Full length articleThe two-faceted nature of impulsivity in patients with borderline personality disorder and substance use disorder
Introduction
Impulsivity is a core feature of both Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD), and studies have indicated that individuals with both disorders (BPD + SUD) have even higher levels of impulsivity than those with either disorder alone (Links et al., 1995, Trull et al., 2004). It remains unclear, however, which factor (BPD or SUD) promotes higher impulsivity and which aspect of impulsivity (self-reported or behavioural) is affected by such conditions.
BPD and SUD are highly comorbid. Based on a systematic review, about 38–57% of BPD patients were also diagnosed with some sort of SUD (Trull et al., 2000). On the other hand, it is estimated that between 5 and 32% of substance-abusing individuals meet the criteria for BPD (Brooner et al., 1997, Weiss et al., 1993). These high comorbidity rates present considerable challenges for those providing mental health and addiction treatment services, given the higher levels of psychosocial impairment, the more severe psychopathology and substance use and the increased rates of self-harm and suicidal behaviour among these populations (Bowden-Jones et al., 2004, Darke et al., 2005, McMain and Ellery, 2008). Thus, we aimed to determine possible reasons for the comorbidity. Besides being a core feature of both BPD and SUD, it is believed that impulsivity may be a common factor behind the high rate of co-occurrence (Bornovalova et al., 2005).
However, our understanding of the role of impulsivity in these disorders and their comorbid presentation is limited due to the lack of attention to the complex, multidimensional nature of the construct of impulsivity (Bornovalova et al., 2005, Evenden, 1999). In general, impulsivity refers to the tendency or predisposition toward rapid, unplanned reactions to internal or external stimuli without appropriately considering the negative consequences for the impulsive individual or for others (Moeller et al., 2001). Impulsivity is generally considered to be a multifaceted phenomenon that can be evaluated with either self-report questionnaires or behavioural measures (Bornovalova et al., 2005, Evenden, 1999, Moeller et al., 2001). For instance, one manifestation of impulsivity on the behavioural or neurocognitive level is the preference for smaller immediate rewards over larger delayed rewards. This phenomenon is referred to as delay discounting (DD) (Madden and Bickel, 2010, Mazur and Commons, 1987).
Several studies have demonstrated that BPD is associated with elevated levels of self-reported impulsivity (Fossati et al., 2004, van Reekum et al., 1996) and the same is true for substance use disorders (de Wit, 2009, Dick et al., 2010). Given that DD is a facet of impulsivity and reflects a prototype pattern present in the clinical phenomenology of addictive behaviours, individuals with BPD and SUD are expected to display higher levels of DD. However, the results are controversial. Out of the five studies (Dougherty et al., 1999, Dom et al., 2006, Miller et al., 2009, Völker et al., 2009, Lawrence et al., 2010), only two (Völker et al., 2009, Lawrence et al., 2010) have found differences between BPD and non-BPD subjects in terms of delay discounting, the other three did not (Maráz and Demetrovics, 2011). On the other hand, based on a meta-analysis of 64 comparisons, a significant but small magnitude effect was found for DD among individuals with SUD vs. those without SUD (MacKillop et al., 2011).
Although many studies highlight the importance of impulsivity in BPD and SUD, very little is known about impulsivity in patients with both diagnoses despite the high comorbidity. The available studies suggest that BPD + SUD comorbidity is associated with higher levels of self-reported impulsivity than in either condition alone (Kruedelbach et al., 1993). Regarding behavioural impulsivity, however, only one study has investigated DD in BPD + SUD patients. Coffey et al. (2011) have found that BPD + SUD individuals preferred smaller immediate gratification to larger delayed rewards more often as compared to those with BPD and a healthy control group, although the difference was small.
Despite the large amount of research, the relation between self-reported and behavioural or neurocognitive measures of impulsivity is not fully clear (Bickel and Marsch, 2001, Reynolds, 2006). For example, in a translational study comparing self-reported impulsivity with DD using both rodents and humans in tests involving impulsive choice and impulsive action, there were no substantial correlations between these different aspects of impulsivity (Broos et al., 2012). Barker et al. (2015) found that, contrary to their expectations, individuals with BPD showed elevated motor impulsivity but not self-reported impulsivity as compared to healthy controls. Furthermore, there are indications that these different measures of impulsivity have a different neural basis (Broos et al., 2012).
The aim of this study was to examine the presence of two separate aspects of impulsivity (self-reported impulsivity and DD) in patients with BPD, SUD, and the combination of both disorders (BPD + SUD) in comparison with a healthy group, controlling for possible covariates (age, gender, education, socio-economic status, psychiatric symptoms and depression).
Section snippets
Participants
Patients were recruited from eight different Hungarian treatment service facilities. All patients with SUD (with or without BPD) were recruited from one of the three Addiction Treatment Services centres in Hungary, where they all received treatment for substance abuse or dependence as their primary diagnosis. BPD (but not SUD) patients were recruited from five Mental Health Services centres where substance dependence is an exclusion criterion for admission. If the patient received a diagnosis
Sample characteristics
The six groups differed significantly in gender, age and years of education at a p < 0.05 level (see Table 1). Regarding socio-economic status (SES), the BPD + AUD group reported significantly lower status compared to all other groups. Furthermore, there were group differences in GSI and Depression scores, with the BPD + DUD group reporting the highest level of psychiatric symptoms and depression.
Impulsivity and group differences
Delay discounting was moderately correlated with the Barratt Impulsiveness Scale Total Score (r = 0.32, p <
Discussion
The present study shows that the behavioural measure of impulsivity is more conservative than self-reported impulsivity among patients with BPD and/or SUD (AUD and/or DUD). Although variables such as psychiatric symptoms, depression and demographic variables (to a lesser extent) explain a large proportion of cases of self-reported impulsivity, these do not change the effect of the diagnosis (BPD and/or SUD). These results show that impulsivity is not a unitary construct and it has different
Conclusions
In summary, we found that BPD and SUD have additive effects on both self-reported impulsivity and delay discounting, although the differences in self-reported impulsivity are more robust than those on the behavioural level. This means that behavioural impulsivity is more conservative than self-reported impulsivity, or in other words, participants with BPD and/or SUD tend to over-estimate their behavioural impulsivity. Future studies should take into consideration the role of comorbid BPD for
Conflicts of interest
None.
Acknowledgements
Present work was supported by the Hungarian Scientific Research Fund Grant 83884 and 111938. Zsolt Demetrovics acknowledges financial support of the János Bolyai Research Fellowship awarded by the Hungarian Academy of Science.
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The last two authors contributed equally to the manuscript.