response inhibition in borderline personality disorder: performance in a go/nogo task

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Original Paper

Psychopathology 2008;41:50–57 DOI: 10.1159/000110626

Response Inhibition in Borderline Personality Disorder: Performance ina Go/Nogo Task

Mirjam Rentrop

a Matthias Backenstrass

b Britta Jaentsch

b Stefan Kaiser

b

Alexander Roth

b Joerg Unger

b Matthias Weisbrod

b Babette Renneberg

a, c

Departments of a Psychology and b

Psychiatry, University of Heidelberg, Heidelberg , and c

Department of Psychology, Free University of Berlin, Berlin , Germany

times and a speed-accuracy tradeoff. Second, they show a genuine deficit of response inhibition. These results are dis-cussed in the context of the conflicting literature on re-sponse inhibition and executive control in borderline per-sonality disorder. Copyright © 2007 S. Karger AG, Basel

Introduction

The number of studies investigating neuropsycholog-ical function in patients with borderline personality dis-order (BPD) has increased substantially during recent years. In the present study, we investigated response in-hibition as a possible core deficit in BPD.

A defining feature of BPD is marked impulsivity [1] , the theme of impulsivity appearing in several diagnostic DSM-IV criteria. Impulsive aggression is related to un-stable interpersonal relationships, inappropriate anger and potentially self-damaging behavior typically found in borderline patients [2] . Furthermore, impulsivity seems to be stable over time and a predictor of the longi-tudinal course of borderline symptomatology [3] . Gener-ally higher impulsivity seems to be associated with a def-icit in response inhibition [4] and differential brain acti-vation patterns during a Go/Nogo paradigm [5] . Go/Nogo paradigms (a very effective form of rapid-decision tasks)

Key Words

Borderline personality disorder � Response inhibition � Go/Nogo � Impulsivity

Abstract

Background: Borderline personality disorder is associated with subtle neuropsychological deficits. A potential impair-ment of response inhibition is of major interest, since it could be related to impulsivity as a clinical feature of borderline personality disorder. Sampling and Methods: Response in-hibition was studied in an auditory Go/Nogo paradigm in a sample of 20 female inpatients with borderline personality disorder and 18 healthy controls. The main measures of in-terest were general task performance, errors and reaction times. Results: Patients with borderline personality disorder performed worse in the Nogo task but not in the Go task. In the Nogo task, when response inhibition was essential, pa-tients made more errors of commission, revealing problems to inhibit a prepotent response. Additionally, the borderline group was characterized by significantly shorter reaction times in both tasks compared to the nonclinical control group. The results for errors of commission in the Nogo task remained significant even after controlling for reaction time. Conclusions: The present results suggest a double impair-ment on this response inhibition task. First, borderline per-sonality disorder patients have inadequately fast reaction

Received: February 9, 2006 Accepted after revision: December 20, 2006 Published online: November 1, 2007

Dr. Babette Renneberg, PD Free University of Berlin, Department of Psychology Habelschwerdter Allee 45 DE–14195 Berlin (Germany) Tel. +49 30 83 855 748, Fax +49 30 83 855 634, E-Mail [email protected]

© 2007 S. Karger AG, Basel0254–4962/08/0411–0050$24.50/0

Accessible online at:www.karger.com/psp

http://dx.doi.org/10.1159%2F000110626

Response Inhibition in Borderline Personality Disorder

Psychopathology 2008;41:50–57 51

assessing behavioral disinhibition are considered appro-priate measures of impulsivity [6, 7] . Impulsivity refers to quick, unplanned behaviors that appear to lack clear fore-thought and are decided on the spur of the moment. The concept of impulsivity therefore is strongly related to the ability to inhibit an urgent wish to act or a dominant re-sponse tendency. Thus, disinhibition is regarded as a po-tentially important component of the impulsivity that characterizes BPD [8] . These considerations strongly suggest an investigation whether in BPD disinhibition is observable as a deficit of response inhibition on neuro-psychological task performance.

Most studies in the area of neuropsychological func-tioning have not focused on response inhibition but on visual information processing, memory and planning abilities [9–13] . Despite the limitations of these studies and heterogeneous results there is now evidence for slight memory dysfunctions and problems with complex infor-mation processing, mostly found with visual material.

A study designed to investigate forgetting of border-line-related emotional words in patients with BPD hy-pothesized an inhibition impairment to be the cause of problems with directed forgetting, leading to a perma-nent rehearsal of stimuli. The results indicate that the on-going rehearsal could not be disrupted despite the in-struction to forget the word [14] .

Response inhibition per se was investigated in 2 stud-ies employing a visual Go/Nogo paradigm. In both stud-ies no significant difference in response inhibition be-tween the groups was found [15, 16] . However, at least in 1 study the sample size of n = 8 might have resulted in insufficient power to detect differences. In his recent meta-analysis Ruocco [17] showed that the mean sample size of past investigations of neurocognitive functioning in BPD subjects was less than half of that which would be necessary to detect group differences with sufficient sta-tistical power. This could explain why no significant group difference did occur.

In another study impulse control and impulsivity in participants with and without BPD was examined [8] . In the applied passive avoidance task, participants had to learn to respond to the correct stimuli by trial and error. Responding to a wrong stimulus counted as an error of commission. Female BPD participants reported higher levels of impulsivity and they made significantly more commission errors than controls, referring to impaired impulse control. The difference in commission errors re-mained significant even after controlling for the influ-ence of the covariates psychopathy, antisocial personality disorder, intelligence, anxiety and depression. According

to this study, impulse control seems to be impaired in pa-tients with BPD.

Other recent research did not focus explicitly on re-sponse inhibition but on the broader concept of execu-tive functions. These are higher-order functions required for complex goal-directed behavior and include task monitoring, error correction, planning and response in-hibition. One study investigated executive functions like decision-making and planning, coming to the conclu-sion that patients with BPD show deficits in decision-making and impulsive responding as well as problems with planning cognition [18] . Performance of patients with BPD was correlated with measures of impulsivity [19] . The Wisconsin Card Sorting Test, a classical test of executive functioning, revealed significant differences between patients with BPD and a matched normal con-trol sample [20] . Within the BPD group, higher levels of control, assessed by one scale of the Multidimensional Personality Questionnaire, were associated with lower levels of perseverative responses and errors in the Wis-consin Card Sorting Test. Remarkably in one study at-tentional and executive functions were correlated in a sample of individuals with a diagnosis of BPD, attention being measured by the Attention Network Task and ex-ecutive functioning by the Wisconsin Card Sorting Test [21] . Furthermore, in a linear regression analysis poorer performance on orienting scores (representing a part of the attention network) predicted higher levels of BPD symptomatology.

In summary there is conflicting evidence regarding response inhibition and executive function in patients with BPD. Apart from sample size other factors like pa-tient sampling certainly have to be considered. Another important point is the choice of the paradigm to investi-gate response inhibition. Therefore, we decided to use a well-established auditory Go/Nogo paradigm that we have successfully used to analyze inhibitory dysfunction in patients with schizophrenia and major depression [22, 23] . In this type of task, subjects have to respond to a given target stimulus in the Go task, while they have to withhold the response to the target stimulus in the Nogo task. While Go and Nogo stimuli are similar in stimulus processing, the Go task mainly requires vigilance, where-as the Nogo task specifically demands inhibition of a re-sponse to the target.

The aim of the present study was to investigate re-sponse inhibition in a group of BPD patients in compari-son to a control group matched for age and education. It was expected that patients with BPD would show a lower level of performance than controls in the Nogo task due

Rentrop /Backenstrass /Jaentsch /Kaiser /Roth /Unger /Weisbrod /Renneberg

Psychopathology 2008;41:50–5752

to impaired response inhibition. More specifically they were expected to show more errors of commission, i.e. reacting when inhibition is required. No significant dif-ference between the groups was expected for accuracy of performance in the Go task not requiring response inhi-bition. Regarding the reaction time, no specific hypoth-esis was formulated. Furthermore, we wanted to shed light on the relation between response inhibition and im-pulsivity. Within the BPD group, impulsivity, assessed by the Barratt Impulsiveness Scale version 10 (BIS-10) [24] , was assumed to be correlated with errors of commission in the Nogo task.

Method

Participants Twenty female psychiatric inpatients with BPD – diagnosed

according to DSM-IV and confirmed with SCID-II [25] – and 18 healthy female controls participated in the study. The nonclinical control group was recruited through flyers and local advertising. Eleven of the 20 borderline patients received medication: antide-pressive (7 patients) atypical neuroleptic (1), and a combination of antidepressive and neuroleptic medication (3).

The groups were matched for age, years of education and ver-bal intelligence [26] ( table 1 ). All participants completed the Questionnaire of Thoughts and Feelings, a self-report scale de-signed to measure borderline-specific basic assumptions and neg-ative feelings [27] as well as the BIS-10, a widely applied self-report inventory consisting of 3 subscales measuring cognitive impul-siveness (‘making quick cognitive decisions’), motor impulsive-ness (‘acting without thinking’) and non-planning impulsiveness (‘present orientation’) [24] . The groups differed significantly on the QFT and the BIS-10 (for more details see table 1 ). Exclusion

criteria were current psychotic disorder, current drug/alcohol abuse or dependency, major medical disorders or impaired hear-ing. All subjects gave written informed consent after the experi-ment had been fully explained.

Task and Procedure The auditory Go/Nogo paradigm consisted of 80% low-pitched

and 20% high-pitched tones presented in random order. In the Go task participants had to press the left mouse button when hearing the rare high-pitched tones but not for the frequent low-pitched ones. Conversely in the Nogo task they had to react to the frequent low-pitched tones and withhold the dominant motor reaction to the rare high-pitched tones. Auditory stimuli were presented via insert headphones using the Stim software package (Neuroscan Inc.). Low tones always had a frequency of 1,000 Hz, whereas the high tone was selected for each of the participants depending on their individual pitch discrimination ability. In order to avoid the difficulty of confounding results, the stimuli were presented in a simple and a difficult version, in which the pitch difference and thus target detection difficulty was varied. Thus, each subject had to perform 4 experimental blocks that were counterbalanced across subjects: Go-simple, Go-difficult, Nogo-simple, Nogo-dif-ficult. Each of the 4 blocks consisted of 200 tones with 40 ms du-ration, the interstimulus interval varied randomly from 1.3 to1.7 s.

The groups did not differ significantly in the selected tone fre-quency, neither for the easy condition (BPD group: mean = 1,081.00, SD = 60.67; control group: mean = 1,084.41, SD = 54.31) nor for the difficult condition (BPD group: mean = 1,059.50,SD = 45.36; control group: mean = 1,061.47, SD = 40.38), indicat-ing that no manifest difference in acoustic discrimination ability between the 2 groups existed.

The participants were seated upright in a dimly lit room. They were instructed to focus on a red dot on a gray screen and to avoid blinking and movement of any sort. Between the 4 experimental blocks of approximately 5 min each, the participants were allowed to rest.

BPD (n = 20)

Controls (n = 18)

p value

Age, years 23.5084.40 24.5085.33 0.530Years of education 13.8083.32 13.7582.38 0.958MWT-B 25.9085.81 25.0085.88 0.644QFT 3.8080.57 1.5980.37 <0.001BIS-10 82.72810.48 64.4788.88 <0.001d’ Go 3.8680.76 4.1880.60 0.164d’ Nogo 2.7880.92 3.6680.78 0.003Commission error rate (Nogo) 0.2180.16 0.0880.09 0.004Omission error rate (Nogo) 0.0580.04 0.0380.04 0.107 Reaction time (Go), s 0.5080.07 0.5580.07 0.034 Reaction time (Nogo), s 0.4280.06 0.5280.10 <0.001

Values are means 8 SD. MWT-B = Mehrfachwahl-Wortschatz-Test, measuring ver-bal intelligence [25]; QTF = Questionnaire of Thoughts and Feelings [26]; BIS = Barratt Impulsiveness Scale [23].

Table 1. Demographic, psychometric and performance data of participants



Data Analysis In order to obtain a behavioral measure permitting direct com-

parison between Go and Nogo task performance, the sensitivity index d’ [28] was calculated: d’ = z(hit rate frequent tone)–z(error rate rare tone). The measure d’ is independent of partici-pants’ response bias. Hence, any differences between the groups cannot be attributed to BPD participants’ possible tendency to re-act more readily under uncertainty than control participants.

For statistical analysis of task performance a 2 (group) ! 2 (task) ! 2 (difficulty) ANOVA with d’ as dependent measure was performed. For a more detailed analysis of the errors exhibited in the Nogo task, an additional 2 (group) ! 2 (difficulty) ! 2 (error type) ANOVA with error rate as the dependent variable was cal-culated to distinguish between errors of omission (leaving out a motor reaction) and errors of commission (reacting although in-hibition is required).

In the Nogo task participants have to react 4 times more often than in the Go task, therefore the motor reaction is initiated more quickly and the reaction times are shorter. Since the reaction times are therefore not directly comparable between the Go and the Nogo tasks, 2 separate 2 (group) ! 2 (difficulty) ANOVAs with reaction time as the dependent variable for the Go and the Nogo tasks were calculated. Pearson correlation coefficients be-tween reaction time, errors of commission and impulsivity scores were calculated with a 2-tailed significance level. Significance was assumed for p ! 0.05. SPSS (version 12.0; SPSS Inc., Chicago) was used for all statistical computations.

Results

Errors The ANOVA with the sensitivity index d’ as dependent

variable showed main effects of task (Go/Nogo) [F(1, 36) = 36.8, p ! 0.001, � 2 = 0.51] and difficulty (simple/difficult) [F(1, 36) = 21.5, p ! 0.001, � 2 = 0.37]. As in prior

investigations [21, 22] , the participants performed better in the Go than in the Nogo task and in the simple com-pared to the difficult condition, illustrated in figure 1 . As expected, a significant main effect of group emerged: BPD patients performed worse than control participants [F(1, 36) = 7.8, p ! 0.01, � 2 = 0.18; for means and standard deviations see table 1 ]. Additionally, the task ! group in-teraction [F(1, 36) = 4.5, p ! 0.05, � 2 = 0.11] reached sig-nificance, the effect size can be considered as medium to large [29] . Post hoc tests showed that d’ differed between the groups only in the Nogo task (p ! 0.01), not in the Go task, where response inhibition is of minor importance. The differences between the groups were not influenced by difficulty (interaction terms: n.s.).

Because the Nogo task is of special interest for deficits regarding response inhibition and post hoc tests showed that the groups differed only in this task, we further con-centrated on error type in the Nogo task. There are 2 pos-sible error types: errors of commission (reacting by mis-take) or errors of omission (leaving out a motor reaction). Since probability of occurrence differs between these er-ror types, relative frequencies of both were used as depen-dent variables. ANOVA for Nogo revealed that both groups had a higher commission than omission error rate [F(1, 36) = 27.9, p ! 0.001, � 2 = 0.44] and more errors oc-curred in the difficult condition [F(1, 36) = 6.2, p ! 0.05, � 2 = 0.15] ( table 1 ). Again, a significant main effect of group was found: BPD patients made more errors than control participants in the Nogo task [F(1, 36) = 9.7, p ! 0.001, � 2 = 0.21]. An additional error type ! group inter-action occurred [F(1, 36) = 7.8, p ! 0.01, � 2 = 0.18]. Post hoc tests confirmed that the borderline group had a high-

0

6

Go simple

1

2

3

4

5

Go difficult Nogo simple Nogo difficult

BPD group Control group

* *

Fig. 1. Group means and standard error of the sensitivity index d’ in the 4 blocks; a smaller d’ indicates more errors. * p ! 0.05.

0

0.7

Re

act

ion

tim

e(s

)

Go simple

0.1

0.2

0.3

0.4

0.5

0.6

Go difficult Nogo simple Nogo difficult

* *

BPD group Control group

* *

Fig. 2. Reaction time in seconds (mean value and standard error of the mean) in the 4 blocks for both groups. * p ! 0.05.



er relative frequency of errors of commission (occurring when response inhibition has failed) than the control group in the Nogo task (p ! 0.01), whereas no significant difference between the groups could be found for errors of omission (n.s., p = 0.10).

Reaction Times For the Go task, the 2 (group) ! 2 (difficulty) ANOVA

revealed faster performance in the simple compared to the difficult condition [F(1, 36) = 18.8, p ! 0.001, � 2 = 0.34]. Furthermore, BPD patients showed quicker reac-tions than controls [F(1, 36) = 4.9, p ! 0.05, � 2 = 0.12]. There was no significant difficulty ! group interaction.

In the Nogo task, BPD patients reacted significantly faster than control participants [F(1, 36) = 15.3, p ! 0.001, � 2 = 0.30; table 1 ]. No other effects were signifi-cant. The reaction times in the 4 blocks are shown in figure 2 .

Correlations A significant correlation between errors of commis-

sion and reaction time in the Nogo task was found (r = –0.45, p ! 0.05), but only within the BPD group. No sig-nificant correlation was found in the control group (allp 1 0.12). This indicates a speed-accuracy tradeoff that is specific to patients with BPD. This finding raised the question whether BPD patients only make more errors of commission because of higher speed of reaction. There-fore, we included reaction time as covariate in our analy-ses of errors of commission in the Nogo task.

An analysis of covariance for the Nogo task was cal-culated with commission error rate as dependent vari-able. The model included group as between-subject fac-tor, difficulty as within-subject factor and reaction time as covariate. The interaction between reaction time and group was also included in the model. The groups still differed significantly in commission errors [p = 0.05,F(1, 34) = 4.1, � 2 = 0.11] even when reaction time was controlled for. The effect for reaction time as covariate was also significant [F(1, 34) = 6.4, p ! 0.05, � 2 = 0.16]. Neither difficulty nor any interaction with difficulty was significant.

No correlations were found between the impulsivity scores of the BIS-10 or its subscales and reaction time or errors of commission, neither for the BPD nor for the control group. Likewise in both groups no correlations occured between Questionnaire of Thoughts and Feel-ings scores, assessing borderline specific thoughts and feelings, and measures of reaction time or errors of com-mission.

Discussion

In this study female inpatients with BPD showed defi-cits in response inhibition compared to a nonclinical con-trol group. Response inhibition was assessed by a well-established auditory Go/Nogo paradigm. In the Nogo task, BPD patients had a lower performance level and made more errors of commission, demonstrating im-paired inhibition of a predominant response. At the same time, BPD patients reacted faster than controls in the Go and the Nogo tasks. They also showed a significant cor-relation between commission errors and reaction time in the Nogo task. However, the difference in commission errors between the BPD and control groups remained sig-nificant even after controlling for reaction time. There-fore, 2 factors seem to contribute to the increase in com-mission errors of the patients. These were a speed-accu-racy tradeoff involving inadequately fast responses and a genuine deficit in response inhibition.

It could be objected that this difference in performance could be the result of nonspecific factors like task diffi-culty, motivation or attention. However, greater difficul-ty did not account for the differences between BPD and controls, as the stimuli were presented in a simple and a difficult version adjusted to the participants’ individual discrimination ability. There was neither a significant difficulty ! group nor a task ! difficulty ! group in-teraction, which should have occured if difficulty had had a different influence on the performance of the 2 groups. Other unspecific factors like motivation and at-tention should also have impaired the performance in the Go task (the Go task being an accepted measure of vigi-lance), which was not the case. Furthermore, the 2 groups did not differ with respect to errors of omission that usu-ally increase when attention drops. Clinical observation of the participants suggests that the BPD group was high-ly motivated and even disappointed, annoyed or irritated after detecting a wrong response. Comparable to patients with frontal lobe lesions, BPD patients did not only notice their commission errors in the Nogo task, some explic-itly complained that their finger moved before they were able to make a distinct decision [30] . Therefore, we are confident that the impairment in the BPD group reflects processes specifically related to the inhibition of ongoing responses.

The patients had significantly shorter reaction times in the Go as well as in the Nogo task, clearly showing a quick reaction style regardless of task or difficulty. It is important to note that a difference in speed of reaction already occurred in the Go task, where both groups did



not show a significantly divergent performance level. In-terestingly, the reaction time results were found although there was no instruction to respond as quickly as possible. The BPD reaction time results therefore do not seem to indicate a consciously chosen strategy or adaptation to the task instructions but rather an involuntary reaction style. The rapid series of tones easily leads to hasty re-sponses, producing some pressure to react as fast as pos-sible, even if it was not explicitly mentioned in the in-structions. In order to avoid too many errors of commis-sion, the speed of reaction has to be controlled with a conscious effort. We suggest that most patients did not succeed in slowing down their reactions deliberately. We had not formulated a hypothesis regarding reaction times because of the complex relationship between impulsivity and speed of reaction [31, 32] . Nevertheless, the results are notable because clinical groups usually show slower reaction times compared to nonclinical groups along with other deficits [33, 34] . Studies investigating plan-ning and decision making, actually found that patients with BPD needed more time to respond [18, 19] . The study by Stevens et al. [12] suggests that BPD patients show varying reaction times depending on the nature and complexity of the task at hand. Therefore, one cannot generally assume that BPD patients show faster reactions, even if it fits naïve ideas of impulsive behavior. Studies with healthy individuals show that participants with higher impulsivity scores do not necessarily react faster, but task demands also seem to play an important role [31, 35] . In simple reaction time tasks high impulsivity leads to shorter reaction times, whereas in more complex tasks it is associated with prolonged deliberation time. In our study the group difference for reaction time was more pronounced in the Nogo task, where the stimulus-re-sponse association is more complex due to the inhibition component. Taken together with the results obtained by Stevens et al. [12] , this suggests a pattern of relatively de-creased reaction time in more complex tasks in BPD, which does not seem to be associated with impulsivity and is different from nonclinical groups [4, 31, 32] .

It is especially interesting that the correlation between decreased response times and increased errors in the in-hibition task was only found in the BPD group. This in-dicates that a speed-accuracy tradeoff is specific to BPD in this task, while in the control group no significant speed-accuracy tradeoff occurred. Healthy participants seemed to control the time they took to respond in order to avoid errors of commission to a larger extent.

After finding a significant correlation between errors and reaction time in the patient group, we had to investi-

gate whether this speed-accuracy tradeoff along with de-creased reaction times alone could explain the increased rate of commission errors in the BPD group. An addi-tional analysis of covariance showed that the results for errors of commission in the Nogo task could not solely be explained by a speed-accuracy tradeoff. Instead, the groups differed in 2 ways: the BPD group was character-ized by a speed-accuracy tradeoff, whereas the control group was not, and the patients showed a response inhi-bition deficit in addition to the increased error rates.

This double impairment seems to differentiate BPD patients from other clinical populations. Patients with antisocial personality disorder display enhanced com-mission errors and decreased probability of inhibition, whereas the mean reaction times are normal [36] . Com-parably, schizophrenic [23] , depressed [22] and hyperac-tive [37] patients show higher error rates but reaction times similar to controls. Therefore, BPD patients – like other patient groups – commit more errors, but they react faster, which is unusual for a clinical group. The results of this study also seem to indicate that higher speed of reaction is no consciously chosen strategy of the BPD group but an involuntary reaction style, which can lead to difficulties when it is necessary to successfully inhibit a predominant response.

Although there was considerable variance in the self-rating of impulsivity, we did not find any correlations be-tween BIS-10 scores and performance measures, neither for the BPD nor for the control group. Other studies also reported no significant correlations for performance in a Go/Nogo task and BIS-scores [5, 15] . The present results are in line with other research indicating that the asso-ciations between behavioral and self-reported measures of impulsivity are rather small [38, 39] . Barratt points out how difficult it is to assess a cognitive component of im-pulsivity in self-report inventories [39] . Therefore, fur-ther research is needed to clarify whether response inhi-bition truly is not associated with impulsivity in a BPD population or whether other self-report measures of im-pulsivity are more likely to represent the kind of impul-sivity relevant to a rapid-decision task. Impulsivity is a multidimensional construct and therefore not easily as-sessed by a single questionnaire [40, 41] .

The present study is the first to demonstrate response inhibition impairment in BPD patients applying an acoustic Go/Nogo paradigm. So far, only visual Go/Nogo tasks have been used in BPD patients, but no indicators were found for impaired performance [15, 16] .

There are several limitations of the study. In addition to the small sample size, it has to be mentioned that the



BPD sample comprised female inpatients only. Thus, the results allow no generalization to male patients with BPD or to outpatients with BPD and a less severely impaired group. We can only make statements for an acoustic Go/Nogo task; further research is needed to demonstrate pat-terns of response inhibition to other stimuli. Further-more, no clinical comparison group was included in the study. Other data from our research group with schizo-phrenic and depressed patients are helpful for a compar-ison; however, differences in the results may also be due to differences between samples in age and level of educa-tion.

In summary the present data reveal decreased reaction times and an impaired response inhibition ability in a group of female BPD patients. Keeping the limitations of the study in mind, the results point to a distinct profile of neuropsychological impairment for BPD.

Acknowledgment

The authors are grateful to Kerstin Herwig for her support in data collection.

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