Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714 https://doi.org/10.24869/psyd.2022.

706 Original paper

© Medicinska naklada - Zagreb, Croatia

THE EFFECT OF EMOTIONAL DYSREGULATION AND

IMPULSIVITY ON SUICIDALITY IN PATIENTS
WITH BIPOLAR DISORDER
Filiz Kulacaoglu1 & Filiz Izci2
1
Health Sciences University Prof. Dr. Mazhar Osman Bakirkoy Research and Training Hospital for Psychiatry
and Neurological Diseases, Department of Psychiatry, Istanbul, Turkey
2
Health Sciences University Erenkoy Research and Training Hospital for Psychiatry and Neurological Diseases,
Department of Psychiatry, Istanbul, Turkey

received: 14.4.2022; revised: 28.6.2022; accepted: 7.7.2022

SUMMARY
Background: We aimed to evaluate the effect of emotional dysregulation and impulsivity on suicidality in patients with bipolar
disorder by comparing patients with bipolar disorder with healthy individuals.
Subjects and methods: The study included 85 patients (59 women, 26 men) with bipolar disorder and education and age-
matched 65 (44 women, 21 men) healthy volunteers. The patient group was separated into 3 different groups if they have a suicide
attempt history, or have suicidal ideation without attempt, or have neither suicide attempt nor ideation. Sociodemographic Form,
The Difficulties in Emotion Regulation Scale (DERS), Barratt Impulsivity Scale (BIS-11), Scale for Suicidal Ideation, Suicide
Behaviors Questionnaire scales were applied to the participants.
Results: Patients with bipolar disorder (n=85) had significantly higher scores for emotion dysregulation and impulsivity than the
healthy controls (p<0.001, p<0.001). The scores of DERS, BIS-11, Suicidal ideation, and Suicide behavior scores were significantly
correlated. DERS Total and BIS Total scores of bipolar patients with suicide attempts were significantly higher than bipolar patients
with suicidal ideation and bipolar patients with neither attempt nor ideation. According to the hierarchical regression analysis,
strategies, clarity, and non-planning impulsiveness were found as the predictors of suicidal ideation in bipolar patients.
Conclusions: Suicidal behavior has a significant relationship between emotional dysregulation and impulsivity in patients with
BD. Clinicians must carefully evaluate emotional dysregulation and impulsivity among this population to develop treatment
strategies in suicide prevention.
Key words: emotional dysregulation – impulsivity - bipolar disorder - suicide

* * * * *
INTRODUCTION Impulsivity (Moeller et al. 2001) is generally linked
with manic episodes of BD, but may also be present in
Bipolar disorder (BD) is a common, vigorous, and euthymic periods. Acting without inhibition and choosing
disabling psychiatric disorder. The prevalence of BD is immediate pleasure are two main components of impul-
about 1-5%. However, among psychiatric disorders, BD sivity. Measuring the impulsivity traits, the Barratt Impul-
has the highest risk of suicide (Goldstein et al. 2012). sivity Scale (BIS-11) is commonly used (Patton et al.
BD patients have approximately 10-30 times higher 1995). It is composed of three subgroups: attention, non-
suicide risk than the population (Undurraga et al. 2011). planning, and motor impulsivity. Impulsivity subtypes
20-60% of BD patients assay suicide at least once may depend on the mood episode. While motor impulsi-
during their lifespan and 20% of them have completed vity is frequently related to mania, non-planning impulsi-
suicide (Undurraga et al. 2011). Since the relationship vity is commonly associated with depression. During
between suicide and BD is an important issue, iden- manic episodes, impulsivity is related to hypersexuality,
tifying the risk factors for suicidality is a critical part of poor judgment, and risky behaviors. In depressive epi-
suicide prevention for BD. sodes, difficulties in impulse control increase the risk for
Suicidality is multidimensional and consists of four suicidality (Eskander et al. 2020). According to Mann et
main features: suicidal ideation, suicide plan, suicidal al. impulsivity increases the individuals’ likelihood of
attempt, and suicidal behavior. Suicidal ideation is acting on their suicidal thoughts. Bryan and Rudd
thoughts to end life, suicide plan is method of the suicidal reported that impulsivity is a more important indicator of
ideation. Suicidal attempt is self-injury behaviors with a suicide attempts than the existence of a suicide plan
non-lethal outcome. Finally, suicidal behavior is the (Klonsky & May 2015).This situation is explained by the
combination of suicidal ideation, plan, and attempt. role of impulsivity in facilitating suicide acts among those
Suicidal behaviors are mainly divided into two groups; with suicidal ideation. However, previous findings have
impulsive suicides are mostly episodic, difficult to confirmed suicide attempters had higher levels of
predict, and lead quickly to suicide attempts. In contrast, impulsivity independent of psychopathology and this
planned suicides are progressive, consists of organized association was linked to neurobiological factors as well
thought, have a longer duration (Malhi et al. 2018). (Gokcay & Balcioglu 2020, Drachman et al. 2022).

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 Filiz Kulacaoglu & Filiz Izci: THE EFFECT OF EMOTIONAL DYSREGULATION AND IMPULSIVITY ON SUICIDALITY IN PATIENTS
WITH BIPOLAR DISORDER Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714

Gratz and Roemer brought forth a formulation of behavior, a semi-structured form was used. The form
emotion dysregulation involving 6 dimensions, accor- had two questions. Participants were asked to respond to
ding to this; emotion dysregulation (ED) is defined as the question, “have you ever attempted suicide in your
deficiency of the following emotion regulation features: life?”. If the participant answered yes, he/she was
(i) emotion acceptance (nonacceptance), (ii) awareness attended to the patient group with suicide attempt.
of emotions (awareness), (iii) the ability to use situa- Screening for suicidal ideation, participants answered
tionally appropriate responses to meet personal aims and the question “have you ever thought to attempt a suicide
situational requirements (strategies), (iv) the capacity to or made a plan for it?”. If participants responded yes,
dominate impulsive acts while going through damaging he/she was considered in the patient group with suicidal
feelings (impulse), (v) acts by desired goals (goals), (vi) ideation. Patients who had no suicide attempt history or
clarity about what emotions are experienced (clarity) suicidal ideation were considered the third group. Sixty-
(De Berardis et al. 2020). Anger bursts, suicide threats, five healthy controls (44 women, 21 men), with no
and aggression are common examples of emotional record of psychiatric illness, and no history of suicide
dysregulation. According to previous researches, emo- attempt or suicide idea before were selected from
tion dysregulation was associated with suicidality. Sui- hospital staff. The exclusion criteria of the healthy
cidal behaviors have been thought of as coping mecha- control group and the patient group were lack of
nisms with negative emotions. Patients who have diffi- education, cognitive weakening, mental retardation, and
culties in accepting their emotions may attempt suicide comorbid psychiatric illness (ie substance use disorder,
when they feel a lack of any other coping strategies personality disorder, anxiety disorder). Thus, thirty-
(Sağlam et al. 2020). Emotion dysregulation type may eight (38) patients were excluded from the study. Barratt
also vary depending on suicidal behavior type. Accor- Impulsivity Scale (BIS-11), The Difficulties in Emotion
ding to Zlotnick et al., adolescents who had suicide Regulation Scale (DERS), The Beck Scale for Suicidal
attempts reported more difficulties with impulse control Ideation, and Suicide Behaviors Questionnaire scales
than adolescents with suicidal ideation (Zlotnick et al. were applied to the participants. Ethics committee
2003). Weinberg and Klonsky reported that emotional approval for the study was granted by the Erenkoy
dysregulation dimensions except awareness were linked Research and Training Hospital for Mental Health and
with suicidal ideation. Furthermore, nonacceptance and Neurological diseases Ethical Committee with approval
strategies had the most powerful relation with suici- number 1 dated January 06, 2020, and written informed
dality (Weinberg & Klonsky 2009). Similarly, BD pa- consent was obtained from the patients.
tients have also problems in regulating emotions com-
pared to healthy controls even during remission periods. Instruments
According to Van Rheenen et al., patients with BD have
the predisposition to use negative attentional strategies Sociodemographic Data Form
such as rumination or catastrophizing, and increased This form consists of demographic features inclu-
impulsivity leads to difficulties in regulation of mood ding age, gender, marital status, education, occupation,
(Van Rheenen et al. 2015). history of suicide attempt, and suicidal ideation.
In light of the findings regarding the role of emotional Barratt Impulsivity Scale -11 (BIS-11)
dysregulation and impulsivity in suicidality, the goal of
The BIS-11 is a self-report scale, consists of 30-item
this study was to see if emotional dysregulation dimen-
questions for examining impulsivity as a trait (Patton et
sions and impulsive traits differ among patients with BD
al. 1995). Cronbach’s alpha of the total scale was 0.83.
who had different suicidal behaviors (suicidal ideation,
It evaluates three types of impulsivity: non-planning
suicide attempt, neither ideation nor attempt). Moreover,
impulsivity, motor impulsivity, and attentional impul-
we aimed to investigate if these dimensions and traits
sivity. High scores mean a higher level of impulsivity.
could predict suicidal behavior in bipolar disorder.
Items are rated between 1 (never) to 4 (very often,
always). The Turkish version had been validated by
SUBJECTS AND METHODS Gulec et al. (2008). Cronbach’s alpha of the total scale
Participants was 0.80, and the subscales ranged between 0.23 and
0.76 in that study. In this present study, Cronbach’s
The participants of this study were consisting of alpha coefficient for BIS-11 was found to be 0.76.
outpatients with bipolar disorder who applied to Eren-
koy Training and Research Hospital for Mental Health The Difficulties in Emotion Regulation Scale (DERS)
and Neurological Diseases psychiatry outpatient clinic DERS is a self-report scales and used to assess diffi-
between November 2020 – January 2021. Eighty-five culties in emotional dysregulation (Gratz & Roemer
outpatient (59 women, 26 men) who met Diagnostic 2004). Sample items from the six subscales include
and Statistical Manual of Mental Disorders -DSM-5 strategies, goals, nonacceptance, impulse, awareness,
criteria for bipolar disorder type-1 (BD), who have been clarity. Items are rated from 1 (never) to 5 (always).
in remission period for at least two months were higher scores mean higher difficulties in emotional
admitted to study. The participants were evaluated by regulation. Cronbach alpha was 0.93, and for subscales
two psychiatry specialists. Screening for the suicidal ranged between 0.80 to 0.89. Its Turkish form has been

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 Filiz Kulacaoglu & Filiz Izci: THE EFFECT OF EMOTIONAL DYSREGULATION AND IMPULSIVITY ON SUICIDALITY IN PATIENTS
WITH BIPOLAR DISORDER Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714

validated by Rugancı & Gençöz (2010). In that study, data are presented with n (%), and for non-normalized
Cronbach’s alpha was 0.94, and the subscales ranged variables are shown as ‘’median (min-max), and normal
between 0.75 to 0.90. In this study, Cronbach’s Alfa distributions are shown as "mean ± SD". In descriptive
coefficient for the scale was found to be 0.92, for the statistics, the difference was examined using Indepen-
subscales from 0.76 to 0.90. dent Samples t test for age, Pearson Chi Square and
Fisher Freeman Halton Exact tests for categorical varia-
The Beck Scale for Suicidal Ideation
bles. The variables were analyzed with Kolmogorov-
The Beck Scale for Suicidal Ideation is a self-report Smirnov’s test of normality. Since our data were not
scale that evaluates passive and active suicidal ideation, normally distributed, we used the Kruskal Wallis-H test
consists of 21-item (Beck et al. 1979). Cronbach’s alpha and Mann-Whitney U test for comparisons, and Spear-
was 0.97. The Turkish version of Suicidal Ideation has man correlation coefficient for correlations. Hierarchical
been validated by Dilbaz et al., and Cronbach’s alpha Regression analysis was done to investigate the asso-
was found as 0.88 (Dilbaz et al. 1995). ciation between suicidal ideation in BD patients and the
Suicide Behaviors Questionnaire DERS, BIS-11, age, and gender. A p-value less than
0.05 was taken into account statistically significant. The
The scale was developed by Linehan and Nielsen in
Bonferroni method was used for multiple comparisons.
1981, consists of four items (Linehan & Nielsen 1981).
The Mann-Whitney U test with Bonferroni correction
First item: ‘suicide plan and attempt’ is about the suicide
was used to compare the DERS total and BIS-11 total
history of the past. The second item is about ‘suicide
scores between the patient groups. A p-value less than
ideation’ and there are 5 options. It is scoring between 0
0.05/3 was considered significant.
and 4 in the Likert method. The third item is about
‘suicide threat’ and consists of two options. ‘No’ is
scored as 0 and ‘yes’ is scored as 1 point. The fourth RESULTS
item is about the repeatability of suicide and consists of Sociodemographic characteristics of the sample
five options and the Likert method is scored between 0
and 4. Cronbach’s alpha was found as 0.80. The Turkish Sociodemographic variables of the patient group and
version of this scale was validated by Bayam et al., and the healthy controls were shown in Table 1. The patient
Cronbach’s alpha was found 0.73 (Bayam et al. 1995). group was divided into 3 groups according to the history
of suicide. 35.29% (n=30) of the participants had a sui-
cide attempt, 28.24% (n=24) of the participants had sui-
Statistical Analysis
cidal ideation, and 36.47% (n=31) of the participants had
All statistical analyses were completed using SPSS neither suicide attempt nor suicidal ideation. In the con-
for Windows, Version 23.0. Descriptive statistics of the trol group, none of the individuals had a suicide history.
Table 1. Sociodemographic Characteristics of Sample
Healthy Controls Bipolar Patients p
Variable Mean SD Mean SD
Age 34.58 8.19 35.21 8.01 0.639a
Variable n % n %
Educational status 0.614b
Other 3 4.61 2 2.35
Elementary School 15 23.08 18 21.18
Middle School 11 16.92 23 27.06
High School 27 41.54 30 35.29
University 9 13.85 12 14.12
Employment 0.846c
Unemployed 28 43.08 40 47.06
Housewife 3 4.62 2 2.35
Civil Servant-Workers 27 41.54 37 43.53
Retired 4 6.15 3 3.53
Student 3 4.61 3 3.53
Marital status 0.900c
Single 19 29.23 22 25.88
Married 44 67.69 60 70.59
Divorced 2 3.08 3 3.53
Gender 0.822b
Female 44 67.69 59 69.41
Male 21 32.31 26 30.59
a = independent sample t test; b = chi square test; c = Fisher Freeman Halton Exact test

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WITH BIPOLAR DISORDER Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714

Table 2a. Comparison of Emotional Dysregulation and Impulsivity Between Bipolar Patients and Healthy Controls
using Mann-Whitney U test
Mean Rank Min. Max. Median U z p
DERS Total Bipolar 46.47 41.00 164.00 91.00
4367.50 -6.09 0.001
Healthy Controls 49.47 36.00 90.00 68.00
DERS-Strategy Bipolar 94.52 7.00 40.00 18.00
4379.50 -6.15 0.001
Healthy Controls 50.62 7.00 17.00 11.00
DERS-Non- Bipolar 93.84 8.00 28.00 15.00
4321.00 -5.93 0.001
acceptance Healthy Controls 51.52 6.00 14.00 11.00
DERS-Clarity Bipolar 86.64 5.00 25.00 13.00
3709.50 -3.61 0.001
Healthy Controls 60.93 5.00 15.00 11.00
DERS-Impulsivity Bipolar 88.56 5.00 30.00 15.00
3873.00 -4.23 0.001
Healthy Controls 58.42 6.00 20.00 12.00
DERS-Goals Bipolar 91.05 6.00 28.00 14.00
4084.00 -5.03 0.001
Healthy Controls 55.17 5.00 16.00 11.00
DERS-Awareness Bipolar 91.21 9.00 30.00 13.00
4098.00 -5.11 0.001
Healthy Controls 54.95 6.00 18.00 11.00
BIS-11 Total Bipolar 92.21 41.00 98.00 60.00
4182.50 -5.39 0.001
Healthy Controls 53.65 33.00 71.00 49.00
BIS-11 Motor Bipolar 89.56 11.00 35.00 20.00
3957.50 -4.55 0.001
Healthy Controls 57.12 12.00 33.00 16.00
BIS-11 Attentional Bipolar 89.14 9.00 29.00 19.00
3921.50 -4.41 0.001
Healthy Controls 57.67 8.00 24.00 15.00
BIS-11 Non- Bipolar 88.92 13.00 40.00 21.00
3903.50 -4.34 0.001
planning Healthy Controls 57.95 10.00 25.00 18.00
Suicide Behaviors Bipolar 95.00 0.00 8.00 1.00
1105.00 -7.466 0.000
Questionnaire Healthy Controls 50.00 0.00 0.00 0.00
Beck Scale for Bipolar 95.76 0.00 20.00 1.00
1040.00 -7.658 0.000
Suicidal Ideation Healthy Controls 49.00 0.00 0.00 0.00
DERS = Difficulties Emotional Regulation Scale; BIS-11 = Barratt Impulsivity Scale -11

Table 2b. Comparison of Emotional Dysregulation and Impulsivity Between Bipolar with neither suicide attempt nor
ideation and Healthy Controls using Mann-Whitney U test
Mean Rank Min. Max. Median U z p
DERS Total Bipolar 49.47 41.00 107.00 68.00
944.50 -0.494 0.621
Healthy Controls 46.47 36.00 90.00 63.00
DERS-Strategy Bipolar 51.50 7.00 17.00 11.00
914.50 -0.734 0.463
Healthy Controls 47.07 7.00 24.00 10.00
DERS-Non- Bipolar 48.88 8.00 18.00 11.00
983.00 -0.194 0.846
acceptance Healthy Controls 47.71 6.00 14.00 10.00
DERS-Clarity Bipolar 53.11 5.00 20.00 11.00
643.00 -2.662 0.053
Healthy Controls 39.74 5.00 15.00 9.00
DERS-Impulsivity Bipolar 52.44 6.00 24.00 12.00
751.50 -1.921 0.057
Healthy Controls 40.24 5.00 20.00 10.00
DERS-Goals Bipolar 48.63 5.00 20.00 11.00
1003.50 -0.032 0.975
Healthy Controls 48.44 6.00 16.00 11.00
DERS-Awareness Bipolar 53.08 10.00 18.00 12.00
865.50 -1.138 0.255
Healthy Controls 46.32 6.00 17.00 11.00
BIS-11 Total Bipolar 55.94 41.00 91.00 55.00
777.00 -1.807 0.071
Healthy Controls 44.95 33.00 71.00 49.00
BIS-11 Motor Bipolar 53.48 12.00 35.00 17.00
853.00 -1.217 0.224
Healthy Controls 46.12 11.00 33.00 16.00
BIS-11 Attentional Bipolar 50.48 8.00 24.00 16.00
946.00 -484 0.628
Healthy Controls 47.55 9.00 24.00 15.00
BIS-11 Non- Bipolar 52.92 16.00 35.00 18.00
945.50 -528 0.590
planning Healthy Controls 49.95 10.00 25.00 20.00
DERS = Difficulties Emotional Regulation Scale; BIS-11 = Barratt Impulsivity Scale -11

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 Filiz Kulacaoglu & Filiz Izci: THE EFFECT OF EMOTIONAL DYSREGULATION AND IMPULSIVITY ON SUICIDALITY IN PATIENTS
WITH BIPOLAR DISORDER Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714

No statistically significant differences were found bet- A Mann-Whitney U test was done to examine
ween the patient and the healthy control groups regarding DERS total, DERS Strategies, DERS Non-accept,
gender (p=0.822), age (p=0.639), marital status (p=0.900), DERS Impulsivity, DERS Goals, DERS Clarity, DERS
educational status (p=0.614), and employment (p=0.846). Awareness, BIS-11 Total, BIS-11 Motor, BIS-11 At-
tentional, and BIS-11 non-planning scores difference
Comparison of Impulsivity, Difficulties in between healthy controls and bipolar patients with no
Emotional Regulation Between Patient suicide history. There were no statistically significant
and Healthy Control Groups differences between two groups in terms of all scales.
The results of the two-tailed Mann-Whitney U test
A Mann-Whitney U test was done to examine DERS were shown in Table 2b.
total, DERS Strategies, DERS Non-accept, DERS Im-
pulsivity, DERS Goals, DERS Clarity, DERS Aware-
Correlations Coefficients among DERS Total,
ness, BIS-11 Total, BIS-11 Motor, BIS-11 Attentional,
BIS-11 Total, Suicide Behaviors Questionnaire,
and BIS-11 Non-planning scores difference between
healthy controls and bipolar patients.
and Beck Scale for Suicidal Ideation
In terms of DERS total, the result of the Mann- Inter-correlations between BIS-11, DERS, Suicide
Whitney U test was significant (U=4367.5, z=-6.09, Behaviors Questionnaire, and Beck Scale for Suicidal
p<0.001). The distribution of DERS total for bipolar Ideation were presented in Table 3. DERS Total was
patients was significantly different from the Healthy found to be significantly and positively correlated with
control distribution. The median for bipolar (Median = BIS-11 Total (rs = 0.744, p<0.001), Suicide Behaviors
91.00) was significantly larger than the median for Questionnaire (rs =0 .770, p<0.001), and Beck Scale
healthy controls (Median = 68.00) Table 2a presents the for Suicidal Ideation (rs = 0.770, p<0.001). BIS-11 To-
result of the two-tailed Mann-Whitney U test. tal was found to be significantly and positively corre-
In terms of BIS-11 Total, the result of the Mann- lated with Suicide Behaviors Questionnaire (rs = 0.567,
Whitney U test was significant (U=4182.5, z=-5.39, p<0.001) and Beck Scale for Suicidal Ideation
p<0.001). The distribution of BIS-11 Total for bipolar (rs = 0.552, p<0.001). Suicide Behaviors Questionnaire
patients was significantly different from the distribution was found to be significantly and positively correlated
for the healthy controls. The median for bipolar (Median with Beck Scale for Suicidal Ideation (rs =0.942,
= 60.00) was significantly larger than the median for p<0.001).
healthy controls (Median = 49.00).

Table 3. Correlation Coefficients among DERS total, Barratt total, Suicide Behaviors Questionnaire, and Beck Scale
for suicidal ideation
DERS Total Barratt Total Suicide Attempt Suicidal Ideation
DERS Total r - - - -
p - - - -
BIS-11 Total r 0.744 - - -
p <0.001 - - -
Suicide Behaviors Questionnaire r 0.770 0.567 - -
p <0.001 <0.001 - -
Beck Scale for Suicidal ideation r 0.770 0.552 0.942 -
p <0.001 <0.001 <0.001 -
DERS = Difficulties Emotional Regulation Scale; BIS-11 = Barratt Impulsivity Scale -11

Table 4. Kruskal-Wallis-H Test for DERS Total and Barratt Total Difference Between patients with Suicide Attempt,
Suicidal Ideation and with neither Attempt nor ideation
Bipolar with Suicide Bipolar with Suicidal Bipolar with Neither Attempt
Attempt (Median) Ideation (Median) nor ideation (Median) P1 P2 P3
(min : max) (min : max (min : max)
134.00 91.00 63.00
DERS Total <0.001 <0.001 0.002
(84.00 : 164.00) (66.00 : 133.00) (41.00 : 107.00)
77.00 60.00 55.00
BIS-11 Total 0.203 <0.001 0.004
(48.00 : 98.00) (46.00 : 79.00) (41.00 : 91.00)
DERS = Difficulties Emotional Regulation Scale; BIS-11 = Barratt Impulsivity Scale -11; P1 = Comparison for Bipolar with
Neither Attempt nor ideation and Bipolar with Suicidal ideation; P2 = Comparison for Bipolar with Neither Attempt nor ideation
and Bipolar with Suicide Attempt; P3 = Comparison for Bipolar with suicidal ideation and Bipolar with Suicidal attempt;
Mann-Whitney U test with Bonferroni correction was used for P1, P2, P3. p <0.017 was considered statistically significant

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WITH BIPOLAR DISORDER Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714

Table 5. Summary of Hierarchical Regression Analysis for Variables Predicting Suicide Ideation
Variable B SE 95% CI β p
Model 1
(Intercept) 1.74 1.18 [-0.60, 4.08] 0.00 0.144
Age -0.00 0.03 [-0.07, 0.06] -0.01 0.896
Gender male -0.40 0.56 [-1.51, 0.71] -0.06 0.472
Model 2
(Intercept) -6.22 1.38 [-8.94, -3.50] 0.00 <0.001
Age 0.04 0.02 [-0.01, 0.08] 0.09 0.134
Gender male -0.03 0.41 [-0.84, 0.78] -0.00 0.940
DERS Clarity 0.25 0.08 [0.09, 0.40] 0.35 0.002
DERS Awareness -0.07 0.07 [-0.22, 0.07] -0.09 0.322
DERS Strategies 0.18 0.04 [0.09, 0.27] 0.43 <0.001
DERS Impulsivity -0.03 0.06 [-0.15, 0.09] -0.05 0.636
DERS Nonacceptance 0.05 0.07 [-0.09, 0.19] 0.09 0.450
DERS Goals -0.02 0.08 [-0.17, 0.14] -0.02 0.842
BIS-11 Motor -0.02 0.05 [-0.12, 0.08] -0.04 0.685
BIS-11 Attentional -0.02 0.05 [-0.13, 0.09] -0.03 0.734
BIS-11 non-Planning 0.11 0.05 [0.01, 0.20] 0.19 0.025
DERS = Difficulties Emotional Regulation Scale; BIS-11 = Barratt Impulsivity Scale -11

Comparison of DERS Total and Barratt Total sivity, DERS Non-accept, DERS Goals, Barratt Motor,
between patients with Suicide Attempt, Suicidal Barratt Attentional, and Barrrat Non-planning explai-
Ideation and with neither attempt nor ideation ned an additional 51.79% of the variation in suicidal
ideation. The Wald criterion demonstrated that DERS
A Kruskal Wallis-H test was conducted to assess if Clarity (p=0.002), DERS Strategies (p=0.001), Non-
there were significant differences in DERS total and planning Impulsiveness (p=0.025), made a significant
Barratt Total scores between patients with suicide contribution to prediction. The results for the model
attempt, suicidal ideation and with neither attempt nor comparisons are in Table 5.
ideation. The results of the Kruskal Wallis-H test were
significant for both DERS total (χ2(2) = 55.09, p<0.001) DISCUSSION
and Barratt Total (χ2(2) = 26.69, p<0.001). The median
of DERS Total and Barratt Total were significantly In this study, we examined the relationship between
different between patients with suicide attempts, emotional dysregulation, impulsivity, and suicidality in
suicidal ideation, and neither attempt nor ideation. The patients with BP. The patient group is divided into 3
Mann-Whitney U test with Bonferroni correction test subgroups according to have suicide attempt history,
results indicated significant that DERS Total and have suicidal ideation without attempt, and have
Barratt Total median values were higher for the bipolar neither suicide attempt nor ideation. According to our
group with suicide attempts than the bipolar group results, bipolar patients had significantly higher scores
with suicidal ideation (p<0.002, p<0.004), and the for emotion dysregulation and impulsivity than health
bipolar group with neither suicide attempt nor ideation control groups as expected. The scores of all of the
(p<0.001, p<0.001). Moreover, DERS total median subscales of DERS and the subscales of impulsivity
values were higher for patients with suicidal ideation were significantly higher than the scores of the healthy
than the patients with neither suicide attempt nor control group. This result is similar to the literature.
suicidal ideation (p<0.001). The results of the Kruskal Emotion regulation problems are more experienced in
Wallis-H Test were presented in Table 4. bipolar pathophysiology models, especially since
mood lability and problems in emotional regulation
The Predictors of Suicidal Ideation in Patients may results negative consequences such as suicidality
with Bipolar Disorder (Townsend & Altshuler 2012). Becerra et al. reported
differences in the six dimensions compared with the
The F-test for Model 1 was not significant, healthy controls and euthymic BD patients reported
F (2, 147) = 0.26, p=0.768, ΔR2 = 0.00. This model in- severe problems in regulating emotions (Becerra et al.
dicates that adding age and gender did not explain an 2013). Recently, Van Rheenen indicated that no matter
extra variation in suicidal ideation. Age and sex were what the present mood episode, among bipolar
considered as non-interest variables and entered in the patients, severe symptoms are associated with severe
first step of the multiple regression. The F-test for problems in emotion regulation. Especially, difficulties
Model 2 was significant, F (9, 138) = 16.60, p<0.001, in impulse control predicted mania tendency, and
ΔR2 = 0.52. This model indicates adding DERS Cla- difficulties in strategy predicted depressive tendency in
rity, DERS Awareness, DERS Strategies, DERS Impul- BD patients (Van Rheenen et al. 2015).

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WITH BIPOLAR DISORDER Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714

Impulsivity which is associated with a manic epi- ideation prediction in patients with BD. According to a
sode may also be found during the euthymic period. recent study that investigated the ability of DERS to
Consistent with the literature, in our study, the impul- predict ideation of suicide in individuals with different
sivity scores of euthymic BD patients were significantly histories of suicidality, scores of strategies subscales of
higher than the healthy control group. Moreover, accor- DERS were significantly higher in individuals with
ding to our results, a positive correlation was found suicide attempts than in the other groups. This result is
between emotion dysregulation, impulsivity, suicidal accordant with the theory that suicidal behaviors are
ideation, and suicide attempt. The association between considered as attempts to get away from negative
suicidality and impulsivity has been shown in many feelings since individuals believe that they cannot
previous researches. Swann et al. reported a relation arrange their feelings with other formulations (Brown
between suicide attempts and impulsivity in bipolar 2006). Thus, we can interpret those results as strategies
patients (Swann et al. 2005). Michaelis et al. also is the emotion dysregulation dimension which is
compared bipolar patients according to their history of strongly related to suicide ideation. Since patients with
suicide attempts. Bipolar patients who had a history of BD are known to have significantly less emotional
suicide attempt had higher impulsivity levels (Michaelis clarity and they avoid or do not accept reactions to
et al. 2004). Maser et al. reported that impulsivity was negative emotions, it can have important functional
one of the best long-term predictors of suicide behavior consequences. It has been assumed that poor emotional
in patients with BD (Maser et al. 2002). Consistent with clarity places greater importance to understand emo-
the literature, in our study, BIS-11 scores were higher in tional experiences and as a result, reduces the
bipolar patients with suicide attempts than patients with allocation of resources required for the arrangement of
suicidal ideation. adaptive behaviors (Salovey et al. 1995). Moreover,
Difficulties in regulating emotion regulation may be suppressing the emotions or avoiding the emotions
an independent risk for suicide attempts and suicidal cause insufficient coping strategies. Finally, these
ideation (Anestis et al. 2011, De Berardis et al. 2020). negative strategies intensify emotions inconsistently
Especially, in patients with post-traumatic stress dis- and contribute to negative experiences (Gratz & Tull
order (PTSD), mood disorder, and borderline persona- 2010). According to Williams, suicidal behavior is a
lity disorder, emotional instability increases the risk of response to a strained circumstance that stimulates
suicidal ideation (Bayes et al. 2016). However, child- feelings of frustration and is seen as inescapable. Thus,
hood trauma is one of the important factors causing less emotional clarity and lack of appropriate strategies
emotional instability in these patients. Especially emo- may lead a patient with BD to feel incapable to get
tional abuse was found as a predictor factor for lifetime over his or her negative feelings and this situation may
suicide attempts in bipolar patients. We may interpret cause suicidal ideation.
these results as emotional abuse may increase the Previous studies reported higher impulsivity scores
suicide risk by leading an inadequate emotional regu- in suicide attempters. However, type of the impulsivity
lation (Janiri et al. 2018). Our findings support the scores of BIS may depend on the psychiatric disorder.
results of previous researches that indicate emotion For example, attempters with borderline personality
dysregulation is associated with suicidal thoughts disorder usually scored higher motor impulsiveness
(Tamás et al. 2007). However, in a very recent study scores. However, according to a recent study, total BIS-
that investigated the relationship between emotional 11 scores and non-planning impulsivity scores were
dysregulation and suicide risk in a younger population significantly higher in patients with schizophrenia, and
(aged between 14-25) with mood disorder, emotional affective disorders with a history of a suicide attempt.
dysregulation had been shown as an independent risk According to our results, non-planning impulsivity is
factor for lifetime suicidal ideation in those population one of the predictors for suicidal ideation in patients
(Janiri et al. 2021). Furthermore, similar to our study with BD. Patients with schizophrenia and affective
design, Palagini et al. reported that insomnia was asso- disorders had frequently used highly lethal suicidal
ciated with emotional dysregulation, impulsivity, and methods and according to these results impulsivity
suicidality in patients with BD (Palagini et al. 2019). could be behind those findings (Doihara et al. 2012).
Weinberg and Klonsky reported that suicidal idea- Our study has some limitations. First, the partici-
tion was linked with each of the emotional dysregu- pants of this study were recruited from one psychiatric
lation dimensions except awareness. Furthermore, outpatient clinic in Turkey. Second, our study is cross-
strategies had the most powerful relation among the sectional, and the sample size was relatively small.
other dimensions (Weinberg and Klonsky 2009). Our Third, variables about pharmacological treatment of the
results also support previous findings in terms of patients, such as compliance of medical treatment,
problems in emotion regulation that differs among sui- duration time without treatment, type of pharma-
cidal ideators and suicide attempters since attempters cological treatment may have an effect on the suicide.
had higher scores for DERS than the ideators (Zlotnick We could not evaluate the treatment history. Finally, we
et al. 2003). Moreover, according to our results DERS used self-rated scales and the investigation method of
strategies, DERS Clarity, and BIS Non-planning suicidal ideation and history of suicide attempt was
impulsivity made a significant contribution to suicide subjective.

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WITH BIPOLAR DISORDER Psychiatria Danubina, 2022; Vol. 34, No. 4, pp 706-714

CONCLUSIONS 8. Dilbaz N, Holat H, Bayam G, Tüzer T, Bitlis V: İntihar

Düşüncesi Ölçeğinin Geçerlilik ve Güvenirliği. 31. Ulusal
In conclusion, our study, although limited, suggests Psikiyatri Bilimler Kongresi Bilimsel Çalışma Kitabı
1995; 40–41
that patients with bipolar disorder had significantly
9. Doihara C, Kawanishi C, Ohyama N, Yamada T,
higher emotion dysregulation problems and higher
Nakagawa M, et al.: Trait Impulsivity in Suicide
impulsivity scores than health control group. there is Attempters: Preliminary Study. Psychiatry Clin Neurosci
positive correlation between emotion dysregulation, 2012; 66: 529–32
impulsivity with suicidal ideation and suicide behavior 10. Drachman R, Colic L, Sankar A, Spencer L, Goldman DA,
in patients with bipolar disorder. Bipolar patients with et al.: Rethinking ‘Aggression’ and Impulsivity in Bipolar
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patients with suicidal ideation and bipolar patients with 11. Eskander N, Emamy M, Saad-Omer SM, Khan F, Jahan
neither attempt not ideation. Clinicians must carefully N: The Impact of Impulsivity and Emotional
evaluate emotional dysregulation and impulsivity Dysregulation on Comorbid Bipolar Disorder and
among this population to develop appropriate Borderline Personality Disorder. Cureus 2020; 12 (8).
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Contribution of individual authors:
14. Gratz KL, Roemer L: Multidimensional Assessment of
Kulacaoglu Filiz: design of the study, literature re- Emotion Regulation and Dysregulation: Development,
search, sample collection, statistical design, inter- Factor Structure, and Initial Validation of the Difficulties
pretation of the data, writing the manuscript. in Emotion Regulation Scale. J Psychopathol Behav
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Correspondence:
Filiz Kulacaoglu, MD
Health Sciences University, Prof. Dr. Mazhar Osman Bakirkoy Research and
Training Hospital for Psychiatry and Neurological Diseases, Department of Psychiatry
Zuhuratbaba, Doktor Tevfik Saglam Cd. 25/2,34147, Bakirkoy, Istanbul, Turkey
E-mail: fkulaca@gmail.com

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