Is emotional impulsiveness (Urgency) a core feature of severe personality disorder?

Highlights

• Urgency was significantly associated with 6 of 10 personality disorders.

• Urgency correlated significantly with measures of severity of personality disorder.

• In regression analysis, Urgency uniquely predicted severity of personality disorder.

• Urgency likely contributes to the link between personality disorder and violence.

Abstract

Recent literature has focused on severity of personality disorder (PD) and a trait-based assessment of PDs in preference to assessment by specific sets of diagnostic criteria. Evidence suggests that emotional impulsiveness, also known as Urgency (Whiteside, & Lynam (2001). The five factor model and impulsivity: Using a structural model of personality to understand impulsivity. Personality and Individual Differences (30, 669–689), might contribute to a broad spectrum of PDs and to overall PD severity. In a sample of 100 forensic psychiatric patients, all men with confirmed PD and a history of serious offending, two hypotheses were tested: first that high Urgency scores would be associated with a broad spectrum of PDs, and with PD severity; and second, that in regression analysis Urgency would uniquely predict measures of PD severity. Results confirmed these hypotheses and are consistent with the idea that emotional impulsiveness/Urgency contributes importantly to overall severity of PD, and in so doing may explain, at least in part, the well-documented link between PD and violence.

Introduction

Impulsiveness can broadly be defined as a predisposition to react rapidly and without planning to internal and external stimuli with little or no regard for the short-term and long-term consequences for oneself and others (Bjørkly, 2013). It is considered to be a symptom of many psychiatric disorders including borderline and antisocial PDs, bipolar disorder, attention deficit/hyperactivity disorder, conduct disorder and substance abuse/dependence (Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001). Impulsiveness is generally recognised to be multifaceted, incorporating a number of dimensions, including a tendency to act rashly and intemperately under the pressure of positive or negative emotions (Shapiro, 1965). When behaving in an emotionally impulsive way, the individual responds to a stimulus or event on the basis of an immediate emotional reaction such as desire or anger, with little if any checking of long-term consequences (Wingrove & Bond, 1997). Measures of impulsiveness, both self-report and behavioural, are limited in the degree to which they tap emotional impulsiveness. For example, a commonly used self-report measure of impulsiveness, the Barratt Impulsivity Scale (BIS: Patton, Stanford, & Barratt, 1995) does not include an explicitly emotional component.

In contrast, a more recent model of impulsive behaviour, developed by Whiteside and Lynam (2001) and derived from the Five Factor Model (FFM) of normal personality, conceptualises and assesses impulsiveness as a multifaceted construct that includes four separable and distinct pathways to impulsive behaviour: Urgency, (lack of) Premeditation, (lack of) Perseverance, and Sensation-seeking (hence it is referred to by its acronym “UPPS”). The Urgency scale from the UPPS clearly and explicitly reflects negative affectivity, measuring “a tendency to experience strong impulses, frequently under conditions of negative affect” (Whiteside & Lynam, 2001, p. 685). Subsequently, UPPS was revised to include a positive Urgency scale to reflect impulsive behaviour occurring in the context of positive affect (Lynam, Smith, Whiteside, & Cyders, 2006). Positive and negative Urgency were found to correlate highly and can therefore be considered as a unitary scale (Few, Lynam, & Miller, 2015). Negative Urgency has been reported to predict aggression and appears to capture a dimension of emotional dyscontrol shared by several psychological disorders, including borderline personality disorder, eating disorders and depression (Miller, Flory, Lynam, & Leukefeld, 2003). More recently, negative Urgency was reported to be associated with poor self-control and high emotional lability in a student sample (Dir, Karyadi, & Cyders, 2013). These authors reported that when all UPPS facets were considered, negative Urgency uniquely predicted deliberate self-harm, eating problems, and problematic alcohol consumption. In summary, therefore, negative Urgency appears to be associated with a broad range of internalising and externalising psychopathologies, and to reflect the intersection of internalising and externalising tendencies seen in severe personality disorder, to be considered in the following section.

There has recently been a shift away from viewing PDs as discrete categories in favour of seeing them dimensionally as constellations of traits (e.g. Section 3 of DSM-5 (American Psychiatric Association [APA], 2013)). Severity of PD has been a particular focus of attention (e.g., Hopwood, Malone, Ansell, Sanislow, Grilo, McGlashan, Pinto, Markowitz, Shea, Akodol, Gunderson, Zanarini & Morey, 2011) and the forthcoming (11th) edition of the International Classification of Diseases (ICD-11: Tyrer, Reed, & Crawford, 2015) intends to abolish diagnostic categories of PD in favour of an assessment according to severity, defined by the degree of harm to self and others. This will range from mild (“not associated with substantial harm to self or others”) to severe (“associated with a past history and future expectation of severe harm to self or others that has caused long-term damage or has endangered life” (Tyrer et al., 2015 p.722)). In a bi-factor analysis of PD traits, Sharp et al. (2015) identified a general (g) factor that transcended diagnostic boundaries and appeared to index overall PD severity. It represented a mixture of antisocial traits (irresponsible, disregard for safety, failure to conform, deceitfulness, impulsivity), traits related to cognitive disturbance (odd beliefs, ideas of reference), and traits related to internalising/neurotic introversion (socially inhibited, avoids social contacts at work, preoccupied with rejection), as well as traits related to obsessionality. Conway, Hammen, and Brennan (2015) identified a similar PD severity factor that reflected both internalising and externalising processes, particularly aggression, anxiety and depression, in a high-risk Australian sample.

To date, only one study has investigated impulsiveness in relation to personality disorder using the UPPS model in a clinical sample (Few et al., 2015). This comprised psychiatric patients who were predominantly female (70%) and of whom 37% were confirmed as having a PD diagnosis on the basis of a semi-structured interview. Regarding DSM-5 (American Psychiatric Association [APA], 2013) Section 3 trait domains, Urgency correlated strongly with 3 of the 5 domains (Negative Affectivity, Antagonism and Disinhibition), and with 14 of 25 lower-order traits. (Lack of) Premeditation also showed significant correlations particularly with traits from the disinhibition domain, including risk taking, impulsivity and irresponsibility. Regarding DSM-5 (American Psychiatric Association [APA], 2013) categorical measures (Section 2), Urgency showed strong associations with 7 of the 10 PDs (paranoid, schizotypal, antisocial, borderline, histrionic, narcissistic and dependent).

These results suggest that high Urgency contributes to a general severity dimension of PD, rather than any particular type of PD, and that PD severity, including a contribution from Urgency, might in part account for the link between PD and violence (Howard, 2015). Significantly, Bousardt et al. (2015) found that the incidence of serious physical violence committed by psychiatric inpatients was increased threefold in those who scored high on Urgency, and was nearly two times higher in those with PD (specific types of PD were not examined in this study). Urgency was found to correlate significantly with a composite measure of serious violence in a sample of 100 personality disordered offenders with a history of violent offending (Howard, Khalifa, & Duggan, 2014). In substantially the same sample it was reported by Howard, Hepburn, and Khalifa (2015) that a measure of PD severity, obtained by summing across individual PD criteria (Hopwood et al., 2011), was associated with scores on two trans-diagnostic PD variables, “acting out” and “anxious-inhibited”, that putatively reflect externalising and internalising features of personality pathology respectively (Blackburn, Logan, Renwick, & Donnelly, 2005). Howard et al. (2015) reported that severe PD, defined by summing scores across DSM-IV (American Psychiatric Association [APA], 1994) PD criteria, was significantly associated violence and with high levels of both externalising and internalising personality features. These findings suggest that UPPS Urgency contributes to a general PD severity dimension that is associated with both internalising (“anxious-inhibited”) and externalising (“acting out”) PD features.

We undertook a re-examination of the data from Howard et al.'s (2014) study, with two objectives in mind. We first aimed to explore in closer detail the relationship of UPPS measures, particularly Urgency, with individual DSM-5 Section 2 PD scores in order to confirm, in a male forensic PD sample (N = 100), Few et al.’s (2015) findings from a non-forensic and predominantly female sample. Second, we aimed to test the hypothesis that Urgency would be associated with two trans-diagnostic features of PD severity: first, a combination of ‘acting out’ and ‘anxious-inhibited’; and second, severity measured by aggregating across dimensional scores of individual PDs. If it were shown, first, that Urgency was associated with PDs across the spectrum of PDs (confirming Few et al.'s (2015) results); and second, that Urgency was associated with high scores on measures of overall PD severity, it might reasonably be concluded that high Urgency contributes to a PD severity dimension that is itself a marker of severe psychopathology (‘p’) and is related to a heightened risk of violent offending (Caspi et al., 2014, Howard, 2015).

Urgency will correlate with scores of personality pathology across the spectrum of PDs, rather than with any specific PD category (e.g. antisocial or borderline PD). In particular, Urgency will correlate with measures of PD severity, viz. the Hopwood et al. (2011) measure and a measure combining ‘acting out’ and ‘anxious-inhibited’ scores.

Regression analysis where measures of PD severity, viz. Hopwood et al.'s (2011) measure and a combination of “acting out” and “anxious-inhibited” scores, are regressed onto Urgency (and other UPPS measures) will show that Urgency uniquely predicts PD severity.