Risk taking behaviors in patients with Borderline Personality Disorder
Procedia – Social and Behavioral Sciences 30 (2011) 2597 – 2601 WCPCG-2011
Maryam Atefia, Behrooz Dolatshahia*, Abbas PourShahbaza, Mohammad Reza Khodaieb, Hamed Ekhtiaric
aUniversity of Social Walfare and Rehabilitaion Science, Depatment of clinical psychology, Tehran,3834198571 ,Iran
bUniversity of Social Walfare and Rehabilitaion Science,Depatment of psychiatry, Tehran, 3834198571 ,Iran
c Institue on Psychology and Addiction Sciences, Tehran, Iran
© 2011 Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
Selection and/or peer-review under responsibility of the 2nd World Conference on Psychology, Counselling and Guidance.
Abstract
The present study investigates risk taking behaviours in hospitalized patients with BPD using BART. Nineteen patients were assessed using the SCID-II and were compared with twenty five healthy subjects without past and present axis-II and current axis-I disorders. Adjusted value, the main indication of risk taking behaviour in BART, for subjects with BPD had no significant difference in compare to control group. This sample of BPD patients shows appropriate behaviour in cases that proper evaluation of ratio of gain to potential loss plays a major role in decision making.
1. Introduction
Borderline personality disorder (BPD) is a significant public health problem with substantial adverse consequences for individuals, families, and society at large. BPD is characterized by persistent problems with emotional (e.g., anger), behavioral, (e.g., self–injury), cognitive (e.g. dissociation), and interpersonal (e.g., chaotic relationships) functioning (APA, 1994). BPD results in considerable costs in terms of human suffering and psychiatric expenses among adult patients. The prevalence of BPD among general population is estimated 1%-2%. It is frequently seen in clinical settings, 10 % of all psychiatric outpatients and 15%-30% of inpatients, characterized by emotional dysregualation and chronic suicidality. Suicide rates of patients diagnosed for BPD are estimated at 10%, and comparable to other psychiatric disorders like major depression and schizophrenia (Paris, 2002). In addition, the frequency of self-injurious behaviours is higher than any other psychiatric diagnosis in these patients. BPD is characterized with high novelty seeking which is related to sensation seeking, tendency to experience novel situations and risk taking behaviours. Individuals with BPD are engaged in risky behaviours such as reckless driving, substance abuse, and gambling. These behaviours in general involve potential negative consequences (Jessor, 1998). Given the relationships between personality characteristics and risky behaviors, and the potential negative health outcomes associated with risky behaviors, more research is needed to evaluate the propensity in risk taking behaviors in high risk patients especially those with axis II psychopathology.
Research on risk-taking propensity has evolved along parallel lines of self-report personality measures and performance-based measures. Assessment impulsivity and risky behaviours by self-report questionnaires in patients with personality disorders are too difficult because the patients generally don’t have insight to their behaviours or they avoid reporting risky behaviours because of negative consequences (Aklin et al, 2005). One of the useful tasks to evaluate risky behaviours is Balloon Analogue Risk Task. The BART task was developed by LeJuez et al. (2002) as a task of risk-taking propensity and consists of different balloons that have to be pumped up by individuals. Each pump means that the individual earns something but after every pump the balloon may explode, which means that the individual loses all the earnings associated with this balloon. The individuals may also decide to stop pumping the balloon and accumulate their earnings in a permanent bank, which is a computerized task that creates a laboratory based, ecologically valid risk-taking scenario (Bornovalova, 2009). Previous studies have shown that performance on BART correlates with real world risk behaviors (White, 2008).
In the end, considering the characteristics of BPD, the aim of this study is to evaluate the propensity in risk taking behaviors in patients with BPD compared to healthy individuals by controlling the confronting variables on BART performance including neurological disorders and intelligence score.
2. Methods
Participants
Nineteen patients with BPD were enrolled to our study from patients who were admitted at the psychiatric inpatients service of psychiatric hospital “Rouzbeh” from January 2010 to October 2010. Participants were diagnosed with BPD based on the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First et al., 1996). The minimum IQ for admission was 85 and at least 8 grades of education were required. Control group was consisted of twenty five healthy individuals without past and present Axis-I and Axis-II disorders. All subjects had to be between age 20 and 35. General exclusion criteria were neurological disorders, serious medical illness, and active substance abuse, head injury with loss of consciousness, active psychotic symptoms and lifetime psychotic disorders. Patients who reported receiving a history of Electroconvulsive Therapy during the previous 90 days were excluded as well.
All patients were undergoing pharmacotherapy for BPD at the time of testing. Most patients qualified for other Axis I disorders: Obsessive-Compulsive Disorder (15.8%), Bipolar Disorder (21.10%), Bipolar-Mood Disorder (34.48%), Major Depressive Disorder (26.30%), Attention-Deficit Hyper Activity (10.5%), Anxiety Disorders (80.3%), about of 21% patients were diagnosed with an Axis II disorder: Histrionic personality disorder (10.5%), Anti-social personality disorder (10.5%).
Procedure
Patients were referred by their psychiatrist if they had BPD criteria. All patients completed the questionnaire of SCID-II just after 14 days after being admitted at hospital. BPD and other PDs diagnosis were made by a psychiatric and trained clinical psychologist using SCID-II. Twenty five patients were considered for the project. Six patients who refused to take part in the study were excluded. The healthy control group was recruited by local advertisement. They were screened clinically for PD by SCID II.
To assess Axis I disorders, SCID I was administered. Patients were allowed to have comorbid personality disorders and/or axis I disorders except substance abuse disorder or psychotic disorders. Non-patient could not have psychological complaints and could not have any lifetime or present axis I or axis II.
All subjects provided written informed consent after the procedures were clearly explained to them. Subjects were assessed by the Ravan Intelligence task to estimate IQ level. All participants fulfilled the demographic questionnaire, Balloon analogue risk taking behavior task, Beck depression inventory (BDI) and (Beck anxiety inventory (BAI).
Instruments:
Balloon Analogue Risk Task (BART; Lejuez et al., 2002)
BART is a computer-based measure, in which participants have the opportunity to win or lose potential earnings, where persistent responding increases gains but also increases the risk of loss on each trial. The BART consists of 30 trials (balloons). The goal is to make the balloons as large as possible without causing it to explode. (Lejuez et al., 2002). Participants must “pump up” an on-screen balloon. On each trial, each individual click on the pump inflates the balloon one degree (about .125” in all directions). The balloons have different explosion probabilities, 1/128 for the first pump, 1/127 for the second, and so on until the 128th pump at which point the probability was 1/1, the average explosion point is 64 pumps. At any point during each trial, the participants can stop pumping the balloon and click the “Collect $$$” button, which transfers money accumulated from that balloon to the permanent bank. When a balloon exploded, all money in the temporary bank was lost, and the next un-inflated balloon appeared on the screen. Yet it is important that participants were given no precise information about the probability of explosion, participants just informed that the balloon can break anywhere from the first pump all the way through enough pumps to make the balloon fill the screen. There are several variables but according to Lejuez (2002), the adjusted value is preferable. It is the average pumps on the balloons which are not exploded.
Beck Inventory Depression
Depressive symptoms were assessed using the Persian version of the Beck Depression Inventory (BDI) (Gharai et al, 2002). The inventory consists of 21 items scored on a four-point scale (0–3). The items include cognitive, affective, somatic, and vegetative aspects of depression. A total score is determined by aggregating the item responses. The BDI has demonstrated good test-retest reliability (r=0.73) and Chronbach’s alpha (0.78) in Iranian normal population (N=125, M=9.79, SD=7.96).
Beck Anxiety Inventory
The current level of anxiety was assessed using the state scale of the Persian version of the Beck Anxiety Inventory (BAI). This scale is a well-validated, 21-item questionnaire addressing the somatic, emotional and cognitive aspects of anxiety targeted to the individual’s present feelings. Subjects rate their feelings on a four-point intensity scale. A total score is determined by aggregating the item responses. The BDI has demonstrated good test- retest reliability (r=0.91) and Chronbach’s alpha (0.92) in Iranian normal population .
Structured Clinical Interview for DSM-IV Axis II Personality Disorder
Axis II disorders were assessed using the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II; First et al., 1997). The SCID-II is an efficient, user-friendly instrument that helps researchers and clinicians to make standardized, reliable, and accurate diagnoses of the DSM-IV PDs. It consists of a 120-item questionnaire to be completed by the participant, followed by an interview.
Structured Clinical Interview for DSM-IV
The Persian Structured Clinical Interview for DSM-IV Axis I disorders was administered to assess Axis I disorders. Kappa coefficient of Persian version of SCID-I was reported 0.6 (Sharifi et al, 2003).
Intelligence
Raven’s Progressive Matrices (often referred to simply as Raven’s Matrices) are multiple choice intelligence tests of abstract reasoning, (Raven, 1936). In each test item, the subject is asked to identify the missing item that completes a pattern. The booklet comprises five sets (A to E) of 12 items each, with items within a set becoming increasingly difficult, requiring ever greater cognitive capacity to encode and analyze information. It assesses the ability to think clearly and make sense of complexity, which is known as educative ability.
Statistical analysis
SPSS for Windows 14.0 version (SPSS Inc, Chicago, IL) was performed for all statistical analyses in this study. Two tailed p values less than 0.05 and a confidence interval of 95% was considered statistically significant for all analyses. T-tests for continuous variables and c2 for categorical variables were used for a comparison of socio demographic characteristics of two groups. Patients’ scores on BART were compared with controls by using t test for independent samples. A univariate analysis of covariance was then carried out to examine the difference between borderline patients and healthy subjects on BART, co-varying for the effects of depression (scores on BDI), anxiety (scores on BAI) and intelligence (scores on Ravan).
3. Results
Demographic features
A total of 19 patients with BPD (9 women and 10 men) and 24 healthy controls (9 women and 15 men) completed the study (c2 =0.424, df=1, p=5.15). The mean age of patients has no significant difference (M=25.58) with healthy controls (M=27.63) (t=-1.32, P=0.193). The mean years of education in patients groups is lower than control group but the difference is not significant (12.53 vs. 13.83, t=-1.806, p>0.05).
Depression, anxiety and IQ
We compared the results between BPD and control group for the BAI and the BDI informed in table 1. BPD patients obtained significantly higher scores than healthy controls across BAI and BDI (t= 2.96, df=26.56, p=0.01; t=4.103, df=25.45, p=0.00). According to results, patients subjects had lower IQ than control groups but the difference was not statistically significant (t=-2.00, df=42, p= 0.053).
Adjusted value
Adjusted value (average of number of pumps for not exploded balloons) for subjects with BPD had no significant difference in compare to control (t= 0.735, df= 42, p=0.467).
Table 1. Comparison of depression, anxiety and IQ in 19 patients and 24 controls
| BPD
Mean (SD) |
Control
Mean (SD) |
P | ||
| Depression (BDI scores) | 22.37(14.27) | 7.60 (7.47) | 0.000 | |
| Anxiety (BAI scores) | 13.63 (9.51) | 6.44 (5.36) | 0.006 | |
| IQ | 99.42 (11.54) | 105.92(10.03) | 0.053 | |
| Adjusted value | 23.046 (10.99) | 20.97 (7.16) | 0.47 | |
|
|
4. Discussion
Although the hospitalized patients with BPD have low function and major problems in decision making, the results did not show significant difference between groups. It means dangerous behaviors in which patients with BPD are engaged may not be due to riskiness. These patients can have impulsive behaviors but they may show appropriate behavior in cases that proper evaluation of ratio of gain to potential loss plays a major role in decision making. In addition, risky behaviors have different aspects; the BART may not be the proper task to evaluate this characteristic of BPD. In addition, no engagement in a particular risk behavior does not guarantee not to engagement in other risk-taking behaviors.
Furthermore, the interpretation of the results of our study is restricted because of several methodological limitations. The first is the small sample size, which is, however, comparable to samples reported previously in BPD studies (Kunert et al., 2003, Lampe et al., 2007 and Lenzenweger et al.,2004). Another limitation would be that we did not exclude BPD subjects with current psychotropic treatment at the time of assessment. However, due to the severity inherent to this disorder, hardly a BPD patient is medication-free that is the reason why the majority of studies in BPD do not exclude patients under medication. Nevertheless, we cannot rule out the possibility that the performance of patients is influenced by the effect of medication. Another limitation is that we did not attend to differences in comorbidity in BPD patients because any samples which are limited to patients with a sole BPD diagnosis of BPD is not considered as representative of BPD as it is diagnosed in clinical population. A clinical comparison group, which should be included in futures studies in order to define the specificity of our findings.
In the end, more research is needed to explore the different aspects of risky behaviors in BPD with larger sample and by different tasks.
Our results support previous findings suggesting the Cloninger’s psychobiological model as a useful model to describe the dimensional personality profile in BPD patients, characterized by high scores on temperament dimensions of novelty seeking and harm avoidance, and low character dimensions of self-directedness and cooperativeness.
Acknowledgements
We appreciate the great help of Dr. Salavati, to bring us the opportunity of doing this study at psychiatric hospital Rouzbeh in Tehran , Iran.
References
Aklin,M.W., Lejuez,C.W., Zvolensky,M.J., Kahler,C.W., Gwadz,M.(2005). Evaluation of behavioral measures of risk taking propensity with inner city adolescents. Behaviour Research and Therapy, 43.215–228
Bornovalova,M., Cashman-Rolls,A.,Lejuez , C.W.,et. al. (2009). Risk taking differences on a behavioral task as a function of potential reward/loss magnitude and individual differences in impulsivity and sensation seeking. Pharmacology, Biochemistry and Behavior, 93, 258–262
First, M. B., Spitzer, R. L.,Gibbon, M., et al.(1997). Structured clinical interview for DSM-IV Axis II personality disorders. Washington, DC: American Psychiatric Association
Gharai,B. (2002). Determining identity styles and its relationship with depression in adolescents in Tehran. Doctoral Dissertation, Iran University Jessor, R. (1998). New perspectives on adolescent risk behavior. In R. Jessor (Ed.). New Perspectives on Adolescent Risk Behavior (pp. 1–10).
Cambridge, UK: Cambridge University Press
Kunert, H. J., Druecke, H.W., Sass, H., et al. (2003). Frontal lobe dysfunctions in borderline personality disorder: Neuropsychological findings,
Journal of Personality Disorders, 17, 497–509
Lampe, K., Konrad, S., Kroener, K., et al. (2007). Neuropsychological and behavioural disinhibition in adult ADHD compared to borderline personality disorder, Psychological Medicine, 1–13
Lenzenweger, M.F., Clarkin, J.F., Fertuck, E.A. and Kernberg, O.F. (2004). Executive neurocognitive functioning and neurobehavioral systems indicators in borderline personality disorder: A preliminary study, Journal of Personality Disorders, 18, 421–438
Lejuez, C. W., Read, J. P., Kahler, C. W., Richards, J. B., Ramsey, S. E., Stuart, G. L., Strong, D. R., & Brown, R. A.(2002). Evaluation of a behavioral measure of risk-taking: The Balloon Analogue Risk Task (BART). Journal of
Experimental Psychology: Applied, 8, 75–84.
Paris, J. (2002). Chronic suicidality among patients with borderline personality disorder. Psychiatric Services, 53, 738-742.
White,T.L., Lejuez,C.W.,Wit,H.D.(2008). Test-Retest Characteristics of the Balloon Analogue Risk Task (BART). Experimental and Clinical Psychopharmacology. 16, 565–570
* Maryam Atefi. Tel.:+98-21- 221800148.
E-mail address: dolatshahee@yahoo.com.
1877-0428 © 2011 Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
Selection and/or peer-review under responsibility of the 2nd World Conference on Psychology, Counselling and Guidance. doi:10.1016/j.sbspro.2011.10.508