|Year : 2019 | Volume
| Issue : 2 | Page : 59-63
Impulsivity, suicidality, and emotional dysregulation in women having borderline personality disorder with and without substance dependence
Samir A Magd1, Moustafa Rakhawy1, Rania Mamdouh2, Somaya Shaheen1
1 Addiction Psychiatry Unit, Psychiatry Department, School of Medicine, Cairo University, Cairo, Egypt
2 Addiction Psychiatry Unit, Psychiatry Department, School of Medicine, Cairo University, Cairo; Serenity Girls Center for Psychiatric and Addiction Management for Women, Egypt
|Date of Submission||13-Aug-2018|
|Date of Acceptance||06-Sep-2018|
|Date of Web Publication||11-Jul-2019|
MSc Psychiatry, Mokattam, street 19 from street 9, villa 587, Zip code: 11571
Source of Support: None, Conflict of Interest: None
Objective The objective of this article is to detect differences between women having borderline personality disorder (BPD) with and without substance dependence regarding impulsivity, suicide, and emotional dysregulation.
Patients and methods A total of 40 women with BPD [diagnosed by structural clinical interview for DSM (SCID) II] were compared with 40 women diagnosed as having BPD with substance dependence (diagnosed by SCID I and SCID II) attending the outpatient clinic in our university hospital using BPD severity index, Barratt Impulsiveness Scale, and Difficulties in Emotional Regulation Scale.
Results BPD with substance dependence women were more impulsive than those without substance dependence, but there were no difference between both groups regarding suicide and emotional dysregulation.
Conclusion The findings of the study have clinical implications for management of women with BPD.
Keywords: borderline personality disorder, emotional dysregulation, females, impulsivity, substance dependence, suicide
|How to cite this article:|
Magd SA, Rakhawy M, Mamdouh R, Shaheen S. Impulsivity, suicidality, and emotional dysregulation in women having borderline personality disorder with and without substance dependence. Egypt J Psychiatr 2019;40:59-63
|How to cite this URL:|
Magd SA, Rakhawy M, Mamdouh R, Shaheen S. Impulsivity, suicidality, and emotional dysregulation in women having borderline personality disorder with and without substance dependence. Egypt J Psychiatr [serial online] 2019 [cited 2020 Aug 9];40:59-63. Available from: http://new.ejpsy.eg.net/text.asp?2019/40/2/59/262550
| Introduction|| |
Emotional regulation difficulties and feelings of emptiness with unstable interpersonal relationships and fear of abandonment are common characteristics of borderline personality disorder (BPD). Many patients with the disorder show impulsivity, risk-taking behaviors, and self-injurious or suicidal behavior. However, other transient features are paranoid ideation and dissociative states (American Psychiatric Association, 2013).
Research estimates that BPD occurs in 1–3% of general population (Trull et al., 2010) and in up to 10% of outpatient population (Zimmerman et al., 2005).
Bandelow et al. (2010) explained the experience of emotion dysregulation and substance dependence in this patient group, by a dysregulation of the endogenous opioid system. This system plays an important role in the brain reward system and in coping with stressors. The objective of this work is to detect differences between women having BPD with and without substance dependence regarding impulsivity, suicide, and emotional dysregulation.
| Patients and methods|| |
Participants were recruited from the outpatient women attendees at our university hospitals. A sample size of 80 women was aimed for, and all consecutive attendees at the clinic were interviewed. They were further divided into two groups: group A included 40 female patients diagnosed as having BPD without substance dependence, diagnosed according to the Diagnostic statistical manual IV (DSM-IV) criteria for axis II disorders, structural clinical interview for DSM (SCID II), with mean age of 24.55± 6.77 years, and group B included 40 women diagnosed as having BPD with substance dependence (SBPD), with mean age of 31.30±11.01 years. Patients were excluded from the study if they had any comorbid psychiatric or personality disorder.
All eligible participants (based on self-reports of drug use) were then subjected to urinalysis for psychoactive substances to confirm or exclude their use of psychoactive substances. The interviews were conducted in quiet, comfortable settings, and the nature and scope of the study was discussed with each patient. A written informed consent was obtained from all patients before the interview. Ethical approval was obtained from the ethical and research committee of the Departments of Psychiatry of the university.
| Measurements|| |
Data were collected by way of semistructured interview, and the following measures were used.
Structured clinical interview for DSM-IV (SCID I) (First et al., 1997a1997b), Arabic version (El Missiry et al., 2004): the structured clinical interview for DSM-IV-TR axis I disorders (SCID I) is a clinician-administered semistructured interview for use in psychiatric patients or nonpatient community participants who are undergoing evaluation for psychopathology. The SCID I was developed to provide coverage of psychiatric diagnosis according to DSM-IV.
Structured clinical interview for DSM-IV axis II disorders (SCID II) (First et al., 1997a1997b) Arabic version (Hatata et al., 2004): the structured clinical interview for DSM-IV axis-II-11 personality disorders is a (semi) structured interview of 108 questions, arranged according to diagnosis, yielding both categorical diagnoses and dimensional scores for each of the DSM-IV personality disorders.
Borderline personality disorder severity index (BPDSI) (Amoud And Bloo, 1999): the BPDSI-IV is a semistructured interview and consists of 70 items, arranged in nine subscales, representing the nine DSM-IV BPD criteria. For each item, the frequency of the last 3 months is rated on an 11-point scale, running from 0 (never) to 10 (daily). Identity disturbance items form an exception and are rated on five-point Likert scales, running from 0 (absent) to 4 (dominant, clear, and well-defined), multiplied with 2.5. The total score is the sum of the nine criteria scores (range, 0–90). The original version was translated into Arabic by the researcher and backtranslated into English by colleague after taking the authors’ permission.
Barratt Impulsiveness Scale (BIS) (Patton et al., 1995) Arabic version (Agoub, 2005): it is a widely used measure of impulsiveness. It includes 30 items that are scored to yield six first-order factors (attention, motor, self-control, cognitive complexity, perseverance, and cognitive instability impulsiveness) and three second-order factors (attentional, motor, and nonplanning impulsiveness).
Difficulties in Emotional Regulation Scale (DERS) (Gratz and Roemer, 2004): the DERS is a brief, 36-item self-report questionnaire designed to assess multiple aspects of emotional dysregulation. Higher scores suggest greater problems with emotion regulation. The original version of the DERS was translated into Arabic and backtranslated into English by colleagues after taking the authors’ permission.
Data were coded and entered using the statistical package for the social sciences, version 23 (USA). Data were summarized using mean, SD, median, minimum and maximum in quantitative data, and using frequency (count) and relative frequency (percentage) for categorical data. Comparisons between quantitative variables were done using the nonparametric Kruskal–Wallis and Mann–Whitney tests (Chan, 2003a). For comparing categorical data, χ2 test was performed. Exact test was used instead when the expected frequency is less than 5 (Chan, 2003b). P values less than 0.05 were considered as statistically significant.
| Results|| |
There was a statistically significant difference between both groups regarding age and marital status. The mean age of group A was 24.55 years whereas of group B was 31.30 years. Divorce rate was higher in group B than group A ([Table 1]).
Results of the BPDSI show that group B patients were significantly more impulsive than group A (means, 2.18 and 0.77, respectively; P=0.001) ([Table 2]). Results of the BIS show that there was no statistically significant difference between both groups regarding attentional (P=0.645), motor (P=0.06), nonplanning (P=0.75), and total impulsivity scales (P=0.368). The most affected scale for impulsivity in both groups was motor scale followed by nonplanning scale, whereas the least affected scale was attentional impulsivity scale in both groups ([Table 3]).
Suicidality and emotional dysregulation
There was no statistically significant difference between both groups regarding suicidal attempts (P=0.633; [Table 4]) and parasuicidal behavior and suicide (P=0.946; [Table 2]). There was no statistically significant difference between both groups regarding abandonment, interpersonal relationships, identity, and total score. According to the BPDSI, affective instability, emptiness, and outbursts of anger did not differ significantly between both groups (P=0.246, 0.775, and 0.248, respectively; [Table 2]). According to the DERS, group A (mean, 58.83) had more difficulties in emotional regulation than group B (mean, 50.55), with no statistical significance (P=0.143; [Table 5]).
| Discussion|| |
In this research, the comorbid substance dependence made a significant difference in the impulsivity symptom only but not the parasuicidal behavior, suicide, and affective dysregulation.
According to the impulsivity part of BPDSI, participants with comorbid substance dependence scored significantly higher than those with borderline personality alone. However, in the study by Van den Bosch et al. (2003), the difference in impulsivity was partly attributable to three of the 11 items examining alcohol and drug intake as manifestations of impulsivity of the same scale. When these three items are excluded, the difference was no longer statistically significant. On the contrary, according to the BIS, the most affected subscale for impulsivity in both groups was motor scale followed by nonplanning scale .The least affected subscale was attentional impulsivity one but without any statistical significant. Lee et al. (2010) found the same regarding the nonplanning scale only. However, they found a difference in the attentional, motor, and total subscales, as the SBPD group scored higher than BPD group on these subscales, but they attributed these differences to the comorbid antisocial personality disorder, which was more than twice as high in SBPD participants of their study. Wilson et al. (2006) confirmed that patients having BPD with substance dependence were more impulsive than patients with BPD without any history of substance use disorder (SUD). In other words, Coffey et al. (2011) studied impulsivity in BPD versus SBPD using BIS and other scales. They found a partial support of the hypothesis that substance dependence when comorbid with BPD scores more impulsivity than BPD alone. It is worth noting that in our study, women with SBPD were older than those with BPD only. This might support the assumption that impulsivity as a core feature of BPD shared, in a way or another, in the development of a new onset of substance dependence in the course of the BPD (Marc et al., 2009). Again, this might explain the higher divorce rates in women with SBPD than those with BPD. Results were consistent with Abolmagd et al. (2011) and Lee et al. (2010) who found that divorce rate was higher in SBPD group than BPD group. Together with other factors, impulsivity in substance dependence with lack of object relation, not taking care of responsibilities at home, extensive relationship problems, often with high levels of relationship dissatisfaction, verbal and physical aggression are coworking toward divorce in those women.
Suicide and emotional dysregulation
At the very beginning, we assumed that substance use serves to decrease feelings of negative affect or increase feelings of positive affect, so it can mask suicide (Baker et al., 2004; Jahng et al., 2011). Surprisingly, we did not find a significant difference in suicidal attempts and emotional dysregulation. Likewise results were those of Lee et al. (2010). On the contrary, Van den Bosch et al. (2003) found that patients with SBPD were four times more likely to have attempted to commit suicide than those without addiction problems. As they did not examine the temporal relationship between substance abuse and suicide attempts, this finding might either indicate that substance abuse lowers the threshold to engage in self-destructive behavior and suicide attempts or reflect that nonintentional overdoses were mistaken for suicide attempts.
Moreover, these data suggest the possibility that if increased impulsivity and emotional dysregulation are observed with the additional diagnosis of SUD among patients with BPD, it may be better accounted for by comorbid antisocial personality disorder features rather than by the presence of comorbid SUD. Findings of Kuo et al. (2015) were nearly the same as ours using the same scale.
| Conclusion|| |
To conclude, apparently, the BPD when complicated with comorbid substance dependence increases impulsivity rather than suicide and emotional dysregulation. Although actually, it seems that the response disinhibition and impulsivity are core features of the BPD, rather than substance dependence comorbidity, so more attention should be paid in treatment of BPD regarding impulsivity and response inhibition.
Financial support and sponsorship
Conflict of Interest
There are no conflicts of interest.
| References|| |
Agoub G (2005). Assessment of impulsivity among patients with schizophrenia. Arab J Psychiatry 8:149–150.
Abolmagd SF, Mobasher MW, Mamdouh R, El Sheikh S (2011). Psychiatric and social profile of recovering female substance dependence [unpublished thesis]. Cairo: Library of Al Kasr Al Aini Psychiatric and Addiction Prevention Hospital, Cairo University.
American Psychiatric Association. (2013): Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Arntz A, Van den Hoorn M, Cornelis J, Verheul R, Van den Bosh WMC, De Bie AJHT (2003). Reliability and Validity of The Borderline Personality Disorder Severity Index. Department of Medical, Clinical and Experimental Psychology, Maastricht University, The Netherlands. Journal of Personality Disorders 17: 45–59
Baker TB, Piper ME, Mc Carthy DE, Majeskie MR, Fiore MC (2004). Addiction motivation reformulated: an affective processing model of negative reinforcement. Psychol Rev 111:33–51.
Bandelow B, Schmahl C, Wedekind D (2010). Borderline personality disorder: a dysregulation of the endogenous opioid system. Psychol Rev 117:623–636.
Chan YH (2003a). Biostatistics102: quantitative data − parametric & non-parametric tests. Singapore Med J 44:391–396.
Chan YH (2003b). Biostatistics 103: qualitative data −tests of independence. Singapore Med J 44:498–503.
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. Personal Disord 2:128–141.
El Missiry A, Sorour A, Sadek A, Fahy T, Abdel Mawgoud M, Asaad T (2004). Homicide and psychiatric illness: an Egyptian study [MD thesis]. Cairo: Faculty of Medicine, Ain Shams University.
First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS (1997a). Structured clinical interview for DSM-IV axis II personality disorders (SCID-II). Washington, DC: American Psychiatric Press, Inc.
First MB, Spitzer RL, Gibbon M, Williams JBW, Benjamin LS (1997b). Structured clinical interview for DSM-IV-clinician version (SCID-CV) axis I (user′s guide interview). Washington, DC: American Psychiatric Press.
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. J Psychopathol Behav Assess 26:41–54.
Lee HJ, Bagge CL, Schumacher JA, Coffey SF (2010). Does comorbid substance use disorder exacerbate borderline personality features ? A comparison of borderline personality disorder individuals with vs. without current substance dependence. Personal Disord 1:239–249.
Hatata H, Abou zeid M, Khalil A, Assad T, Okasha T (2004). Dual diagnosis in substance abuse, a study in an Egyptian sample [MD thesis]. Cairo: Ain Shams University.
Jahng S, Solhan MB, Tomko RL, Wood PK, Piasecki TM, Trull TJ (2011). Affect and alcohol use: an EMA study of outpatients with borderline personality disorder. J Abnorm Psychol 120:572–584.
Kuo JR, Khoury JE, Metcalfe R, Fitzpatrick S, Goodwill A. (2015). An examination of the relationship between childhood emotional abuse and borderline personality disorder features: The role of difficulties with emotion regulation. Child Abuse Negl 39:147–155.
Marc W, John GG, Mary CZ, Charles AS, Carlos MG, Thomas HMc. et al.
(2009). New onsets of substance use disorders in borderline personality disorder over 7 years of follow-ups: findings from the collaborative longitudinal personality disorders study. Addiction 104:97–103.
Patton JH, Stanford MS, Barratt ES (1995). Factor structure of the Barratt Impulsiveness Scale. J Clin Psychol 51:768–774.
Trull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ (2010). Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. J Pers Disord 21:412–426.
Van den Bosch LMC, Verheul R, van den Brink W (2003). Substance abuse in borderline personality disorder: clinical and etiological correlates. J Pers Disord 15:416–424.
Wilson ST, Fertuck EA, Kwitel A, Stanley MC, Stanley B (2006). Impulsivity, suicidality and alcohol use disorders in adolescents and young adults with borderline personality disorder. Int J Adolesc Med Health 18:189–196.
Zimmerman M, Rothschild L, Chelminski I (2005). The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162:1911–1918.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]