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Delay discounting and response disinhibition under acute experimental stress in women with borderline personality disorder and adult attention deficit hyperactivity disorder

  • A. Krause-Utz (a1) (a2) (a3) (a4), S. Cackowski (a1) (a2), S. Daffner (a2) (a5), Esther Sobanski (a2) (a5) (a6), Michael M. Plichta (a2) (a5), M. Bohus (a1) (a2) (a7), G. Ende (a2) (a8) and C. Schmahl (a1) (a2) (a9)...



Impulsivity is a core feature of borderline personality disorder (BPD) and attention deficit hyperactivity disorder (ADHD). In BPD, impulsive behavior primarily occurs under acute stress; impulse control deficits under non-stress conditions may be partly related to co-morbid ADHD. We aimed to investigate whether acute experimental stress has an impact on self-reported impulsivity, response inhibition (action withholding, action cancelation) and delay discounting in BPD compared to ADHD.


Thirty female BPD patients, 28 female ADHD patients (excluding patients with co-morbid BPD and ADHD), and 30 female healthy controls (HC) completed self-reports and behavioral measures of impulsivity (IMT, assessing action withholding; GoStop, measuring action cancelation, Delay Discounting Task) under baseline conditions and after an experimental stress induction (Mannheim Multicomponent Stress Test).


Both patient groups reported higher impulsivity than HC, ADHD reported higher trait impulsivity than BPD. On the IMT, ADHD showed significant action-withholding deficits under both conditions, while BPD performed significantly worse than HC under stress. In BPD but not ADHD and HC, action-withholding deficits (IMT) were significantly increased under stress compared to baseline, while no group/stress effects were found for action cancelation (GoStop). Delay discounting was significantly more pronounced in BPD than in HC (no stress effect was found).


In BPD, behavioral deficits in action withholding (but not in action cancelation) appear to be influenced by acute experimental stress. Delay discounting seems to be a general feature of BPD, independent of co-morbid ADHD and acute stress, possibly underlying typical expressions of behavioral impulsivity in the disorder.


Corresponding author

*Address for correspondence: Dr Annegret Krause-Utz, Ph.D., Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, J5, D-68159 Mannheim, Germany. (Email:


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APA (2000). Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association: Washington, DC.
APA (2012). Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric Association: Washington, DC.
Antrop, I, Stock, P, Verte, S, Wiersema, JR, Baeyens, D, Roeyers, H (2006). ADHD and delay aversion: the influence of non-temporal stimulation on choice for delayed rewards. Journal of Child Psychology and Psychiatry 47, 11521158.
Arntz, A, Appels, C, Sieswerda, S (2000). Hypervigilance in borderline disorder: a test with emotional Stroop paradigm. Journal of Personality Disorders 14, 366373.
Barker, V, Romaniuk, L, Cardinal, RN, Pope, M, Nicol, K, Hall, J (2015). Impulsivity in borderline personality disorder. Psychological Medicine 45, 19551964.
Beck, AT, Steer, RA, Brown, GK (1996). Manual for the Beck Depression Inventory – II. Psychological Corporation: San Antonio, TX.
Bernstein, DP, Stein, JA, Newcomb, MD, Walker, E, Pogge, D, Ahluvalia, T, Stokes, J, Handelsman, L, Medrano, M, Desmond, D, Zule, W (2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect 27, 169190.
Bernstein, EM, Putnam, FW (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease 174, 727735.
Bitsakou, P, Psychogiou, L, Thompson, M, Sonuga-Barke, EJ (2009). Delay aversion in attention-deficit/hyperactivity disorder: an empirical investigation of the broader phenotype. Neuropsychologia 47, 446456.
Bohus, M, Kleindienst, N, Limberger, MF, Stieglitz, RD, Domsalla, M, Chapman, AL, Steil, R, Philipsen, A, Wolf, M (2009). The short version of the Borderline Symptom List (BSL-23): development and initial data on psychometric properties. Psychopathology 42, 3239.
Bornovalova, MA, Lejuez, CW, Daughters, SB, Rosenthal, ZM, Lynch, TR (2005). Impulsivity as a common process across borderline personality and substance use disorders. Clinical Psychology Review 25, 790812.
Cackowski, S, Reitz, AC, Ende, G, Kleindienst, N, Bohus, M, Schmahl, C, Krause-Utz, A (2014). Impact of stress on different components of impulsivity in borderline personality disorder. Psychological Medicine 44, 33293340.
Carmona, S, Hoekzema, E, Ramos-Quiroga, JA, Richarte, V, Canals, C, Bosch, R (2012). Response inhibition and reward anticipation in medication naïve adults with attention-deficit/hyperactivity disorder: a within-subject case control neuroimaging study. Human Brain Mapping 33, 23502361.
Carpenter, RW, Trull, TJ (2013). Components of emotion dysregulation in borderline personality disorder: a review. Current Psychiatry Reports 15, 335.
Chapman, AL, Leung, DW, Lynch, TR (2008). Impulsivity and emotion dysregulation in Borderline Personality Disorder. Journal of Personality Disorders 22, 148164.
Coffey, SF, Schumacher, JA, Baschnagel, JS, Hawk, LW, Holloman, G (2011). Impulsivity and risk-taking in borderline personality disorder with and without substance use disorders. Personality Disorders: Theory, Research, and Treatment 2, 128141.
Conners, CK, Erhardt, D, Sparrow, E (1999). CAARS Conners’ Adult ADHD Rating Scales. Multi-health Systems, Inc: North Tonawanda, NY.
Crowell, SE, Beauchaine, TP, Linehan, MM (2009). A biosocial developmental model of borderline personality: elaborating and extending Linehan's theory. Psychological Bulletin 135, 495510.
Cubillo, A, Halari, R, Ecker, C, Giampietro, V, Taylor, E, Rubia, K (2010). Reduced activation and inter-regional functional connectivity of fronto-striatal networks in adults with childhood Attention-Deficit Hyperactivity Disorder (ADHD) and persisting symptoms during tasks of motor inhibition and cognitive switching. Journal of Psychiatric Research 44, 629639.
Cubillo, A, Halari, R, Smith, A, Taylor, E, Rubia, K (2012). A review of fronto-striatal and fronto-cortical brain abnormalities in children and adults with Attention Deficit Hyperactivity Disorder (ADHD) and new evidence for dysfunction in adults with ADHD during motivation and attention. Cortex 48, 194215.
Dai, Z, Harrow, SE, Song, X, Rucklidge, J, Grace, R (2013). Gambling, delay, and probability discounting in adults with and without ADHD. Journal of Attention Disorders. Published online: 21 August 2013. doi:10.1177/1087054713496461.
Demurie, E, Roeyers, H, Baeyens, D, Sonuga-Barke, E (2012). Temporal discounting of monetary rewards in children and adolescents with ADHD and autism spectrum disorders. Developmental Science 15, 791800.
Depue, BE, Burgess, GC, Bidwell, LC, Willcutt, EG, Banich, MT (2010). Behavioral performance predicts grey matter reductions in the right inferior frontal gyrus in young adults with combined type ADHD. Psychiatry Research 182, 231237.
Dibbets, P, Evers, L, Hurks, P, Marchetta, N, Jolles, J (2009). Differences in feedback-and inhibition-related neural activity in adult ADHD. Brain and Cognition 70, 7383.
Dixon-Gordon, KL, Chapman, AL, Weiss, NH, Rosenthal, MZ (2014). a preliminary examination of the role of emotion differentiation in the relationship between borderline personality and urges for maladaptive behaviors. Journal of Psychopathology and Behavioral Assessment 36, 616625.
Domes, G, Winter, B, Schnell, K, Vohs, K, Fast, K, Herpertz, SC (2006). The influence of emotions on inhibitory functioning in borderline personality disorder. Psychological Medicine 36, 11631172.
Dougherty, DM, Marsh, DM, Mathias, CW (2002). Immediate and delayed memory tasks: a computerized behavioral measure of memory, attention, and impulsivity. Behavioral Research Methods: Instruments and Computers 34, 391398.
Dougherty, DM, Mathias, CW, Marsh, DM, Jagar, AA (2005). Laboratory measures of impulsivity. Behavior Research Methods 37, 8290.
Ehring, T, Fischer, S, Schnülle, J, Bösterling, A, & Tuschen-Caffier, B (2008). Characteristics of emotion regulation in recovered depressed versus never depressed individuals. Personality and Individual Differences 44, 15741584.
Ende, G, Cackowski, S, Van Eijk, J, Sack, M, Demirakca, T, Kleindienst, N, Bohus, M, Sobanski, E, Krause-Utz, A, Schmahl, C (in press). Impulsivity and aggression in female BPD and ADHD patients: association with ACC glutamate and GABA concentrations. Neuropsychopharmacology.
Epstein, JN, Johnson, DE, Varia, IM, Conners, CK (2001). Neuropsychological assessment of response inhibition in adults with ADHD. Journal of Clinical and Experimental Neuropsychology 23, 362371.
First, MB, Spitzer, RL, Gibbon, M, Williams, JBW (1997). Structured Clinical Interview for DSM-V Axis I Disorders – Clinical Version (SCID-CV). American Psychiatric Press: Washington, DC.
Fossati, A, Gratz, KL, Maffei, C, Borroni, S (2014). Impulsivity dimensions, emotion dysregulation, and borderline personality disorder features among Italian nonclinical adolescents. Borderline Personality Disorder and Emotion Dysregulation 1, 5.
Fossati, A, Novella, L, Donati, D, Donini, M, Maffei, C (2002). History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality disorder: a controlled study. Comprehensive Psychiatry 43, 369377.
Gratz, KL, Roemer, L (2004). Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment 26, 4154.
Hart, H, Radua, J, Nakao, T, Mataix-Cols, D, Rubia, K (2013). Meta-analysis of functional magnetic resonance imaging studies of inhibition and attention in attention-deficit/hyperactivity disorder: exploring task-specific, stimulant medication, and age effects. JAMA Psychiatry 70, 185198.
Henderson, RK, Snyder, HR, Gupta, T, Banich, MT (2012). When does stress help or harm? The effects of stress controllability and subjective stress response on stroop performance. Frontiers in Psychology 7, 179.
Hervey, A, Epsten, JN, Curry, JF (2004). Neuropsychology of adults with attention deficit/hyperactivity disorder: a meta-analytic review. Neuropsychology 18, 485503.
Holtmann, J, Herbort, MC, Wüstenberg, T, Soch, J, Richter, S, Walter, H, Roepke, S, Schott, BH (2013). Trait anxiety modulates fronto-limbic processing of emotional interference in borderline personality disorder. Frontiers in Human Neuroscience 7, 54.
Horn, R (2009). Standard Progressive Matrices (SPM) [Deutsche Bearbeitung und Normierung nach J. C. Raven], 2nd edn. Pearson Assessment: Frankfurt.
Jacob, GA, Gutz, L, Bader, K, Lieb, K, Tüscher, O, Stahl, C (2010). Impulsivity in borderline personality disorder: impairment in self-report measures, but not behavioral inhibition. Psychopathology 43, 180188.
Jacob, GA, Zvonik, K, Kamphausen, S, Sebastian, A, Maier, S, Philipsen, A, van Tebartz Elst, L, Lieb, K, Tüscher, O (2013). Emotional modulation of motor response inhibition in women with borderline personality disorder: an fMRI study. Journal of Psychiatry & Neuroscience 38, 164172.
Kolotylova, T, Koschke, M, BäR, KJ, Ebner-Priemer, U, Kleindienst, N, Bohus, M, Schmahl, C (2010). Development of the ‘Mannheim Multicomponent Stress Test’ (MMST). Psychotherapie, Psychosomatik, medizinische Psychologie 60, 6472.
Krause-Utz, A, Elzinga, BM, Oei, NY, Spinhoven, P, Bohus, M, Schmahl, C (2014). Susceptibility to distraction by social cues in borderline personality disorder. Psychopathology 47, 148157.
Krause-Utz, A, Oei, NYL, Niedtfeld, I, Bohus, M, Spinhoven, P, Schmahl, C & Elzinga, BM (2012). Influence of emotional distraction on working memory performance in borderline personality disorder. Psychological. Medicine 42, 21812192.
Krause-Utz, A, Sobanski, E, Alm, B, Valerius, G, Kleindienst, N, Bohus, M, Schmahl, C (2013). Impulsivity in relation to stress in patients with borderline personality disorder with and without co-occurring attention-deficit/hyperactivity disorder: an exploratory study. Journal of Nervous and Mental Disease 201, 116123.
Lampe, K, Konrad, K, Kroener, S, Fast, K, Kunert, HJ, Herpertz, SC (2007). Neuropsychological and behavioural disinhibition in adult ADHD compared to borderline personality disorder. Psychological Medicine 37, 17171729.
Lawrence, KA, Allen, JS, Chanen, AM (2010). Impulsivity in borderline personality disorder: reward-based decision-making and its relationship to emotional distress. Journal of Personality Disorders 24, 786799.
Lehrl, S (2005). Mehrfach-Wortschatz-Intelligenztest MWT-B, 5th edn. Spitta Verlag: Balingen.
Leyton, M, Okazawa, H, Diksic, M, Paris, J, Rosa, P, Mzengeza, S, Young, SN, Blier, P, Benkelfat, C (2001). Brain Regional alpha-[11C]methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder. American Journal of Psychiatry 158, 775782.
Lijffijt, M, Kenemans, JL, Verbaten, MN, Engeland, H (2005). A meta-analytic review of stopping performance in attention-deficit/hyperactivity disorder: deficient inhibitory motor control? Journal of Abnormal Psychology 114, 216222.
Linehan, MM (1993). Cognitive-behavioural Treatment of Borderline Personality Disorder. The Guilford Press: New York.
Loranger, AW (1999). International Personality Disorder Examination (IPDE): DSMIV and ICD-10 Modules. Psychological Assessment Resources: Odessa, FL.
Lupien, SJ, Maheu, F, Tu, M, Fiocco, A, Schramek, TE (2007). The effects of stress and stress hormones on human cognition: implications for the field of brain and cognition. Brain and Cognition 65, 209237.
Mancke, F, Herpertz, SC, Bertsch, K (2015). Aggression in borderline personality disorder: a multidimensional model. Personality Disorders 6, 278291.
Marco, R, Miranda, A, Schlotz, W, Melia, A, Mulligan, A, Muller, U (2009). Delay and reward choice in ADHD: an experimental test of the role of delay aversion. Neuropsychology 23, 367380.
Matthies, SD, Philipsen, A (2014). Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)–review of recent findings. Borderline Personality Disorder and Emotion Dysregulation 1, 3.
McCloskey, MS, New, AS, Siever, LJ, Goodman, M, Koenigsberg, HW, Flory, JD, Coccaro, EF (2009). Evaluation of behavioral impulsivity and aggression tasks as endophenotypes for borderline personality disorder. Journal of Psychiatric Research 43, 10361048.
Mischel, W, Ayduk, O, Berman, MG, Casey, BJ, Gotlib, IH, Jonides, J, Kross, E, Teslovich, T, Wilson, NL, Zayas, V, Shoda, Y (2011). ‘Willpower’ over the life span: decomposing self-regulation. Social Cognitive and Affective Neuroscience 6, 252256.
Moeller, FG, Barratt, ES, Dougherty, DM, Schmitz, JM, Swann, AC (2001). Psychiatric aspects of impulsivity. American Journal of Psychiatry 158, 17831793.
New, A, Siever, L (2002). Neurobiology and genetics of Borderline Personality Disorder. Psychiatric Annals of Clinical Psychiatry 32, 329336.
Patton, JH, Stanford, MS, Barratt, ES (1995). Factor structure of the Barratt impulsiveness scale. Journal of Clinical Psychology 51, 768774.
Peters, JR, Upton, BT, Baer, RA (2013). Brief report: relationships between facets of impulsivity and borderline personality features. Journal of Personality Disorders 27, 547552.
Philipsen, A, Limberger, MF, Lieb, K, Feige, B, Kleindienst, N, Ebner-Priemer, U, Barth, J, Schmahl, C, Bohus, M (2008). Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder. The British Journal of Psychiatry 192, 118123.
Plichta, MM (2009). Neural Correlates of Delay Discounting: Effects of Dopamin Bioavailability and Implications for Attention-Deficit/Hyperactivity Disorder (ADHD). Würzburg University: Würzburg.
Plichta, MM, Vasic, N, Wolf, RC, Lesch, K-P, Brummer, DD, Jacob, C, Fallgatter, AJ, Grön, G (2009). Neural hyporesponsiveness and hyperresponsiveness during immediate and delayed reward processing in adult attention-deficit/hyperactivity disorder. Biological Psychiatry 65, 714.
Prehn, K, Schulze, L, Rossmann, S, Berger, C, Vohs, K, Fleischer, M, Hauenstein, K, Keiper, P, Domes, G, Herpertz, SC (2013). Effects of emotional stimuli on working memory processes in male criminal offenders with borderline and antisocial personality disorder. World Journal of Biological Psychiatry 14, 7178.
Rentrop, M, Backenstrass, M, Jaentsch, B, Kaiser, S, Roth, A, Unger, J, Weisbrod, M, Renneberg, B (2008). Response inhibition in borderline personality disorder: performance in a Go/Nogo task. Psychopathology 41, 5057.
Rösler, M, Retz-Junginger, P, Retz, W, Stieglitz, RD (2008). Homburger ADHS-Skalen für Erwachsene (HASE). Manual. Göttingen: Hogrefe.
Schecklmann, M, Ehlis, AC, Plichta, MM, Dresler, T, Heine, M, Boreatti-Hümmer, A, Romanos, M, Jacob, C, Pauli, P, Fallgatter, AJ (2013). Working memory and response inhibition as one integral phenotype of adult ADHD? A behavioral and imaging correlational investigation. Journal of Attention Disorders 17, 470482.
Scheres, A, Tontsch, C, Thoeny, AL, Kaczkurkin, A (2010). Temporal reward discounting in attention-deficit/hyperactivity disorder: the contribution of symptom domains, reward magnitude, and session length. Biological Psychiatry 67, 641648.
Scheres, A, Tontsch, C, Thoeny, LA (2013). Steep temporal reward discounting in ADHD-Combined type: acting upon feelings. Psychiatry Research 209, 207213.
Sebastian, A, Gerdes, B, Feige, B, Klöppel, S, Lange, T, Philipsen, A, Tebartz van Elst, L, Lieb, K, Tüscher, O (2012). Neural correlates of interference inhibition, action withholding and action cancelation in adult ADHD. Psychiatry Research: Neuroimaging 202, 132141.
Sebastian, A, Jacob, G, Lieb, K, Tüscher, O (2013). Impulsivity in borderline personality disorder: a matter of disturbed impulse control or a facet of emotional dysregulation? Current Psychiatry Reports 15, 339–0.
Sebastian, A, Jung, P, Krause-Utz, A, Lieb, K, Schmahl, C, Tüscher, O (2014). Frontal dysfunctions of impulse control – a systematic review in borderline personality disorder and attention-deficit/hyperactivity disorder. Frontiers in Human Neuroscience: Psychiatry 3, 698.
Sieswerda, S, Arntz, A, Mertens, I, Vertommen, S (2007). Hypervigilance in patients with borderline personality disorder: specificity, automaticity, and predictors. Behaviour Research and Therapy 45, 10111024.
Silbersweig, D, Clarkin, JF, Goldstein, M, Kernberg, OF, Tuescher, O, Levy, K, Beutel, M, Epstein, J, Kernberg, OF, Thomas, K, Posner, MI, Stern, E (2007). Failure of fronto-limbic inhibitory function in the context of negative emotion in borderline personality disorder. American Journal of Psychiatry 164, 18321841.
Spielberger, CD (1996). Manual for the State-Trait Anger Expression Inventory: Professional Manual. Psychological Assessment Resources: Odessa, FL.
Stahl, C, Voss, A, Schmitz, F, Nuszbaum, M, Tüscher, O, Lieb, K, Klauer, KC (2014). Behavioral components of impulsivity. Journal of Experimental Psychology: General 143, 850886.
Stiglmayr, C, Schmahl, C, Bremner, J, Bohus, M, Ebner-Priemer, U (2009). Development and psychometric characteristics of the DSS-4 as a short instrument to assess state dissociative experience during neuropsychological experiments. Psychopathology 42, 370374.
Tomko, RL, Lane, SP, Pronove, LM, Treloar, HR, Brown, WC, Solhan, MB, Wood, PK, Trull, TJ (in press). Undifferentiated negative affect and impulsivity in borderline personality and depressive disorders: a momentary perspective. Journal of Abnormal Psychology.
Tragesser, SL, Robinson, RJ (2009). The role of affective instability and UPPS impulsivity in borderline personality disorder features. Journal of Personality Disorders 23, 370383.
Völker, KA, Spitzer, C, Limberg, A, Grabe, H-J, Freyberger, HJ, Barnow, S (2009). Exekutive Dysfunktionen bei Patientinnen mit Borderline-Persönlichkeitsstörung unter Berücksichtigung von Impulsivität und Depressivität. doi: 10.1055/s-2008-1067437 [Executive dysfunctions in female patients with borderline personality disorder with regard to impulsiveness and depression]. Psychotherapie, Psychosomatik, medizinische Psychologie 59, 264272.
Whiteside, SP, Lynam, DR (2001). The Five Factor Model and impulsivity: using a structural model of personality to understand impulsivity. Personality and Individual Differences 30, 669689.
Wingenfeld, K, Rullkoetter, N, Mensebach, C, Beblo, T, Mertens, M, Kreisel, S, Toepper, M, Driessen, M, Woermann, FG (2009). Neural correlates of the individual emotional Stroop in borderline personality disorder. Psychoneuroendocrinology 34, 571–86.
Wingrove, J, Bond, AJ (1997). Impulsivity: a state as well as trait variable. Does mood awareness explain low correlations between trait and behavioural measures of impulsivity. Personality and Individual Differences 22, 333339.
Yerkes, RM, Dodson, JD (1908). The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology 18, 459482.


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