this has shaped kind of the way that he relates to people now especially women so there's a lot of social anxiety toward women so in addition to BPD he was diagnosed with recurrent major depression we do have a very comprehensive workup on and he also had some difficulties with alcohol abuse in the past when he becomes significantly dysregulated emotionally one thing that he often turned to in the past was alcohol and so it's important to consider substance abuse when we talk about somebody's cognitive functioning and as I said he was really reluctant to engage in psychotherapy for his difficulties and I think a lot of it had to do with having so limited access to treatment in Toronto that he just didn't want to even at the at this point unfortunately really fight for the treatment and we were able to get him ahead of the waiting list and get him into treatment but first I want to first talk about what happened to him I want to talk about um his neuropsychological functioning so one thing that I want to point out is that we always get an estimate of somebody's IQ when we evaluate somebody and one thing that I don't like to hear is a lot of people think well maybe you know I'm just not smart enough you know and um I'm you know that that's what's going on here but it's not actually for him he was still within the average range okay anywhere from here to here is average um but most of the people that I see with BPD on average are actually a little bit higher than our healthy individuals with regard to IQ so it's not a problem of IQ that I don't know what to do or I'm having you know I'm not smart enough to do this it's not an IQ problem instead if we look at each of the cognitive or neuropsychological domains that I presented earlier what we see is that for example his ability to process information is perfectly normal he has good attention both brief and sustained where we start to see some lower scores moving toward that 1.5 mark that I talked about is verbal memory response inhibition his ability to control his behavior and what we can see is being really significantly impacted it's planning so you might think about what are some of the difficulties that you'd expect in therapy with somebody like this you know what would we expect to see would he be planning out what he should be doing on a weekly basis would he be able to control his impulses as well as somebody else who may be objectively has good impulse control would will he have a good he will only be able to remember what you did in each therapy session I think that all of this is so important when we think about planning treatment for these people so despite his difficulties here he actually expressed to me that he's maybe a little more optimistic this time around for treatment and by the time that we finished our assessments with him he really talked about being more enthusiastic about his his prospects for getting better with DBT so he scheduled his first psychotherapy session but he didn't attend the appointment okay so maybe this isn't entirely surprising considering his you know his neuropsychological profile and when the clinic coordinator contacted him he basically stated that he was no longer interested in therapy so this was unfortunate and we're obviously still trying to get him in and seeing what we can do to kind of motivate him to engage in this treatment but there the study that I talked about the one study that's actually been published so far on BPD and treatment found that planning and visual memory are the greatest predictors the strongest predictors of treatment dropout so it's not entirely surprising when we look at how poor his planning abilities were and by the way this is when he's emotionally stable you can imagine how worse things might get when he's you know experiencing some stress um it's not entirely surprising given the research that we actually see out there all right so I have a second case that I want to talk about and this is a woman who came to see us as well for her workup for DBT at CAMH in Toronto if you've heard Shelley macmaine Sheldon macmaine is the the coordinator of this clinic and she was referred because of extensive self-harming behaviors and she's actually probably one of my favorite people to be honest with you that I've evaluated she was a really outgoing individual um and she you know at first I thought it was her being neurotic you know when when she scheduled her appointment to come see me she called me over and over again saying okay where exactly do I need to meet you where does the bus drop me off on the campus you know where do I go from here and you'll see what that may have actually been in a moment not just being a little neurotic but you know we talked about her case history she talked a lot about having interpersonal problems going back to childhood she said that she couldn't even get on the waiting list unfortunately for treatment in Toronto and that finally getting this hope to actually get into treatment was a really really big deal for her and so she was excited to finally be in on the on at the end of the waiting list and to get into the treatment so she talked a lot about interpersonal problems unemployment and she attributed a lot of these things to her emotion dysregulation um this is not uncommon by the way for us to see people who are chronically basically unemployed have a hard time finding work and some of the research that we've done so far actually suggests that some of these neuropsychological deficits might be contributing to this but that'll be a topic for another day now in addition to BPD our assessments showed that she was diagnosed with major depression alcohol dependence so a big thing for her when she was feeling emotionally disregulated in the past was to turn to alcohol and unfortunately when alcohol was no longer an option for her because of the really harmful consequences it was having for her she turned to her self-harming behaviors so you know it was kind of the switching from one thing to another all in a sense you know forms of self-harm she also described PTSD related to physical abuse from a romantic partner in the past and paranoid personality disorder so we could we already know that she will have difficulties with trust you know going into this okay so when we look at her neuro psychological profile it's quite different from the young man that I just presented we can see here that her IQ is actually high within the average range so not surprising for us to see people with very high IQs yet difficulties you know holding a job or being able to you know really stick with treatments well what's really going on is we can actually see a big dip here when it comes to verbal memory and especial especially visually visual memory um so we see processing speed attention planning response inhibition all intact so what's going on well the test a visual memory is actually quite difficult and she really distorted the image that that she had to just to present to us she had a hard time recalling the lists of words and it's not so then that after completing the neuropsychological testing and I looked at the results of it I thought wow she has some really significant cognitive difficulties I should say by the way that we always give tests of effort so it's not that she's just not trying we actually give tests that see how hard people are trying this is so these are all valid performances this is actually how she does on these tests not that she's not trying so after she completed the testing I got a phone call while severy several phone calls later that night and the next day because she couldn't remember if she had actually participated in a study of mine or if it was another study and NW she was actually talking about somebody else's study at a completely different Hospital so I could start to see here how memory might be playing a role um and in talking to her therapist I learned that psychotherapy and by the way she's been in therapy for about four months now I'm in DBT has progressed somewhat slowly slower than they would have liked and one of the main themes was that she tends to leave a lot of messages for her therapist I actually got a lot of messages to the next day saying I forgot to tell you this I forgot to tell you've had right and her therapist apparently has a difficult time kind of managing all these phone calls so it would be nice to know how can we actually use memory aids or other types of things during the week in between therapy sessions rather than kind of calling her therapist multiple times to say oh I remember this and this is really important for me to say right I know that it is important but maybe trying to knowing that these could be problems and you know planning ahead of time we can avoid maybe some difficulties and maybe psychotherapy would be even more effective so and another big thing was you know not knowing how to handle a situation you know I often hear people saying that I don't know what to do in this situation and what our research suggests is that they know that it's actually in their their memory even though it's not you know as great as we might hope on average for these people the information gets in there the hard part is actually using the information so it's not that they don't know it or remember it the hard part is retrieving it from their memory and using it okay so some of the take-home messages that I have then is that you know BPD is associated with a range of cognitive deficits and that no two individuals necessarily will look the same some people will have deficits with memory and concentration other people will have really difficult problems with planning and impulse control and so we can't say that everybody with BPD has these problems in fact we found that there's a good proportion of people I'd say a good 25 to 30% of people who don't show any significant deficits at all actually so this is not common across all people with BPD and no two people look alike but what we can say is the most frequently affected domains are memory response inhibition and planning and these deficits are really subserved by many of the same brain systems that are involved in regulating emotion so usually we're talking about frontal regions of the brain being responsible for regulating emotions they're also involved in regulating controlling focusing attention now we talk about treatment you know worse executive functioning and visual memory in this one study i bifur took at all in 2012 actually suggested that it's visual memory and these executive functions if you're do particularly worse on those that is a predictor it helps us understand who's gonna end up dropping out of treatment people in terms of people with BPD so it's you know there might be a lot of potential here if we can actually study this in a systematic way and I would recommend to many of the clinicians here today you know if somebody comes to you and says you know I do have memory problems I have a really hard time paying attention to trust your patient okay this is something you know real for them and might warrant a neuropsychological evaluation and so an individualized neuropsychological assessment might actually really with with treatment planning and could improve the treatment outcomes for these people and really briefly what I want to say here is that the study that we're doing is actually looking at DBT and kind of how how cognition and brain function might change through treatment and if we're talking about DBT and the mindfulness component of DBT but you know this is really an attentional intervention can people really use their attentional skills in a more effective way and if somebody is having problems with concentration and distractibility if you can actually improve their attention through some of the things that we do you know as part of therapy if you can improve attention then actually that has a good impact on memory you can actually improve memory as well so there are a lot of really interesting ways that therapy can actually take advantage of what we know about cognitive deficits and BPD and maybe improve them and improve therapy hopefully outcomes for these people all right so where are things going with this research well we have as I said this study B that's funded by the American Foundation for Suicide Prevention and we're incorporating the scenario psychological testing that I've already talked about and brain imaging to see whether we can predict who with BPD who is also self harming who's going to benefit the most from DBT and how might these things actually impact treatment I think you know an important question that hasn't been evaluated just yet so look out in about a year or so if we should have the results of this study available and hopefully we've got some interesting findings and another thing that I want to talk about because this is a study that we're running in our lab right now in Toronto is that these cognitive deficits that we talked about in BPD might actually be heritable within families so we have this small pilot study we've now got probably 60 families in the study at this point um we're actually looking at people who have BPD and their first-degree biological relatives and looking at whether people related to people's BPD by virtue of being genetically related to them do we see some very subtle cognitive inefficiencies and the long story short is that we have it seems that we do actually very subtle not everybody obviously so if your family member here today this is on average okay um and what we're finding is that there might be difficulties with controlling impulses memory and vigilance or sustained attention so we can actually use this information to potentially identify genes that might be contributing to BPD so a lot of interesting things that don't necessarily have a clinical application but that could eventually help us identifying causes all right so that is everything I do want to acknowledge my laboratory at the University of Toronto Scarborough campus where all this research is taking place and my primary collaborator Sally macmaine and the BPD clinic at CAMH in Toronto and this research funded by AF SP and the Canadian Institutes of Health Research and last but not least really this research wouldn't be possible with people you know actively participating in our research and so I want to thank people with BPD their families who really make this research possible thank you thank you dr. Roco we have an addition to questions we have complements both to you and dr. ball for these for these very wonderful informative discussions I've got a big stack of questions I'll start going through there's some overlapping questions in some of these we could also bring to the panel at the end we'll start with I've always worked with the assumption that there that stress anxiety impairs cognition do you know of any research looking at fluctuation in cognitive functioning related to stress affective states and then the question goes on but let's start there yeah that's a really great question the reason it's so important is because unfortunately right now all these standardized tests that we use as clinical neuropsychologist um they don't really get at the heart of what's going on with BPD frankly you know that under conditions of stress that's often when cognition is most significantly impacted so what I'll say in terms of research out there right now there are a few studies that try to integrate emotion with some of these cognitive tests for the most part the results haven't been that fruitful I think the reason is that you know having somebody try to draw something for example that's very emotional from memory isn't really what's going on I think that inducing a mood you know being able to get greater be able to go into the real world and seeing what's going on with cognition when people are emotionally disregulated what we need to do so what I will say quickly though is that um in my laboratory at the University of Toronto we actually have a brain imaging device that is not an MRI okay it actually is slapped on to the person's for have not slapped on but you know put onto the person's forehead nobody's gonna wanna be in my research now after I said that um but what we can do is actually Andy uses infrared light I should say to image the brain you can actually then have the data that's you know while you're imaging the brain downloaded to your iPhone if you really wanted to and be able to follow somebody or in their everyday life so this is the kind of research that we're gonna be doing over the next few years trying to understand how this might be playing in the real world there is a question about can you describe what memory aids are to a decline to help a client with BPD with the deficits so another very good question there are actually people working on and there's actually a lot of work done with schizophrenia actually on and memory and how we can improve treatment adherence so making sure you take your medications so some things really it's common-sense stuff you know and things like you know I actually haven't been involved in psychotherapy for a few years now as a neuropsychologist but I can say that I've heard people do is you know writing things down you know at the end of a psychotherapy session in the next session reviewing what has been done really memory aids can be things like even pill boxes that people use to remember take medications usually we think of this associated with like Alzheimer's disease but if it helps it helps you know so really pragmatic things usually it just comes down to writing things down and reviewing things the thing that I said earlier is that we know that people with BPD even though they might have a hard time recalling information it's in there so as long as you can find a cue to help the person remember the skill or whatever it might be they usually are able to retrieve it from their memory so it's not that they're completely forgetting things it's in there it's just trying to use some cue so that they can use to recognize what skill they should be using or what the memory was that they've actually stored so I hope that helps but we actually need more research done in this area in terms of what would be helpful for BPD this one is you've discussed the neurocognitive deficits in borderline personality disorder but how do you tease out the impact of neuro cognitive problems due to other comorbid disorders for example in case number two could it be related to the alcohol abuse so it's another very good question and I feel like you're old reviewers of my papers right now but it's a very good question so one issue with the research that's done in this area is that we don't have large enough sample sizes to say okay let's look at these people who have you know no substance abuse history and those that that do and comparing their cognitive functioning um so the research that we're doing now we're trying to get the largest sample that's ever been studied so we want to have at least a hundred people tested but right now we're at about sixty so we can't actually tease this these things apart what I will say is that there have been questions about substance use disorders and PTSD and the research suggests that's in terms of substance use these probably are these the people who have extensive histories of let's say alcohol dependence or cocaine dependence these are the types of drugs or substances that tend to be associated with worse cognitive functioning but I should say that once somebody abstains from a lot of these substances for a long enough period of time cognition tends to go back to normal you know so we don't expect unless somebody is currently actually currently has one of these disorders that they would that they that they would be affecting these people and all the research that we do we actually screen people out who have these disorders currently in a way it's actually a good thing because these people say I really want to be in your research so they'll actually abstain for a month and it actually is kind of the start to them getting on the road to recovery with that in that respect and I'll say about PTSD the jury's still out but it overlaps a lot the neuropsychological profile in PTSD overlaps a lot with BPD and we still need more research on this topic I wish we could give you an answer but not just yet this question is how do the visual spatial impairments in BPD affect their behavior would it be different than individuals who have visual spacial impairments but without BPD mm-hmm I actually have never thought of this so it's a good question um because when I think about visual spatial abilities I'm usually I was surprised but that they're even impacted here right um what I would say is that executive functions actually do play a role visual spatial abilities so if you think about navigating your way like I did from the New Haven hotel here um you know you do need to be able to use your problem-solving abilities you need to be able to use a lot of these complex thinking abilities to be able to navigate you know to the to where we are today so I think that it's probably other functions that are related to visual spatial abilities that are actually having an impact and that's very different from somebody who maybe had a stroke that ends up really affecting very strongly visual spatial abilities you know when I see patients with dementia and different types of you know brain insults they will actually have difficulties you know if I say would you like to go to the cafeteria for lunch now they I need to actually walk them over because they actually wouldn't be able to orient themselves in space appropriately especially the more severe ones so it's a little different I would associate the BPD visual spatial problems more to the problem-solving abilities rather than what we see in actual disorientation in space this is a question can you comment on dissociation as a cognitive deficit perhaps in relation to some of these memory yeah so you know what the research that I've started to see coming up that's not published yet but that I have reviewed actually does suggest that those who have dissociation might actually be the worst off neuro cognitively we don't have enough data on that just yet but that is the research that's starting to come out what is going on with dissociation you know what's causing it you know I'm not sure that that's a hundred percent clear just yet what I would say is that the people who have disowned the more severe dissociation tend to be those who describe the worst difficulties with cognition and when we test them it's confirmed through that can you describe response inhibition and then there's another question about for case two is it possible the memory deficits are actually deficits in response inhibition so in terms of response inhibition I actually did and maybe I did actually update these slides um and didn't actually provide them here what I actually presented was a test this test called the Connors continuous performance test where somebody needs to look at a computer screen and every time they see a letter of the alphabet which can be any letter of the alphabet they need to press a space bar so it sounds pretty simple but these things come up on the screen pretty quickly people don't like me when I ask them to do this test I'll tell you right now and you know what they have to do though is every time they see the letter X they have to not press the spacebar they've to stop themselves that's a way that we measure response inhibition one of the ways that we measure response inhibition in our laboratory so it's can you stop yourself from doing something that you're inclined to do so we asked somebody to do this type of a test not just for two or three minutes we asked them to do it for over 10 minutes okay um sometimes people are dozing off some people you know are getting really angry at me well thankfully it's my research assistants who are doing it and not me anymore but this is what we mean by response inhibition so response inhibition definitely plays a role in lots of other cognitive functions I should say that some people are just off the charts I mean I showed you people who have pretty reasonable neuropsychological profiles some people z-scores are just way off the charts on that test specifically they can they literally cannot stop themselves from pressing that button so in the person that there's the second case in terms of how response inhibition might actually be impacting memory what I would say is that for the tests that we use for memory it's like a shopping list okay will actually give somebody a shopping list and we don't think that the ability to control yourself necessarily plays a role in your ability to just kind of recall your shopping list right um but it's possible maybe in that moment that that person is really anxious and they're having a hard time inhibiting their mood or kind of regulating their mood and that's interfering with their memory so I can see how maybe problems with emotion regulation could be actually impacting a lot of what's going on here you know when you present somebody with a huge list of words they usually get anxious you know so if you have a hard time controlling that anxiety then I wouldn't be surprised if you're not doing as well as you could be on that test are there any simple verbal memory tests that could be used in outpatient offices providers a very good question and I'm for sexually there are some very straightforward tests that are out there I would recommend something like the Hopkins verbal learning test that's one that I'm actually talking about almost like a shopping list in a way it has 12 words on it and three learning trials and it's a really interesting test what I will say is you're not going to detect these memory problems using the mini-mental State Examination you know three words is just not enough in order to evaluate this it's just not sensitive enough and so I would recommend definitely using a test that's more extensive than you know kind of a simple brief memory test and one of them as I said is called the Hopkins verbal learning test a longer test if you really want to go there is called the California verbal learning test and that has 16 words and lots of other fun things that your patients will not like you asking them to do I don't like doing a what our effort testing profiles like in neuro psych testing with individuals with BPD are they are high failure rates very good question because I actually am writing a paper on this right now and this is what I found I found that in 50 people with BPD who are outpatients what I found is that 10% of them have questionable performance so we don't really know why there's questionable performance you know what their motivation is I think it's just that they maybe are having a hard time concentrating or something like that on these tests but they really are our test of effort so what I would say is that they're most people are trying and the reason I think that that question is so important is because so many clinicians you know the stigma out there is that these people are manipulating people you you know they're untreatable but in fact if we look at our tests our objective tests are actually showing that they're trying they're not they're trying to you know you know pull a fast one you know I've got memory problems but I really don't do you know if you test me we're finding that there really are you know they're trying on these tests and I think that alone will go a long way I hope toward reducing stigma that they're they're trying and in my research protocol the people who aren't trying our healthy controls actually we're finding that people are just saying oh yeah I want to be in your research and then they end up failing our test because they just want the money from Huss um so it's actually our healthy people who are failing the test more frequently than our people with BPD does your practice diagnose borderline personality disorder from neuro psych testing so that's a really good question because I've gotten emails about this so I actually am not involved in clinical practice all of this is really an you know related to the DBT clinic and mainly for research what I will say though is that you cannot no neuropsychological profile is diagnostic I know a lot of people like to say okay look my neuropsychological profile looks like that but there are a lot of people who have depression or who have no mental health history you know issues at all and they might look like who actually so it's never diagnostic even for somebody with Alzheimer's disease it's not diagnostic so what it does is it's descriptive it tells us what are some problems that people might have and is it consistent with what we know about people who have this diagnosis I like to use it as I said for treatment planning and also to assist with diagnosing things like ADHD and learning disorders because neuropsychological testing is part of the diagnosis of that how my cognitive deficits impact interpersonal relationships yes so much so one of my students is actually looking at another aspect of cognition that I'm not even talking about today it has to do with it processing emotions from in phases and when I presented this research in Boston two weeks ago people family members were saying you need to get this the word out there about this the what our main finding was this people's BPD looking at faces actually process neutral faces in a very different way than people who don't have BPD they tend to actually see a negative emotion in a neutral face and we actually found that they have a hard time recognizing disgust in faces which is interesting considering disgust signifies rejection and an anger as well so in a different aspect of cognition it's a social cognition so I think that some of these things are contributing to how people are actually interpreting social cues like faces so the research is suggesting that actually something that's unique to BPD that you don't see in schizophrenia bipolar disorder because I've actually done research on this and those disorders is misinterpretation of neutral faces and difficulty really identifying and recognizing faces that are signifying threat or or or rejection how can a treater or family member address these problems in perception cognition without seeming to invalidate the experience of someone with borderline given that feeling invalidated may lead to more dysregulation yeah it's a good question and I have to give it you know give credit to the to the therapists out there who you know really are trying to manage emotion dysregulation on the one hand and then also you know cognitive dysfunction um I found that you know in my training validating that these are real experiences you know that if you're having memory problems to validate it this is a real experience something I didn't even get into here is that think of the average BPD person if you've got somebody who's got high IQ generally speaking even if their memory is in the average range let's say it's low any average range if you have a really high IQ you're gonna experience that as a memory problem so I think it's important to keep in mind that people with BPD tend to have high IQs okay as I said my research it's actually a little bit higher for BPD versus our healthy individuals but if their memory is average they experience that as a memory problem so validating that maybe even pointing out that you can have a high IQ and an average menu menu memory and for you that might actually be conspira-con it I think to acknowledge it is the first step in validating it and trying to work in some of these you know memory aids whoever if whatever it might be in treatment and hopefully we'll have some more you know empirical support for types of AIDS you can use in treatment in the future right now we don't really have the science supporting it a final question before our break you mentioned that all patients with BPD do not have the same cognitive deficits is there any evidence that there are clusters within BPD perhaps indicating that what we call BPD is actually several distinct disorders lumped together hmm yeah and that and this is the reason that I talked about having a large enough when you're doing studies sample size right you know fortunately unfortunately I'm not sure what to say here in Toronto you know we have so many people with BPD and their family members who want to be in our research part of it is because of the lack of access to treatment and people really wanting to be able to do something so we're really fortunate I have to say to have so many people interested in the research and this is why I have this slide here um when we have enough people in our research we can actually try to identify subgroups and I know it's not the topic of today's presentation but when I talk about these different profiles and family members and controls the research that I've done actually suggests that those who have the worst impulse control problems based on neuropsych testing in terms of people with BPD their relatives are more likely to also have really bad impulse control problems using the tests that I've talked about and this is a suggestion that maybe there's a subgroup of people where there were response inhibition impulse control is a core inheritable component of the disorder and maybe there are other aspects of cognition memory attend that differentiate these people from another group of people where these are the main problems so this is why I talked about going beyond clinical uses we can actually use this these cognitive deficits and brain imaging markers as as ways to maybe figure out if there are subgroups of people with BPD and I think most people would agree that probably are and if you look at the research on autism spectrum disorders schizophrenia the research is showing once you go down to this level beyond symptoms going down to cognitive functioning and brain imaging you see subgroups of people that are probably related to different causes for the disorder and that's what the way that I use these types of tests in my laboratory thank you dr. Roco [Applause]

Channel: YaleUniversity

Views: 135,195

Keywords: Neuropsychology, Borderline, ADHD, Learning, Attention, Memory, Planning, IQ, Borderline Personality Disorder (Disease Or Medical Condition)

Id: RgZy_E3nHRc

Length: 61min 36sec (3696 seconds)

Published: Mon Jul 01 2013