Impulsivity, emotional dysregulation, aggression, and hopelessness in suicide attempts among bipolar disorder patients: A cross sectional study

ABSTRACT

Background:

Suicide attempts are common in bipolar affective disorder (BPAD), but the contribution of enduring psychological traits to suicidal behavior during remission remains unclear.

Aim:

To compare impulsivity, aggression, emotional dysregulation, and hopelessness between remitted BPAD patients with and without a lifetime history of suicide attempts, and to identify independently associated factors of suicidal behavior.

Materials and Methods:

This cross-sectional comparative study included 150 remitted BPAD patients recruited from a tertiary-care psychiatry center in India. Participants were divided into suicide-attempt (n = 72) and non-attempt (n = 78) groups. The sample included 86 females and 64 males. Trait variables were assessed using the Barratt Impulsiveness Scale–11, Buss–Perry Aggression Questionnaire, Difficulties in Emotion Regulation Scale, and Beck Hopelessness Scale.

Results:

Patients with a lifetime history of suicide attempts had significantly higher impulsivity, aggression, and emotional dysregulation scores compared to non-attempters (all P < 0.001). Hopelessness scores were also higher among suicide attempters (P = 0.050). Logistic regression analysis identified impulsivity (OR = 1.05, 95% CI: 1.02–1.08, P < 0.001) and emotional dysregulation (OR = 1.03, 95% CI: 1.01–1.05, P = 0.002) as independently associated with suicide attempts, whereas aggression and hopelessness were not independently associated.

Conclusion:

Impulsivity and emotional dysregulation appear to represent important trait-related vulnerabilities associated with suicide attempts in patients with remitted BPAD. Incorporating assessment of these dimensions into routine clinical evaluation may improve long-term suicide prevention strategies in bipolar disorder.

INTRODUCTION

Bipolar disorder (BD) is a chronic and severe mood disorder characterized by recurrent episodes of mania, hypomania, and depression, leading to marked functional impairment and increased mortality. Epidemiological data indicate that the disorder affects a significant portion of the global population, with lifetime prevalence estimates for bipolar spectrum conditions reaching approximately 2.4% worldwide, encompassing bipolar I, bipolar II, and subthreshold bipolar presentations.[1] In India, large population-based surveys report a lifetime prevalence of bipolar affective disorder of approximately 0.5%, with current prevalence around 0.3%.[2] Meta-analytic data indicate that approximately one-third of individuals with BD report at least one lifetime suicide attempt, with estimates often ranging from 20% to 60%, and completed suicide rates of about 10–19% across studies.[3]

The risk of suicidal behavior in BD arises from both state-dependent clinical factors and enduring trait vulnerabilities. State factors, for example, current or recent depressive or mixed episodes, severity of depressive symptoms, and acute affective instability significantly elevate suicide risk during active phases of illness.[4] Conversely, trait factors represent relatively stable psychological characteristics that persist beyond acute mood episodes and may confer a chronic vulnerability to suicidal behavior. As only a subset of individuals with suicidal ideation progress to suicide attempts, identifying the psychological attributes associated with this transition remains a clinical priority. Although impulsivity, aggression, emotional dysregulation, and hopelessness have each been linked to suicide attempts in bipolar disorder, the existing evidence is fragmented and methodologically heterogeneous, with most studies examining these traits in isolation, during acute mood states, or without adequately accounting for symptom remission.[5,6,7,8] Consequently, it remains unclear which trait dimensions independently distinguish bipolar patients with a history of suicide attempts from those without, particularly during euthymic or remitted phases, when state-related confounding is minimized. Therefore, the present study aims to compare levels of impulsivity, aggression, emotional dysregulation, and hopelessness between remitted bipolar disorder patients with and without a lifetime history of suicide attempts, and to examine whether these trait dimensions are independently associated with suicide-attempt status after adjusting for relevant clinical and sociodemographic variables.

METHODOLOGY

The study was conducted in the outpatient and inpatient psychiatry services of a tertiary-care teaching hospital in Central India after obtaining approval from the Institutional Ethics Committee (MGM/EC/April25/32). Adult patients aged 18–60 years with a diagnosis of bipolar disorder as per DSM-5 criteria were recruited from outpatient and inpatient services. Written informed consent was obtained from all participants prior to enrollment.[9]

A total of 150 remitted patients with BD were included and divided into two groups based on lifetime history of suicide attempts: those with at least one documented suicide attempt and those with no such history. The sample size was calculated based on the prevalence of lifetime suicide attempts in bipolar disorder reported by Dong et al. (33.9%).[3] Using OpenEpi software with 95% confidence level, 80% power, and equal allocation between groups, the minimum required sample size was estimated to be approximately 64 participants per group.[10] To improve statistical reliability and compensate for incomplete assessments, a total of 150 participants were included, comprising 72 suicide attempters and 78 non-attempters. All participants were required to be in clinical remission at the time of assessment. Remission was operationally defined as a score of less than 7 on the Young Mania Rating Scale[11] and less than 7 on the Hamilton Depression Rating Scale,[12] along with the absence of a current mood episode on consultant psychiatric evaluation. Individuals with current manic, hypomanic, depressive, or mixed episodes, comorbid schizophrenia spectrum disorders, intellectual disability, major neurocognitive disorders, active substance dependence (except nicotine), or serious medical or neurological illnesses were excluded to minimize confounding.

Sociodemographic data were collected using a semi-structured proforma. Lifetime suicide-attempt status was determined using Item 1 of the Suicide Behaviors Questionnaire–Revised (SBQ-R),[13] which assesses previous suicide attempts and was supplemented by clinical interview and review of medical records whenever available. Trait psychological characteristics were assessed using standardised, validated self-report instruments administered in English. Impulsivity was measured using the 30-item Barratt Impulsiveness Scale–11 (BIS-11; Cronbach’s α = 0.83)[14]; aggression using the 29-item Buss–Perry Aggression Questionnaire (BPAQ; Cronbach’s α = 0.89)[15]; emotional dysregulation using the 36-item Difficulties in Emotion Regulation Scale (DERS; Cronbach’s α = 0.93)[16]; hopelessness using the 20-item Beck Hopelessness Scale (BHS; Cronbach’s α = 0.93)[17]; and suicidal behavior using the 4-item Suicide Behaviors Questionnaire–Revised (SBQ-R; Cronbach’s α = 0.76–0.88).[13] These instruments have demonstrated good validity and reliability across clinical populations and are widely used in psychiatric research. All assessment instruments were used in accordance with their respective copyright, licensing, and permission requirements. Where required, permission for use was obtained from the copyright holders before commencement of the study. Data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA).[18]

RESULTS

A total of 168 patients were screened for eligibility. Of these, 18 were excluded: five were not in clinical remission at the time of assessment, eight declined to provide informed consent, and five had comorbid substance dependence. The remaining 150 participants were enrolled and included in the final analysis. Based on lifetime history of suicide attempts, participants were divided into two groups: patients with a history of suicide attempts (n = 72) and patients without a history of suicide attempts (n = 78). The mean age of participants was 38.56 ± 13.52 years. Patients with a history of suicide attempts had a mean age of 39.83 ± 13.51 years, whereas those without suicide attempts had a mean age of 37.38 ± 13.47 years; this difference was not statistically significant (P = 0.268). Among the 150 participants, 86 were females and 64 were males. Among female participants, 41 had a lifetime history of suicide attempts, while 45 had no such history. Among male participants, 31 had a lifetime history of suicide attempts, and 33 had no history of suicide attempts. There were no significant differences in gender distribution between the two groups (P = 0.145). Among patients with a history of suicide attempts, the phase of illness during which the suicide attempt occurred could not be reliably assessed because of retrospective recall limitations and potential recall bias.

Comparison of psychological trait variables between the two groups is presented in Table 1. Univariate analysis demonstrated that patients with a lifetime history of suicide attempts had significantly higher mean scores for aggression (83.54 ± 23.53 vs. 68.38 ± 21.52, P < 0.001), emotion dysregulation (105.31 ± 17.40 vs. 93.33 ± 23.15, P < 0.001), and impulsivity (84.57 ± 14.17 vs. 68.65 ± 17.90, P < 0.001) compared with patients without suicide attempts. Hopelessness scores were also higher in the suicide-attempt group, although the difference was of borderline statistical significance (8.94 ± 5.16 vs. 7.32 ± 4.89, P = 0.050). Binary logistic regression analysis [Table 2] demonstrated that greater impulsivity (OR = 1.05, 95% CI: 1.02–1.08, P < 0.001) and emotion dysregulation (OR = 1.03, 95% CI: 1.01–1.05, P = 0.002) were independently associated with lifetime suicide-attempt status, whereas aggression and hopelessness were not independently associated after adjustment. Correlation analysis [Table 3] revealed a moderate positive correlation between aggression and impulsivity (r = 0.48, P < 0.05), while no significant correlations were observed among the remaining psychological variables.

Table 1.

Comparison of trait variables between bipolar patients with and without lifetime suicide attempts

Variable	Non-attempt (Mean±SD)	Attempt (Mean±SD)	t	P
Hopelessness (BHS)	7.32±4.89	8.94±5.16	1.97	0.050
Aggression (BPAS)	68.38±21.52	83.54±23.53	4.11	<0.001
Emotion dysregulation (DERS)	93.33±23.15	105.31±17.40	3.60	<0.001
Impulsivity (BIS-11)	68.65±17.90	84.57±14.17	6.06	<0.001

BHS: Beck Hopelessness Scale; BPAS: Buss–Perry Aggression Scale; DERS:Difficulties in Emotion Regulation Scale; BIS-11: Barratt Impulsiveness Scale–11; SD: Standard deviation

Table 2.

Binary logistic regression analysis examining factors independently associated with lifetime suicide-attempt status

Variable	β	SE	P	Odds Ratio (OR)	95% CI for OR
Hopelessness (BHS)	0.063	0.040	0.12	1.06	0.98 – 1.15
Aggression (BPAS)	0.016	0.009	0.099	1.02	1.00 – 1.03
Emotion dysregulation (DERS)	0.032	0.010	0.002	1.03	1.01 – 1.05
Impulsivity (BIS-11)	0.049	0.013	<0.001	1.05	1.02 – 1.08

Model statistics: χ²=48.7, P<0.001, Nagelkerke R²=0.234. BHS: Beck Hopelessness Scale; BPAS: Buss–Perry Aggression Scale; DERS: Difficulties in Emotion Regulation Scale; BIS-11: Barratt Impulsiveness Scale–11; SD: Standard deviation, OR: Odds Ratio

Table 3.

Pearson correlation coefficients among trait variables (n=150)

Variable	BHS	BPAS	DERS	BIS-11
Hopelessness (BHS)	1	–0.01	0.12	0.07
Aggression (BPAS)	–0.01	1	0.09	0.48*
Emotion dysregulation (DERS)	0.12	0.09	1	0.09
Impulsivity (BIS-11)	0.07	0.48*	0.09	1

BHS: Beck Hopelessness Scale; BPAS: Buss–Perry Aggression Scale; DERS: Difficulties in Emotion Regulation Scale; BIS-11:Barratt Impulsiveness Scale–11; SD: Standard deviation. *P<0.05

DISCUSSION

The present study aimed to examine whether trait impulsivity, aggression, emotional dysregulation, and hopelessness differentiate remitted patients with bipolar affective disorder (BPAD) with and without a lifetime history of suicide attempts. To minimize the confounding influence of acute mood symptoms, all assessments were conducted during clinical remission, and patients were categorised into suicide attempt and non-attempt groups based on lifetime history.

Impulsivity emerged as the strongest independent psychological factor associated with lifetime suicide attempts in the present study. This finding reinforces the conceptualization of impulsivity as a core, trait-like vulnerability in bipolar affective disorder that persists beyond acute mood episodes and contributes substantially to suicidal behavior even during clinical remission. Elevated impulsivity may lower behavioral thresholds for self-harm by impairing inhibitory control, increasing sensitivity to immediate emotional cues, and reducing consideration of long-term consequences, thereby facilitating the transition from suicidal ideation to suicidal action.[19] Neurobiological and psychological models further support this association, linking impulsivity in bipolar disorder to dysregulation within fronto-limbic circuits involved in executive control and affective regulation.[20] Such dysfunction may be particularly relevant during periods of emotional distress, when impaired top-down control increases the likelihood of acting on suicidal urges. Prior studies have consistently demonstrated higher impulsivity scores among bipolar patients with a history of suicide attempts compared to non-attempters, as well as a graded relationship between impulsivity severity and lethality of attempts.[20] The present findings extend this literature by demonstrating that impulsivity remained independently associated with lifetime suicide-attempt status even after accounting for aggression, emotional dysregulation, and hopelessness, underscoring its independent contribution to suicide risk.

Emotional dysregulation was also independently associated with lifetime suicide attempts after controlling for impulsivity, aggression, and hopelessness. This suggests that impaired modulation of emotional responses represents a distinct and clinically meaningful vulnerability in bipolar disorder. Emotional dysregulation may increase suicide risk by reducing tolerance for intense negative affect, limiting access to adaptive coping strategies, and promoting maladaptive behaviors such as self-harm when emotional arousal becomes overwhelming.[6] Importantly, the persistence of this association during remission supports the conceptualization of emotional dysregulation as a trait-like deficit rather than merely a consequence of acute mood episodes. These findings are consistent with prior research demonstrating that emotion regulation difficulties are independently associated with suicide attempts across mood disorders, even after accounting for depressive symptom severity and other psychological risk factors.[21]

Aggression was significantly higher among patients with a lifetime history of suicide attempts in univariate analysis; however, it did not retain independent significance in the multivariable regression model. This pattern suggests that while aggressive traits are more prominent among bipolar patients with suicidal behavior, their contribution to suicide risk may be indirect rather than autonomous. Aggression in bipolar disorder is closely linked to impulsivity and behavioral disinhibition, and its association with suicide attempts may therefore be mediated through these overlapping constructs.[22] The strong correlation observed between aggression and impulsivity in the present study further supports this interpretation.

Prior research has similarly demonstrated that aggression is associated with suicidal behavior primarily when accompanied by heightened impulsivity or poor behavioral control, rather than functioning as an independent risk factor.[7] From a psychological perspective, aggressive traits may reflect difficulties in modulating anger and frustration, which, in the absence of adequate inhibitory control, can be directed inward as self-harm.[23] The loss of independent significance for aggression after adjustment underscores the importance of considering the interplay between behavioral traits rather than interpreting aggression in isolation when assessing suicide risk in bipolar disorder.

Hopelessness was modestly elevated among patients with a lifetime history of suicide attempts in univariate analysis but did not emerge as an independent association in the multivariable regression model. This pattern suggests that hopelessness may contribute to suicide risk in bipolar disorder primarily as a state-dependent factor, rather than as a stable trait vulnerability. Hopelessness has been consistently linked to suicidal ideation and behavior, particularly during depressive episodes, when negative expectations about the future are most pronounced.[24,25] As all participants in the present study were assessed during clinical remission, the attenuated association between hopelessness and suicide attempts is consistent with prior evidence indicating that hopelessness fluctuates with mood state and may have limited association to suicide attempts in euthymic bipolar patients.[26]

Furthermore, the loss of independent significance for hopelessness after adjustment for impulsivity and emotional dysregulation suggests that its effect on suicidal behavior may be mediated through these more proximal psychological mechanisms. Individuals experiencing hopelessness may be more likely to develop suicidal thoughts; however, the transition from ideation to action appears to depend on factors such as impaired behavioral control and difficulty regulating emotional distress. This interpretation aligns with contemporary models of suicide that distinguish between the emergence of suicidal ideation and the capability to engage in suicidal behavior.[27,28]

Additionally, correlation analysis was conducted to examine the interrelationships among the studied psychological traits and to clarify their degree of overlap. A strong positive correlation was observed between impulsivity and aggression, suggesting that these constructs share a common behavioral substrate characterised by disinhibition and poor inhibitory control. This finding is consistent with prior literature demonstrating substantial overlap between impulsivity and aggression in bipolar disorder and suicidal populations, where aggression is often conceptualized as an outward manifestation of impulsive dyscontrol.[7,23] Such overlap provides a plausible explanation for the loss of independent significance of aggression in multivariable models once impulsivity is accounted for.

In contrast, emotional dysregulation showed only weak and non-significant correlations with impulsivity and aggression, indicating that difficulties in emotion regulation represent a largely distinct psychological dimension. Previous studies similarly suggest that emotion dysregulation contributes to suicidal behavior through mechanisms related to affective intensity, distress intolerance, and maladaptive coping, rather than behavioral disinhibition per se.[6] Hopelessness also demonstrated weak and non-significant correlations with other trait variables, supporting prior evidence that negative future expectations are more closely linked to current mood state than to stable personality traits, particularly in euthymic bipolar patients.[25] Taken together, these correlation findings complement the regression results by reinforcing impulsivity and emotional dysregulation as relatively independent contributors to suicide risk, while clarifying why aggression and hopelessness did not retain independent association.

Collectively, these findings support contemporary models of suicidal behavior that distinguish between the emergence of suicidal ideation and the capacity to act on such thoughts, highlighting impulsivity and impaired emotion regulation as key trait-level vulnerabilities in bipolar disorder.[27,28] Routine assessment of these dimensions, even during euthymic phases, and targeted interventions aimed at improving impulse control and emotion regulation may therefore represent critical components of long-term suicide prevention strategies in this population.[23,24]

From a clinical perspective, these results underscore the importance of incorporating trait-based psychological assessment into routine risk evaluation, rather than limiting suicide risk assessment to current mood symptoms alone. Screening for impulsivity and emotion regulation difficulties during periods of remission may help identify patients who appear clinically stable yet remain at elevated risk for suicidal behavior. Furthermore, treatment planning in bipolar disorder may benefit from integrating psychosocial interventions that specifically target impulse control and emotion regulation skills, alongside pharmacological mood stabilisation. Interventions focused on enhancing distress tolerance, behavioral inhibition, and adaptive emotion regulation may reduce the likelihood that suicidal thoughts translate into suicidal actions, thereby addressing a critical gap in long-term suicide prevention for individuals with bipolar disorder.

Limitations

The findings of this study should be interpreted in light of certain methodological limitations. The study included limited sociodemographic information, and variables such as educational status, marital status, employment status, socioeconomic status, and social support were not systematically assessed. These factors may influence both suicidal behavior and psychological trait measures and therefore could not be accounted for in the present analyses. Assessments were conducted during clinical remission, which reduced the influence of acute mood symptoms on psychological measures and allowed examination of trait-related factors associated with suicidal behavior. At the same time, the cross-sectional design limits causal inference, and lifetime suicide attempts were assessed retrospectively, introducing the possibility of recall bias. The reliance on self-report instruments may have influenced responses, and relevant clinical variables such as illness course characteristics and medication effects were not examined in the regression model. As the sample was drawn from a single tertiary-care center, generalizability to other clinical settings may be limited, and the absence of longitudinal follow-up precludes conclusions regarding the prospective prediction of suicidal behavior.

Future research should employ longitudinal designs to examine whether impulsivity and emotional dysregulation prospectively predict suicidal behavior in bipolar disorder across different phases of illness. Incorporating detailed illness course variables, neurobiological correlates, and ecological or behavioral measures of impulsivity and emotion regulation may further clarify underlying mechanisms. Additionally, intervention studies evaluating whether targeted treatments addressing impulse control and emotion regulation reduce suicidal behavior in BD would be valuable.

CONCLUSION

The present study demonstrates that remitted patients with bipolar affective disorder who have a history of suicide attempts exhibit a distinct psychological profile characterised by elevated impulsivity and emotional dysregulation, even in the absence of acute mood symptoms. Though aggression and hopelessness were higher among suicide attempters at the univariate level, these factors are not independently associated with suicidal behavior after adjustment for related psychological traits. The findings highlight the importance of moving beyond symptom-based assessments toward identifying enduring psychological vulnerabilities that may facilitate the transition from suicidal ideation to suicidal action. Incorporating assessment and targeted management of impulsivity and emotion regulation difficulties into routine clinical care may therefore enhance long-term suicide prevention strategies in BD.

Declaration of AI use

None was used.

Data availability

Data can be made available upon reasonable request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.