Viviani, T., Ahmadi, S., Tran, B., et al. 5th International Congress on Borderline Personality Disorder, Barcelona, Spain, 2018

1. The Interplay of Borderline Personality and Conduct Disorders
among previously suicidal adolescents
Viviani T., M.A., Ahmadi S., Ph.D, Tran B., Boodaghians, L., Weiss M., PhD, Mishara B., Ph.D, De Castro F., Ph.D and Greenfield B., MD
Introduction
• Sixty to ninety percent of those with borderline personality disorder
(BPD) engage in some form of suicidal behaviour [1], with up to
10% of them completing suicide [2].
• Suicide risk is high when such individuals have a comorbid
diagnosis of BPD and antisocial personality disorder (ASPD) [3].
• It has been suggested that BPD mediates the relationship between
externalizing disorders and suicide [4-6], however, there is a
paucity of longitudinal research of these constructs in a pediatric
population.
• BPD has also been observed to be frequently comorbid with
conduct disorder (CD), among previously suicidal adolescents [7-
10].
Objective
To further explore the BPD and CD association in a population of
adolescents undergoing a suicidal crisis evaluation at a Montreal
hospital emergency room (ER).
Methods
o Procedure
• A secondary analysis to a study that followed 286 suicidal youth
presenting to a Montreal hospital ER for a psychiatric evaluation,
between 1996 and 1998. A battery of tests and a standardized 3-
hour interview was conducted with participants.
• This study received ethics approval and abided by all guidelines
outlined in the Tri-Council policy for ethical conduct in research.
o Measures
• Socio-demographic data
• Diagnostic Interview Schedule for Children (DISC)
• Spectrum of Suicidal Behavior (SSBS)
• Children’s Global Assessment Scale (CGAS)
• Codding Life Events Scale
• Index of Family Relations (IFR)
• Abbreviated Diagnostic Interview for Borderlines (Ab-DIB)
• Temperament and Character Inventory (TCI-R)
• Defense Style Questionnaire (DSQ)
Conclusiono Sample
Figure I: Population recruitment and sampling
Discussion
Data (T1 & T4)
Measures
T4: 4-year
follow-up
T2: 6-month
follow-up
T1: Recruitment n = 286
n = 263 (92%)
n = 229
(80%)
Completed
n = 219
(77%)
Completed
n = 204 (71%)
Unmatched
n = 15
Incomplete
n = 10
Attrition
n = 34
1. Suicidal youth with CD (with or without BPD) will differ
psychosocially from those without CD, at recruitment and at
follow-up.
2. At recruitment, CD will be comorbid with BPD, and at follow-up,
there will be a bifurcation of both pathologies as has been
indicated in the literature.
Hypotheses
o Data analysis
• T-test and Chi-squared, with Fisher’s exact test, for group
differences between CD and non-CD.
• Risk ratios: general linear model with log-link function.
• Poisson distribution and standard error for bivariate and
multivariate models.
Results
1. Youth with CD are more vulnerable to BPD at recruitment
(cognition and impulsivity) and follow-up (impulsivity) than non-
CD subjects.
2. Prevalence of CD and BPD co-occurrence is higher than
prevalence of CD alone at recruitment and follow-up.
Table II: Group differences between those with and without Conduct disorder
follow up
Variable Conduct
Disorder yes
Conduct
Disorder no
p value
Conduct Disorder at Follow-Up* 17 (7.87) 199 (92.13)
BPD1 14 (87.50) 153 (80.53) Fisher’s exact= .742
Impulsivity2 14.88 (4.79) 7.09 (5.28) 5.87; p=.000β
CGAS > 501 5 (29.41) 152 (76.77) 17.82; p=.000β
Suicide1 5 (29.41) 13 (6.57) 10.65; p=.001β
Defense Style Questionnaire (DSQ)
Image Distorting (ID)2 67.00 (22.14) 54.26 (16.77) 2.92; p=.001β
Temperament and Character
Inventory (TCI)
Novelty Seeking (NS)2 14.76 (2.80) 10.66 (3.59) 4.59; p=.000β
Self-Directedness (SD)2 12.12 (4.57) 16.41 (5.75) 3.00; p=.002β
Cooperativeness (CS)2 15.06 (5.15) 19.20 (3.75) 4.23; p=.000β
Bonferroni correction: .05/28=.002
1: N (%) unit 2: Mean (SD) unit
Table I: Group differences between those with and without Conduct disorder at
recruitment
Variable Conduct
Disorder yes
Conduct
Disorder no
p value
Conduct Disorder at Recruitment* 67 (23.93) 213 (76.07)
BPD1 61 (98.39) 172 (84.31) Fisher’s exact= .002β
Cognitive2 8.6 (4.85) 6.13 (4.57) 3.74; p=.000β
Impulsivity2 14.17 (4.99) 8.10 (4.96) 8.54; p=.000β
Coddington Stress Life Events2 13.11 (7.85) 9.92 (6.21) 3.40; p=.000β
1. BPD distinguishes youth with CD from non-CD youth at
recruitment and follow-up.
2. CD youth with BPD are more impaired and more suicidal at
follow-up than youth without CD.
3. CD is highly comorbid with BPD until at least age 18.
• Neither are proxies for the other disorder.
• There is a start of divergence at follow-up.
• Suicidal youth with CD are distinguishable from non-CD youth,
mainly by virtue of BPD subscales.
• There is a very high prevalence of BPD among youth with CD.
• This may have significant impact on suicidal dynamics.
• There is only a trend towards bifurcation of CD and BPD in
pediatric population.
• Treatment needs to address both the externalizing disorder and
the axis-II disorder.
Acknowledgments
Special thanks to the Sir Wilfrid Laurier School Board and our
research volunteers Zoe Atsaidis and Chanel Lafontaine for their
dedication and assistance.
References
[1] Linehan MM, Heard H. Borderline personality disorder: costs, course, and
treatment outcomes. In: Miller N, Magruder K, editors. The cost-effectiveness of
psychotherapy: A guide for practitioners, researchers, and policy-makers. New
York: Oxford Press; 1999. p. 291–305.
[2] Paris J, Zweig-Frank H. A 27-year follow-up of patients with borderline
personality disorder. Compr Psychiatry. 2001;42(6):482–7.
[3] Paris J. Antisocial and borderline personality disorders: Two separate diagnoses
or two aspects of the same psychopathology? Compr Psychiatry. 1997;38(4):237–
42.
[4] James LM, Taylor J. Associations between symptoms of borderline personality
disorder, externalizing disorders, and suicide-related behaviors. J Psychopathol
Behav Assess. 2008;30(1):1–9.
[5] Paris J. The development of impulsivity and suicidality in borderline personality
disorder. Dev Psychopathol [Internet]. 2005;17(4):1091–104. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16613432
[6] Maloney E, Degenhardt L, Darke S, Nelson EC. Impulsivity and borderline
personality as risk factors for suicide attempts among opioid-dependent individuals.
Psychiatry Res. 2009;169(1):16–21.
[7] Freestone M, Howard R, Coid JW, Ullrich S. Adult antisocial syndrome co-
morbid with borderline personality disorder is associated with severe conduct
disorder, substance dependence and violent antisociality. Personal Ment Health.
2013;7(1):11–21.
[8] Zanarini MC, Frankenbourg FR, Hennen J, Reich DB, Silk KR. Axis I
comorbidity in patients with borderline personality disorder: 6-Year follow-up and
prediction of time to remission. Am J Psychiatry. 2004;161(11):2108–14.
[9] Ha C, Balderas JC, Zanarini MC, Oldham J, Sharp C. Psychiatric comorbidity in
hospitalized adolescents with borderline personality disorder. J Clin Psychiatry.
2014;75(5).
[10] Eppright TD Robinson BD, Reid JC KJH. Comorbidity of Conduct Disorder
and Personality Disorders in an Incarcerated Juvenile Population. Am J Psychiatry.
1993;150:1233–6.