Elsevier

Psychiatry Research

Volume 249, March 2017, Pages 321-326
Psychiatry Research

Aggressive behavior and self-harm in Borderline Personality Disorder: The role of impulsivity and emotion dysregulation in a sample of outpatients

https://doi.org/10.1016/j.psychres.2017.01.011Get rights and content

Highlights

  • Trait impulsivity is significantly related to Borderline aggression and self-harm.

  • A key role of emotion dysregulation in their fulfillment is proposed.

  • Emotion dysregulation causes a significant vulnerability together with impulsivity.

  • Emotion dysregulation may increase the risk of dysfunctional behaviors.

  • Utility of therapies centered on emotion regulation strategies is supported.

Abstract

Impulsivity has often been related to aggressive and self-mutilative behavior in Borderline Personality Disorder (BPD). Many authors focused on the key role of emotion dysregulation in explaining vulnerability to dysfunctional behavior in BPD in addition to trait impulsivity. Furthermore, recent works have shed light on a gap in empirical research concerning the specific mechanisms by which a lack of affective regulation produces aggression proneness. The purpose of the study was to investigate the role of impulsivity and emotion dysregulation in determining vulnerability to aggression and deliberate self-harm in a sample of BPD outpatients. Enrolled patients with BPD (N =79) completed a comprehensive assessment for personality disorder symptoms, trait impulsivity, emotional dysregulation, aggressive and self – mutilative behavior. Trait impulsivity significantly predicted both aggressive and self-mutilative proneness. Furthermore, emotion dysregulation was found significantly to account for the vulnerability to aggression and self–injury, in addition to the variance explained by impulsivity. In conclusion, these findings support evidence that emotion dysregulation plays an important role in increasing the risk of dysfunctional behavior in impulsive BPD individuals.

Introduction

Borderline Personality Disorder (BPD) is a Cluster B personality disorder defined as a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity (Gunderson and Links, 2008). This range of clinical features critically affects patients’ general functioning (Skodol et al., 2002), treatment compliance (Chiesa et al., 2010, Martino et al., 2012), physical health status (Douzenis et al., 2012) as well as the relationship dimension (Martino et al., 2014).

Impulsivity has frequently been considered a central factor in BPD psychopathology (Zanarini, 1993, Links et al., 1999) and related to dysfunctional behavior, such as self-harm and aggression. In particular, impulsive action and traits were found to be associated with suicide attempts in adult (Soloff et al., 1994, Brodsky et al., 1997) and adolescent samples (Dougherty et al., 2009). Higher levels of impulsivity appear to be strongly related to non-suicidal self–injury (Herpertz et al., 1997, Carli et al., 2010), both planned and unplanned (Rawlings et al., 2015). Furthermore, with regard to the relationship between impulsivity and aggression, reduced 5–HT system function and, more recently, corticolimbic dysfunction (Coccaro, 1992, New et al., 2007, Coccaro et al., 2011) were found to be associated with trait dysregulation of impulse control, increasing the likelihood of aggressive behavior in these patients. Given the abundant evidence of a strong association between impulsivity and aggression, some authors (Siever and Davis, 1991, Bornovalova et al., 2005) have defined them as a single construct called “impulsive – aggression”. However, differences between impulsivity and aggression have been found. Results have shown there is little relationship between measures of aggression and impulsivity in BPD (Critchfield et al., 2004, García-Forero et al., 2009). Furthermore, impulsivity and aggression show different patterns of correlation with clinical manifestations of BPD (Bellino et al., 2008). In particular, impulsivity has been related to higher overall symptom severity and psychiatric treatment at a younger age, while aggression appears to be connected to younger age and a lower level of depressive symptoms. These authors thus agreed in describing impulsivity and aggression as two essentially distinct (although related) constructs, both in clinical (Critchfield et al., 2004, Bellino et al., 2008) and in nonclinical samples (García-Forero et al., 2009).

Emotional dysregulation has been identified as a key facet of BPD patient functioning and a latent factor associated with typical dysfunctional behaviors such as self-harm and aggression (Sanislow et al., 2000, Glenn and Klonsky, 2009, Sebastian et al., 2013, Stepp et al., 2014). The high importance of emotion dysregulation in BPD was primarily defined by Linehan (1993) as a result of the interaction between a key biological factor (viz. a tendency towards emotional vulnerability) and an invalidating rearing environment (characterized by punishing, ignoring, or trivializing the individual's communication of thoughts and emotions). Intense emotional reactions elicit invalidating behavior from caregivers, which then leads to further emotional dysregulation, and vice versa. In this frame, emotion dysregulation plays a fundamental role in determining typical dyscontrolled behavior (such as aggression and self-harm). Crowell et al. (2009) extended Linehan's model and highlighted the importance of early trait impulsivity as a predisposing vulnerability for both current and future difficulties in emotion regulation, consistently with the results of theorists who conceived both impulsivity and emotion dysregulation to be underlying factors in BPD leading to the features and symptoms of the disorder (Siever and Davis, 1991, New and Siever, 2002; Tragesser et al., 2009). Fossati et al. (2014) drew similar conclusions in an adolescent sample, finding both impulsivity and emotion dysregulation to be significantly related to BPD traits.

In this context, self-mutilative behavior has been conceptualized as maladaptive strategies for coping with negative emotions (Brown et al., 2002). Deliberate self-harm has been associated with a shift to more neutral or positive emotions in individuals with BPD, serving as an emotion regulatory function (Chapman and Dixon-Gordon, 2007). In addition, emotion dysregulation has been found to be the strongest predictor of self-harm over time (Yen et al., 2004, Tragesser et al., 2007). Furthermore, that emotion dysregulation plays a key role behind self-mutilation is further supported by the successful reduction of various forms of deliberate self–harm, e.g. cutting or burning oneself, obtained by acceptance–based emotion regulation group therapy (Gratz, 2007, Gratz et al., 2015). The results of a study by Zaki et al. (2013) suggested that the ability to differentiate emotional experiences into nuanced emotion categories might be a protective factor against self-injury, consistently with the evidence mentioned.

On the other hand, regarding aggressive behavior, Scott et al. (2014) reported a gap in the literature concerning research into the specific mechanisms by which BPD features increase the risk of aggression. Some authors have claimed the importance of cognitive dysfunctional mechanisms, such as anger rumination, in leading to aggressive behavior (Selby et al., 2008, Martino et al., 2013, Martino et al., 2015). Others have focused on the central role of emotion dysregulation in determining aggressive behavior in BPD (Allen and Links, 2012, Gardner et al., 2012, Newhill et al., 2012, Scott et al., 2014). In particular, recent studies have shown how BPD diagnosis in itself and trait impulsivity were not significant predictors of aggression when emotion dysregulation was taken into account, shedding light on the role played by emotion dysregulation in accounting for aggressive behavior in both longitudinal (Newhill et al., 2012, Scott et al., 2014) and cross-sectional studies (Gardner et al., 2012).

In our clinical sample of BPD outpatients, we aimed to assess:

  • a)

    firstly, whether trait impulsivity was a significant predictor of aggression and self–harm, according to previous findings which highlighted the connection between trait impulsivity and dysfunctional behavior in BPD patients, such as aggression (Coccaro, 1992, Coccaro et al., 2011) and self–harm (Soloff et al., 1994, Brodsky et al., 1997, Herpertz et al., 1997, Dougherty et al., 2009, Carli et al., 2010; Rawlings et al., 2015);

  • b)

    secondly, whether emotion dysregulation significantly adds to trait impulsivity in predicting self-harm and aggression, according to previous evidence which shed light on the key role of emotion dysregulation in determining proneness to dyscontrolled behavior like self-harm (Gratz, 2007, Tragesser et al., 2007, Zaki et al., 2013, Gratz et al., 2015) and aggression (Allen and Links, 2012, Gardner et al., 2012, Newhill et al., 2012) in BPD, in addition to temperamental impulsive vulnerability (Yen et al., 2004, Crowell et al., 2009, Scott et al., 2014).

Section snippets

Study design

All patients enrolled in the present cross–sectional study underwent a dimensional psychometric assessment, which included the administration of specific self–report questionnaires testing the constructs we were interested in. Baseline data about trait impulsivity, emotional dysregulation, aggression and self-harm from patients who met a BPD diagnosis were considered for the present study.

Setting

The present research was conducted from November 2013 to October 2014 within a Personality Disorder

Correlations

We conducted correlation analyses between measures of trait impulsivity, emotion dysregulation, aggression and self–harm (Table 2). Pearson's correlation indexes ranged from weak to moderate.

Impulsivity, emotion dysregulation and aggression

In the first hierarchical linear regression analysis trait impulsivity, as designated by the overall score of BIS, was entered as an independent variable in the first step and was found to be a significant predictor of aggressive proneness, defined by the overall score of the AQ questionnaire (dependent

Discussion

Given the background we mentioned on trait impulsivity and the gap in the literature concerning specific mechanisms of dysfunctional behavior in BPD (Scott et al., 2014), the objectives of the present study were, in a clinical sample of outpatients, to assess the impact of trait impulsivity in explaining aggression and self-harm, and to investigate the role played by emotion dysregulation in this relationship.

Our analysis showed that trait impulsivity was a significant predictor of both

Acknowledgement

There are no conflicts of interest to disclose.

Data collection and publication of the study were approved by the Ethical Committee of the Bologna Local Health Unit on 25/11/2013 (EC code: 0002045).

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