خصومت و سوء استفاده جنسی در دوران کودکی بعنوان پیش بینی کننده رفتار خودکشی در اختلال شخصیت مرزی

Impulsivity is a multidimensional construct and has been previously associated with suicidal behaviour in borderline personality disorder (BPD). This study examined the associations between suicidal behaviour and impulsivity-related personality traits, as well as history of childhood sexual abuse, in 76 patients diagnosed with BPD using both the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders III (DSM-III) Axis-II diagnoses and the self-personality questionnaire. Impulsivity-related traits were measured using the Barratt Impulsiveness Scale-11 (BIS-11), the Buss–Durkee Hostility Inventory (BDHI) and the Temperament and Character Inventory-Revised (TCI-R). We found that hostility and childhood sexual abuse, but not impulsivity or other temperament traits, significantly predicted the presence, number and severity of previous suicide attempts. Hostility traits and childhood sexual abuse showed an impact on suicide attempts in BPD. Our results support previous findings indicating that high levels of hostility and having suffered sexual abuse during childhood lead to an increased risk for suicidal behaviour in BPD.

Recurrent suicidal behaviours constitute one of the most severe features of borderline personality disorder (BPD), present in 70% of patients, with an average of three lifetime suicide attempts (Soloff et al., 2000). Prevalence rates for complete suicide in this disorder are around 3–10% (Paris and Zweig-Frank, 2001 and Leichsenring et al., 2011). Among the factors that could be related to suicidality in BPD, personality traits, such as impulsivity (Rihmer and Benazzi, 2010, Courtet et al., 2011 and Lynam et al., 2011), and early adverse experiences during childhood (Horesh et al., 2009 and Wingenfeld et al., 2011) have been found to increase the risk of suicidal behaviours. However, few studies have investigated the joint contribution of these two factors to suicide risk in BPD. Impulsivity, understood as a stable trait of personality, has been characterised as a multidimensional construct. In BPD, it is a nuclear feature that is generally expressed by a severe behavioural disturbance, manifested by recurrent self-aggressive behaviours, such as substance abuse, risky sexual behaviour and angry outbursts, among others (Links et al., 1999 and American Psychiatric Association, 2000). Previous studies have consistently demonstrated that patients with BPD show high scores on scales measuring several aspects of impulsivity (Paris et al., 2004 and Peters et al., 2012). The multidimensional nature of impulsivity observed in BPD ranges from greater motor activation to less attention and decreased planning (Bornovalova et al., 2005 and Ferraz et al., 2009). In addition, aggressiveness or aggressive behaviours, also characteristic in subjects with BPD, can be measured as a dimension of attitudinal and behavioural hostility (Evren et al., 2011). In fact, patients with BPD usually exhibit high levels of hostility in several dimensions of the aggressiveness trait, such as assault, indirect aggression, irritability, resentment, suspicion and guilt (Dougherty et al., 1999, Paris et al., 2004 and Ferraz et al., 2009). Impulsivity and aggression have both been previously associated with suicidal behaviours across different diagnoses (Horesh et al., 1999, Carballo et al., 2006 and Conner et al., 2009), as well as in BPD (Brodsky et al., 1997, Soloff et al., 1994, Soloff et al., 2000, Kolla et al., 2008 and Giegling et al., 2009). There is also some evidence suggesting that this relationship is stronger in younger individuals and decreases in importance with age (McGirr et al., 2008). Although these psychological traits are somehow related, they are different constructs. To date, the literature regarding this issue is confusing and contradictory (Gvion and Apter, 2011), as some authors consider them as a single global category, impulsive–aggressive diathesis (Mann et al., 1999 and Seroczynski et al., 1999), while others believe that they represent distinct phenomena (Critchfield et al., 2004, Keilp et al., 2006 and García-Forero et al., 2009). Impulsivity is a stable trait of personality that can be defined by spontaneous, poorly planned or situationally inappropriate behaviours that may or may not include aggressive behaviours (Evenden, 1999). Aggression or trait aggressiveness can be measured through attitudinal and behavioural hostility, defined as a general propensity to engage in acts of physical and verbal aggression, a proneness to anger and a proneness to hold hostile beliefs about other people across situations (Buss and Perry, 1992 and Bushman, 1996). Another impulsivity-related trait is the temperament dimension of Novelty Seeking (NS). According to Cloninger′s model, NS includes four personality traits associated with exploratory activity in response to novel stimulation, impulsive decision making, extravagance in approach to reward cues and quick loss of temper and avoidance of frustration (Cloninger et al., 1993). With regard to BPD, NS along with temperament dimension of Harm Avoidance (HA) have been consistently reported to be altered in these patients (Barnow et al., 2005, Calati et al., 2008 and Ferraz et al., 2009). Furthermore, these two temperament dimensions were previously related to suicidal behaviours, both in BPD (Chapman et al., 2009 and Giegling et al., 2009) and in other psychiatric disorders (Conrad et al., 2009, Pawlak et al., 2013 and Perroud et al., 2013). Early childhood traumatic experiences have been associated with self-destructive and suicidal behaviour later in life (Chen et al., 2010 and Trask et al., 2011). Due to the high prevalence of history of childhood abuse among patients with BPD, some authors have studied its developmental consequences and its implication in the aetiology of the disorder (Zanarini and Frankenburg, 1997, Bandelow et al., 2005 and Lobbestael et al., 2010). Apart from personality traits, having suffered adverse experiences in childhood could also underlie the behavioural disturbances of BPD, and especially self-injurious behaviours (Gratz, 2003, Gratz et al., 2011 and Wingenfeld et al., 2011). Childhood abuse, and particularly childhood sexual abuse (CSA), has been previously related to suicide risk in BPD (Brodsky et al., 1997, Soloff et al., 2002, Soloff et al., 2008 and Horesh et al., 2009). Soloff et al. (2002) showed that the occurrence and severity of CSA predicted suicidal behaviour independent of other known risk factors. In fact, this group found that in patients with CSA, the risk of suicidal behaviour was 10 times more than in patients without such history. Despite the central role of impulsivity in BPD, and although it has been previously associated with suicidal-related variables, we still do not know how specific components of this trait and other related personality traits such as hostility and NS could be linked to suicidal behaviours. The relationship between impulsivity-related traits and suicide may be confounded by the heterogeneous nature of impulsivity and aggression constructs (Gvion and Apter, 2011). Moreover, childhood experiences of abuse, specifically with CSA, have been suggested as a potential risk factor for suicide in BPD. This being so, the aim of the present study was to determine the relationships between impulsivity-related traits and history of CSA in suicidal behaviours in patients with BPD. We specifically aimed to study these two factors in order to establish the joint effect of both psychological and environmental risk factors on suicidal behaviours in BPD. We expected to find that high levels of impulsiveness (as a stable personality trait measured with the BIS-11) and high levels of hostility (as behavioural and emotional dimensions of trait hostility measured with the BDHI) would predict the presence and a higher number of suicide attempts. In addition, higher levels of NS and HA temperament traits would also predict the presence and higher number of suicide attempts. Finally, having suffered CSA would be associated with higher suicidality.