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123]
Impulsivity, suicidality, and emotional dysregulation in women
having borderline personality disorder with and without
substance dependence
Samir A. Magda, Moustafa Rakhawya, Rania Mamdouha,b, Somaya Shaheena
a
Addiction Psychiatry Unit, Psychiatry
Department, School of Medicine, Cairo
University, Cairo, Egypt, bSerenity Girls Center
for Psychiatric and Addiction Management for
Women
Correspondence to Rania Mamdouh, MD, MSc
Psychiatry, Mokattam, street 19 from street 9,
villa 587, Zip code: 11571. Tel: 01141770072;
e-mail: rania.mamdouh.rm@gmail.com
Received 13 August 2018
Accepted 6 September 2018
Egyptian Journal of Psychiatry 2019,
40:59–63
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.
© 2019 Egyptian Journal of Psychiatry | Published by Wolters Kluwer - Medknow
Original article 59
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
Egypt J Psychiatr 40:59–63
© 2019 Egyptian Journal of Psychiatry
1110-1105
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
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new
creations are licensed under the identical terms.
DOI: 10.4103/ejpsy.ejpsy_16_18
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60 Egyptian Journal of Psychiatry, Vol. 40 No. 2, May-August 2019

use of psychoactive substances. The interviews were perseverance, and cognitive instability impulsiveness)
conducted in quiet, comfortable settings, and the and three second-order factors (attentional, motor,
nature and scope of the study was discussed with and nonplanning impulsiveness).
each patient. A written informed consent was
obtained from all patients before the interview. Difficulties in Emotional Regulation Scale (DERS) (Gratz
Ethical approval was obtained from the ethical and and Roemer, 2004): the DERS is a brief, 36-item self-
research committee of the Departments of Psychiatry report questionnaire designed to assess multiple aspects
of the university. of emotional dysregulation. Higher scores suggest
greater problems with emotion regulation. The
original version of the DERS was translated into
Measurements Arabic and backtranslated into English by colleagues
Data were collected by way of semistructured after taking the authors’ permission.
interview, and the following measures were used.
Statistical analysis
Structured clinical interview for DSM-IV (SCID I) (First Data were coded and entered using the statistical
et al., 1997a1997b), Arabic version (El Missiry et al., package for the social sciences, version 23 (USA).
2004): the structured clinical interview for DSM-IV- Data were summarized using mean, SD, median,
TR axis I disorders (SCID I) is a clinician- minimum and maximum in quantitative data, and
administered semistructured interview for use in using frequency (count) and relative frequency
psychiatric patients or nonpatient community (percentage) for categorical data. Comparisons
participants who are undergoing evaluation for between quantitative variables were done using the
psychopathology. The SCID I was developed to nonparametric Kruskal–Wallis and Mann–Whitney
provide coverage of psychiatric diagnosis according tests (Chan, 2003a). For comparing categorical data,
to DSM-IV. χ 2 test was performed. Exact test was used instead
when the expected frequency is less than 5 (Chan,
Structured clinical interview for DSM-IV axis II disorders 2003b). P values less than 0.05 were considered as
(SCID II) (First et al., 1997a1997b) Arabic version statistically significant.
(Hatata et al., 2004): the structured clinical interview
for DSM-IV axis-II-11 personality disorders is a
(semi) structured interview of 108 questions, Results
arranged according to diagnosis, yielding both There was a statistically significant difference between
categorical diagnoses and dimensional scores for both groups regarding age and marital status. The
each of the DSM-IV personality disorders. mean age of group A was 24.55 years whereas of
group B was 31.30 years. Divorce rate was higher in
Borderline personality disorder severity index (BPDSI) group B than group A (Table 1).
(Amoud And Bloo, 1999): the BPDSI-IV is a
Table 1 Sociodemographic data in both groups
semistructured interview and consists of 70 items,
Group A Group B P value
arranged in nine subscales, representing the nine (N=40) (N=40)
DSM-IV BPD criteria. For each item, the frequency Mean SD Mean SD
of the last 3 months is rated on an 11-point scale, running
Age 24.55 6.77 31.30 11.01 0.001**
from 0 (never) to 10 (daily). Identity disturbance items
Education [n (%)]
form an exception and are rated on five-point Likert Illiterate 3 (7.5) 6 (15.0) 0.620
scales, running from 0 (absent) to 4 (dominant, clear, and Primary 3 (7.5) 3 (7.5)
well-defined), multiplied with 2.5. The total score is the Preparatory 7 (17.5) 7 (17.5)
sum of the nine criteria scores (range, 0–90). The original Secondary 17 (42.5) 11 (27.5)
version was translated into Arabic by the researcher and University 10 (25.0) 13 (32.5)
backtranslated into English by colleague after taking the Occupation [n (%)]
Student 9 (22.5) 6 (15.0) 0.242
authors’ permission.
Not working 21 (52.5) 17 (42.5)
Working 10 (25.0) 17 (42.5)
Barratt Impulsiveness Scale (BIS) (Patton et al., 1995) Marital status [n (%)]
Arabic version (Agoub, 2005): it is a widely used Single 19 (47.5) 8 (20.0) 0.010*
measure of impulsiveness. It includes 30 items Married 18 (45.0) 21 (52.5)
that are scored to yield six first-order factors Divorced 3 (7.5) 11 (27.5) 0.620
(attention, motor, self-control, cognitive complexity, *significant P value. **significant P value.
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Emotional dysregulation in women having BPD Magd et al. 61

Impulsivity
Results of the BPDSI show that group B patients were Discussion
significantly more impulsive than group A (means, 2.18 In this research, the comorbid substance dependence
and 0.77, respectively; P=0.001) (Table 2). Results of the made a significant difference in the impulsivity
BIS show that there was no statistically significant symptom only but not the parasuicidal behavior,
difference between both groups regarding attentional suicide, and affective dysregulation.
(P=0.645), motor (P=0.06), nonplanning (P=0.75), and Impulsivity
total impulsivity scales (P=0.368). The most affected According to the impulsivity part of BPDSI,
scale for impulsivity in both groups was motor scale participants with comorbid substance dependence
followed by nonplanning scale, whereas the least affected scored significantly higher than those with
scale was attentional impulsivity scale in both groups borderline personality alone. However, in the study
(Table 3). by Van den Bosch et al. (2003), the difference in
impulsivity was partly attributable to three of the 11
Suicidality and emotional dysregulation items examining alcohol and drug intake as
There was no statistically significant difference manifestations of impulsivity of the same scale.
between both groups regarding suicidal attempts When these three items are excluded, the difference
(P=0.633; Table 4) and parasuicidal behavior and was no longer statistically significant. On the contrary,
suicide (P=0.946; Table 2). There was no according to the BIS, the most affected subscale for
statistically significant difference between both impulsivity in both groups was motor scale followed by
groups regarding abandonment, interpersonal nonplanning scale .The least affected subscale was
relationships, identity, and total score. According to attentional impulsivity one but without any statistical
the BPDSI, affective instability, emptiness, and significant. Lee et al. (2010) found the same regarding
outbursts of anger did not differ significantly the nonplanning scale only. However, they found a
between both groups (P=0.246, 0.775, and 0.248, difference in the attentional, motor, and total subscales,
respectively; Table 2). According to the DERS, as the SBPD group scored higher than BPD group on
group A (mean, 58.83) had more difficulties in these subscales, but they attributed these differences to
emotional regulation than group B (mean, 50.55), the comorbid antisocial personality disorder, which was
with no statistical significance (P=0.143; Table 5). more than twice as high in SBPD participants of their
study. Wilson et al. (2006) confirmed that patients
Table 2 Suicidal attempts in both groups having BPD with substance dependence were more
Suicidal attempts Group A Group B P
impulsive than patients with BPD without any history
(N=40) (N=40) value of substance use disorder (SUD). In other words,
[n (%)] [n (100%)] Coffey et al. (2011) studied impulsivity in BPD
No suicidal 28 (70.0) 26 (65.0) 0.633 versus SBPD using BIS and other scales. They
attempts found a partial support of the hypothesis that
Suicidal attempts 12 (30.0) 14 (35.0)
substance dependence when comorbid with BPD
scores more impulsivity than BPD alone. It is worth
Table 3 Borderline Personality Disorder Severity Index in
both groups
Table 4 Barratt Impulsiveness Scale in both groups
Group A Group B P value
(N=40) (N=40) Group A Group B P value
(N=40) (N=40)
Mean SD Mean SD
Scales Mean SD Mean SD
Abandonment 3.25 2.20 2.73 1.78 0.336
Interpersonal 3.37 1.84 3.36 2.12 0.965 Attentional 16.65 2.80 16.90 2.82 0.645
relationships Motor 29.52 4.90 27.78 4.08 0.06
Identity 4.53 1.97 4.70 2.38 0.478 Nonplanning 26.28 5.47 26.43 3.77 0.75
Impulsivity 0.77 0.73 2.18 1.29 <0.001** Total 72.75 10.58 71.10 7.64 0.368
Parasuicidal behavior 1.20 1.35 1.17 1.08 0.946
and suicide
Table 5 Difficulties in Emotional Regulation Scale in both
Affective instability 6.71 2.63 6.22 2.17 0.246 groups
Emptiness 5.86 2.27 5.89 2.29 0.775
Scale Group A Group B P
Outbursts of anger 4.75 2.20 4.03 2.69 0.248 (N=40) (N=40) value
Dissociation and 3.65 2.18 1.99 1.70 <0.001**
Mean SD Mean SD
paranoid ideation
Total 34.34 8.82 32.25 10.73 0.308 Difficulties in Emotional 58.83 14.42 50.55 23.82 0.143
Regulation Scale
*significant P value. **significant P value
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62 Egyptian Journal of Psychiatry, Vol. 40 No. 2, May-August 2019
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
Nil.
Conflict of Interest
There are no conflicts of interest.
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