Wang CM, Xue H, Xin B, Zhang K, Wang S, Wang JC, An CX, Li N. Cognitive impairment in patients with bipolar disorder alone versus those with bipolar disorder comorbid with borderline personality disorder. World J Psychiatry 2024; 14(8): 1174-1181 [DOI: 10.5498/wjp.v14.i8.1174]
Corresponding Author of This Article
Na Li, MD, PhD, Doctor, Department of Psychiatry, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Yuhua District, Shijiazhuang 050031, Hebei Province, China. linaxdrs@163.com
Research Domain of This Article
Psychiatry
Article-Type of This Article
Case Control Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Chao-Min Wang, Hua Xue, Bo Xin, Kun Zhang, Shuo Wang, Jin-Cheng Wang, Cui-Xia An, Na Li, Department of Psychiatry, The First Hospital of Hebei Medical University, Shijiazhuang 050031, Hebei Province, China
Author contributions: Wang CM, Xue H, Xin B, and Li N designed the research; Zhang K, Wang S, and Wang JC analyzed the data; Wang CM, An XC, and Li N wrote the manuscript.
Supported byHebei Province Medical Science Research Project, No. 20221407.
Institutional review board statement: This study was approved by the institutional review board of The First Hospital of Hebei Medical University.
Informed consent statement: Informed consent was obtained form each participant.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data are available from the corresponding author.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Na Li, MD, PhD, Doctor, Department of Psychiatry, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Yuhua District, Shijiazhuang 050031, Hebei Province, China. linaxdrs@163.com
Received: April 24, 2024 Revised: May 28, 2024 Accepted: July 10, 2024 Published online: August 19, 2024 Processing time: 109 Days and 20.4 Hours
Abstract
BACKGROUND
Bipolar disorder (BD) is a severe mental illness. BD often coexists with borderline personality disorders, making the condition more complex.
AIM
To explore the differences in cognitive impairment between patients with BD and those with BD comorbid with borderline personality disorder.
METHODS
Eighty patients with BD and comorbid borderline personality disorder and 80 patients with BD alone were included in groups A and B, respectively, and 80 healthy volunteers were included as controls. Cognitive function in each group was evaluated using the Chinese version of the repeatable battery for the assessment of neuropsychological status (RBANS), the Stroop color-word test, and the Wechsler intelligence scale-revised (WAIS-RC).
RESULTS
The indices of the RBANS, Stroop color-word test, and WAIS-RC in groups A and B were significantly lower than those of the control group (P < 0.05). Group A had significantly longer Stroop color-word test times for single-character, single-color, double-character, and double-color, lower scores of immediate memory, visual breadth, verbal function dimensions and total score of the RBANS, as well as lower scores of verbal IQ, performance IQ, and overall IQ of the WAIS-RC compared with group B (P < 0.05). Compared to group B, group A exhibited significantly longer single-character time, single-color time, double-character time, and double-color time in the Stroop color-word test (P < 0.05).
CONCLUSION
The cognitive function of patients with BD complicated with borderline personality disorder is lower than that of patients with BD.
Core Tip: This study explored the differences in cognitive impairment between patients with bipolar disorder and those with bipolar disorder comorbid with borderline personality disorder. The cognitive function of both patients with bipolar affective disorder alone and those with bipolar affective disorder complicated with borderline personality disorder showed extensive damage, and the cognitive impairment was considerably aggravated in patients with bipolar affective disorder comorbid with borderline personality disorder compared with those with bipolar affective disorder alone.
Citation: Wang CM, Xue H, Xin B, Zhang K, Wang S, Wang JC, An CX, Li N. Cognitive impairment in patients with bipolar disorder alone versus those with bipolar disorder comorbid with borderline personality disorder. World J Psychiatry 2024; 14(8): 1174-1181
Bipolar disorder is a severe mental illness[1,2]. The patients experience both manic and depressive episodes[3]. The global incidence rate is approximately 1%-2% and the suicide rate is 9%-15%[4]. Cognitive impairment is one of the core symptoms of bipolar disorder, which can lead to decreased attention, memory, and executive function[5,6]. The clinical features of borderline personality disorder include emotional regulation instability, poor impulse control, difficult interpersonal relationships, poor self-intention, and a high risk of self-injury and suicide[7-9]. Bipolar disorder often coexists with borderline personality disorders, making the condition more complex[10].
Cognitive function refers to the brain's ability to process information, including perceptual ability, working memory ability, logical reasoning ability, and thinking ability. Research both domestically and internationally has found that bipolar disorder and borderline personality disorder can both cause cognitive impairment. At present, there are many related studies on cognitive impairment caused by single diseases such as bipolar disorder and borderline personality disorder in clinical practice. However, there is relatively little research on whether comorbidity of bipolar disorder with borderline personality disorder will exacerbate cognitive impairment. This study explored whether there is a difference in the degree of cognitive impairment between patients with bipolar disorder alone and those with comorbid borderline personality disorder.
MATERIALS AND METHODS
Subjects
From January 2022 to July 2022, 80 patients with bipolar disorder and comorbid borderline personality disorder and 80 patients with bipolar disorder alone treated at our hospital were included in groups A and B, respectively, and 80 healthy volunteers were included as controls. The patients in group A and group B were further divided into bipolar depression and bipolar mania groups. A comparison of the clinical data between the observation and control groups is shown in Table 1. The inclusion criteria were: (1) The diagnosis of bipolar disorder was consistent with the diagnostic criteria of the "American Diagnostic and Statistical Manual of Mental Disorders"[11]. The diagnosis of borderline personality disorder was confirmed using a personality diagnosis questionnaire (PDQ-4+)[12] and personality disorder clinical examination (SCID-II)[13]; (2) age 18-45 years, regardless of sex; (3) disease course over 2 years; (4) the duration of use of antidepressants, atypical antipsychotics, or emotional stabilizers was < 14 d, and benzodiazepine drugs were not used; (5) no electroconvulsive therapy administered within 6 mo; (6) the subjects can read and fully understand the contents of the research scale; and (7) the subjects or their families provided written informed consent. The exclusion criteria were a history of substance abuse or dependence, previous or current brain organic diseases, severe uncontrolled physical diseases, visual impairment (including color blindness), auditory impairment, and physical diseases affecting cognitive function.
Repeatable battery for the assessment of neuropsychological status[14]: The repeatable battery for the assessment of neuropsychological status (RBANS) was completed under the guidance of researchers. The RBANS contains 12 subtests including attention, speech function, visual breadth, immediate memory ability, and delayed memory ability. Among these, immediate memory includes two sub-items: Vocabulary learning and story recall; visual breadth includes two sub-items: Graphic imitation and line positioning; verbal function includes two sub-items: Picture naming and semantic fluency; attention includes two sub-items: Digital span and coding test; delayed memory includes four sub-items: Vocabulary recall, vocabulary recognition, story recall, and graphic recall. Scores for each item can be obtained from the table, and the total score of the scale is obtained by summing the scores of all items according to the table.
Stroop color-word test[15]: The Stroop color-word test mainly evaluates perceptual conversion, selective attention, and inhibition of habitual response patterns. It is divided into four parts: (1) Reading 30 black words 'red', 'green', 'blue', and 'yellow'. The time to complete is the single word time; (2) reading 30 blocks of red, green, blue, and yellow. The time to complete is the single-color time; (3) reading 30 words with inconsistent meanings and colors. The time to complete is the two-word time; and (4) reading 30 records according to print color. The completion time is the two-color time.
Wechsler intelligence scale[16]: The Wechsler intelligence scale-revised (WAIS-RC) includes verbal IQ and performance IQ. Higher IQ scores indicate better intelligence.
Statistical analysis
SPSS22.0 software was used for data analyses. Measurement data, including age, body mass index, and RBANS scores, are expressed as the mean ± SD, and the differences between groups were analyzed by the independent t-test or F-test. Count data, including sex, disease type, etc., are expressed as n (%), and the differences between groups were compared using the chi-square test.
RESULTS
Comparison of RBANS, Stroop color-word test, and WAIS-RC scores in different groups
The scores of the RBANS, Stroop color-word test, and WAIS-RC in groups A and B were compared with those of the control group (P < 0.05). The scores of immediate memory, visual breadth, and verbal function dimensions and the total score of the RBANS in group A were significantly lower than those of group B. The scores of verbal IQ, performance IQ, and overall IQ of the WAIS-RC test in group A were significantly lower than those of group B (P < 0.05). In the Stroop color-word test, the single-word, single-color, double-word, and double-color times were significantly longer in group A than in group B (P < 0.05) (Table 2).
Table 2 Comparison of repeatable battery for the assessment of neuropsychological status assessment, Stroop color-word test, and Wechsler intelligence scale-revised scores in each group.
Comparison of RBANS, Stroop color word test, and WAIS-RC scores in patients with bipolar depression between group A and group B
The scores of immediate memory, visual span, and speech function dimensions and the total score of the RBANS in patients with bipolar depression in group A were significantly lower than those of group B. The scores of the verbal IQ, performance IQ, and overall IQ of the WAIS-RC were significantly lower in group A than in group B (P < 0.05). In the Stroop color-word test, the single character time, single color time, double character time, and double color time of patients with bipolar depression in group A were significantly longer than those of group B (P < 0.05) (Table 3).
Table 3 Comparison of repeatable battery for the assessment of neuropsychological status assessment, Stroop color word test, and Wechsler intelligence scale-revised scores in bipolar depression patients between group A and group B.
Index
Group A (n = 43)
Group B (n = 45)
t
P value
RBANS
Immediate memory score
61.51 ± 9.21
67.02 ± 9.04
-2.832
0.006
Visual breadth score
65.12 ± 8.01
70.31 ± 8.44
-2.956
0.004
Speech function score
76.89 ± 9.15
83.32 ± 9.10
-3.304
0.001
Attention function score
83.80 ± 10.00
84.18 ± 10.14
-0.177
0.860
Delayed memory score
71.02 ± 9.14
70.43 ± 9.04
0.304
0.762
Total score
66.83 ± 9.02
72.23 ± 9.15
-2.787
0.007
Stroop color-word test
Single word time (s)
15.12 ± 2.09
13.02 ± 2.10
4.700
0.000
Single color time (s)
19.82 ± 2.43
18.20 ± 2.43
3.126
0.002
Double word time (s)
16.92 ± 2.30
14.15 ± 2.10
5.904
0.000
Double color time (s)
35.92 ± 7.09
29.94 ± 6.16
4.229
0.000
WAIS-RC
Verbal IQ score
90.11 ± 9.14
97.02 ± 9.40
-3.494
0.001
Performance IQ score
83.12 ± 4.88
89.02 ± 5.14
-5.517
0.000
Overall IQ score
91.34 ± 9.05
97.50 ± 10.10
-3.008
0.003
Comparison of RBANS, Stroop color-word test, and WAIS-RC scores in patients with bipolar mania between group A and group B
The scores of immediate memory and speech function dimensions and the total score of the RBANS in patients with bipolar mania in group A were significantly lower than those of group B. The scores of the verbal IQ, performance IQ, and overall IQ of the WAIS-RC in patients with bipolar mania were significantly lower in group A than in group B (P < 0.05). In the Stroop color-word test, the single character time, single color time, double character time, and double color time of bipolar mania patients in group A were significantly longer than those of group B (P < 0.05) (Table 4).
Table 4 Comparison of repeatable battery for the assessment of neuropsychological status assessment, Stroop color word test, and Wechsler intelligence scale-revised scores in patients with bipolar mania between group A and group B.
Index
Group A (n = 37)
Group B (n = 35)
t
P value
RBANS
Immediate memory score
61.38 ± 9.03
66.95 ± 9.10
-2.606
0.011
Visual breadth score
67.28 ± 8.14
69.88 ± 8.56
-1.321
0.191
Speech function score
77.17 ± 9.04
85.31 ± 9.05
-3.817
0.000
Attention function score
83.52 ± 10.16
84.50 ± 10.22
-0.408
0.685
Delayed memory score
70.65 ± 9.15
72.24 ± 9.09
-0.739
0.462
Total score
67.41 ± 9.10
73.26 ± 9.15
-2.719
0.008
Stroop color-word test
Single word time (s)
15.35 ± 2.17
13.20 ± 2.14
4.230
0.000
Single color time (s)
20.47 ± 2.12
18.49 ± 2.05
4.025
0.000
Double word time (s)
16.68 ± 2.11
14.33 ± 2.21
4.616
0.000
Double color time (s)
37.02 ± 7.40
30.42 ± 6.24
4.080
0.000
WAIS-RC
Verbal IQ score
88.14 ± 9.23
96.20 ± 9.31
-3.688
0.000
Performance IQ score
83.51 ± 4.50
88.56 ± 5.14
-4.442
0.000
Overall IQ score
93.02 ± 9.14
97.91 ± 10.11
-2.155
0.035
DISCUSSION
Bipolar disorder is a chronic mental disorder with a high disability rate; however, its etiology has not been fully elucidated[17-19]. Existing studies have suggested that it may be related to environmental and genetic factors and need to be treated with mood stabilizers[20,21]. The lifetime prevalence of bipolar disorder is as high as 3.9%[22]. Clinical studies have found that an increasing number of patients with bipolar affective disorders are accompanied by personality disorders, particularly borderline disorders[23-25]. The comorbidity of the two makes the treatment of bipolar disorder more complicated and even contradictory, which leads to a poor prognosis and greatly increases the difficulty of clinical diagnosis and treatment[26]. Many studies have shown that both bipolar disorder and borderline personality disorder are associated with obvious cognitive impairment; however, there are few studies on the degree of cognitive impairment in patients with bipolar disorder complicated with borderline personality disorder. Gudden et al[27] found that young and middle-aged patients with first-episode depression and borderline personality disorder had more severe cognitive impairment and higher interpersonal sensitivity than those without borderline personality disorder.
In this study, the RBANS, Stroop color-word test, and WAIS-RC were used to evaluate cognitive function. It was found that the RBANS and WAIS-RC test results of patients with bipolar disorder alone and bipolar disorder complicated with borderline personality disorder were higher than those of healthy people. The scores of the Stroop color-word test indicators were lower than those in the normal population. This result suggests that the cognitive function of patients with bipolar disorder is worse than that of healthy people, regardless of whether they have a borderline personality disorder. This is due to the presence of lesions in the hippocampus, frontal lobe, and basal nucleus of the brain in patients with bipolar disorder, affecting attention, speech function, visual breadth, immediate memory, delayed memory, perceptual conversion ability, selective attention, inhibition of habitual response patterns, intelligence, and other cognitive functions[28-30].
This study found that the scores of the immediate memory, visual breadth, and speech function dimensions and the total score of the RBANS, as well as the scores of verbal IQ, performance IQ, and overall IQ of the WAIS-RC in patients with bipolar affective disorder and borderline personality disorder were significantly lower than those of patients with bipolar affective disorder alone. In the Stroop color-word test, the single-word, single-color, double-word, and double-color times of bipolar affective disorder patients with borderline personality disorder were significantly longer than those of bipolar affective disorder patients without. This result suggests that cognitive impairment in patients with bipolar affective disorder with borderline personality disorder is more serious than that of patients with bipolar affective disorder alone. This is due to structural dysfunction in the brain of patients with borderline personality disorder. MRI results in patients with borderline personality disorder suggest reduced hippocampal and amygdala volumes or only reduced amygdala volume[31]. Structural brain damage in patients with bipolar disorder and borderline personality disorder is more serious and may be one of the reasons for more serious cognitive impairment in this population.
This study also compared the cognitive function of patients with different manifestations of bipolar affective disorder. The scores of the immediate memory, visual breadth, and speech function dimensions and total score of the RBANS in patients with bipolar depression were significantly lower in patients with bipolar affective disorder and borderline personality disorder than in those with bipolar affective disorder alone. The scores of verbal IQ, performance IQ, and overall IQ of the WAIS-RC in patients with bipolar depression were significantly lower in patients with bipolar affective disorder and borderline personality disorder than in those with bipolar affective disorder alone, whereas the scores of the Stroop color-word test indicators were higher in patients with bipolar affective disorder and borderline personality disorder than in those with bipolar affective disorder alone. The scores of the immediate memory and speech function dimensions and the total score of the RBANS in patients with bipolar mania were significantly lower in patients with bipolar affective disorder and borderline personality disorder than in those with affective disorder alone. The scores of the verbal IQ, performance IQ, and overall IQ of the WAIS-RC in patients with bipolar mania were significantly lower in patients with bipolar affective disorder and borderline personality disorder than in those with bipolar affective disorder alone, whereas the single-word time, single-color time, double-word time, and double-color time in the Stroop color-word test were significantly longer in patients with bipolar affective disorder and borderline personality disorder than in those with bipolar affective disorder alone. These results suggest that cognitive impairment in patients with bipolar affective disorder and borderline personality disorder is more serious than in patients with simple depressive or manic bipolar affective disorder.
CONCLUSION
In summary, there is a wide range of cognitive impairment in patients with bipolar disorder and bipolar disorder complicated with borderline personality disorder. Cognitive impairment in patients with bipolar disorder complicated with borderline personality disorder is more significant than that of patients with bipolar disorder alone.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade B
Creativity or Innovation: Grade B
Scientific Significance: Grade B
P-Reviewer: Imran I S-Editor: Gong ZM L-Editor: Wang TQ P-Editor: Cai YX
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