Psychiatry Research 246 (2016) 432–437

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Maladaptive Five Factor Model personality traits associated with Borderline

Personality Disorder indirectly affect susceptibility to suicide ideation
crossmark
through increased anxiety sensitivity cognitive concerns
Raymond P. Tuckera, Greg J. Lengela, Caitlin E. Smitha, Dan W. Capronb,
⁎
Stephanie N. Mullins-Sweatta, LaRicka R. Wingatea,
a
Oklahoma State University, 116 North Murray, Stillwater, OK 74078, USA
b
University of Southern Mississippi, 118 College Drive #5025, Hattiesburg, MS 39406-5025, USA

A R T I C L E I N F O A BS T RAC T

Keywords: The current study investigated the relationship between maladaptive Five-Factor Model (FFM) personality
Anxiety sensitivity traits, anxiety sensitivity cognitive concerns, and suicide ideation in a sample of 131 undergraduate students
Borderline Personality Disorder who were selected based on their scores on a screening questionnaire regarding Borderline Personality Disorder
Suicide (BPD) symptoms. Those who endorsed elevated BPD symptoms in a pre-screen analyses completed at the
Five Factor Model
beginning of each semester were oversampled in comparison to those with low or moderate symptoms. Indirect
effect (mediation) results indicated that the maladaptive personality traits of anxious/uncertainty, dysregulated
anger, self-disturbance, behavioral dysregulation, dissociative tendencies, distrust, manipulativeness, opposi-
tional, and rashness had indirect effects on suicide ideation through anxiety sensitivity cognitive concerns. All of
these personality traits correlated to suicide ideation as well. The maladaptive personality traits of despondence,
affective dysregulation, and fragility were positive correlates of suicide ideation and predicted suicide ideation
when all traits were entered in one linear regression model, but were not indirectly related through anxiety
sensitivity cognitive concerns. The implication for targeting anxiety sensitivity cognitive concerns in evidence-
based practices for reducing suicide risk in those with BPD is discussed.

1. Introduction ideation at a higher frequency and earlier in their lives in comparison

BPD is a significant clinical syndrome characterized by heightened
emotion dysregulation, impulsivity, rocky and unstable interpersonal
relationships, and chronic feelings of emptiness. Suicidal behavior and
suicide ideation are common experiences for those with BPD and are
included as symptoms of the disorder in the Diagnostic and Statistical
Manual of Mental Disorders-5 (DSM-5; APA, 2013). Psychological
autopsy studies have suggested that up to 33% of participants who died
by suicide might have been diagnosed with BPD if they had been
assessed (Kullgren et al., 1986; Runeson and Beskow, 1991). The risk
for attempting suicide is significantly increased in psychiatric inpati-
ents diagnosed with an affective disorder (e.g., major depressive
disorder, schizoaffective disorder, and bipolar disorder) when BPD is
comorbid (Zeng et al., 2015). Prospective studies have also linked
suicide attempts to BPD symptoms and diagnosis (Yen et al., 2004;
Soloff and Chiappetta, 2012). In regards to suicide ideation, research
indicates that adolescents diagnosed with BPD experience suicide
to clinical controls (Venta et al., 2012). Additionally, Zisook et al.
(1994) demonstrated that over one-third of outpatients diagnosed with
BPD indicated experiencing suicide ideation and plans for suicide.
Additionally, those diagnosed with BPD who report a history of
previous self-harm demonstrate increased risk for suicide ideation in-
comparison to those with BPD who have not previously self-harmed
(Turner et al., 2015). One important factor to consider when evaluating
the relationship between suicide and BPD is the fact that “recurrent
suicidal behavior, gestures, or threats, or self-mutilating behavior”
(APA, 2013) is a diagnostic criterion of BPD (Criterion 5). This can lead
to “criterion contamination” when comparing suicidal behavior among
individuals with and without BPD. Therefore, it is important to
examine research which examined the relationship between BPD and
suicidal behavior with Criterion 5 omitted. For instance, Brodsky et al.
(1997) omitted this criterion from all measures, and only included
subjects who met five or more other BPD criteria. After additionally
controlling for lifetime diagnosis of depression and substance abuse,

⁎
Correspondence to: Oklahoma State University, Department of Psychology, 116 North Murray Hall, Stillwater, OK 74078, USA.
E-mail address: laricka.wingate@okstate.edu (L.R. Wingate).

http://dx.doi.org/10.1016/j.psychres.2016.08.051
Received 22 November 2015; Accepted 17 August 2016
Available online 03 September 2016
0165-1781/ © 2016 Elsevier Ireland Ltd. All rights reserved.
R.P. Tucker et al.
the authors found a robust relationship between impulsivity and a
higher number of previous attempts. Furthermore, Yen and colleagues
(2004) also controlled for Criterion 5 and found that affective
instability, identity disturbance, and impulsivity predicted suicidal
behavior, and that affective instability and childhood sexual abuse
were associated with suicide attempts. Accordingly, there is evidence
that BPD is associated with suicide ideation and behavior, even with
Criterion 5 removed. Taken together, this research indicates that
suicide ideation and behavior are prevalent in those suffering from
BPD.
Research regarding BPD has highlighted important personality
traits associated with BPD, including research utilizing the Five
Factor Model (FFM) as a framework. The FFM is a general theory of
personality that has been applied to the understanding of mental health
concerns including suicide risk (DeShong et al., in press). The FFM
posits five broad domains of personality (neuroticism, extraversion,
openness to experience, agreeableness, and conscientiousness; Costa
and McCrae, 1995). Each of the five broad domains are comprised of 6
more exact facets (e.g., the broad domain of extraversion contains the
six facets of warmth, gregariousness, assertiveness, activity level,
excitement-seeking, the experience of positive emotions). The 5
domain, 30 facet structure of the FFM has been well-validated across
multiple measures of these personality constructs (Costa and McCrae,
1995; McCrae and Costa, 1987). Maladaptive, or extreme levels of
specific facets of FFM domains appear to be highly-related to BPD. As
measured by the Five-Factor Borderline Inventory (FFBI; Mullins-
Sweatt et al., 2012), the maladaptive personality traits of anxious
uncertainty, dysregulated anger, dependence, self-disturbance, beha-
vioral dysregulation, affective dysregulation fragility, dissociative ten-
dencies, distrust, manipulativeness, oppositional tendencies, and rash-
ness are particularly relevant to the understanding of BPD (Mullins-
Sweatt et al., 2012). These maladaptive personality traits correspond to
neuroticism facets (anxiety, hostility, depression, self-consciousness,
impulsiveness, and vulnerability to stress), the conscientious facet of
deliberation, agreeableness facets of trust, straightforwardness, and
compliance, and the openness to experience facet of fantasy.
Maladaptive FFM personality traits associated with BPD may
confer risk for suicide ideation via their relationship with anxiety
sensitivity cognitive concerns (ASCC), an important predictor of suicide
ideation. ASCC refers to experiencing fears about the cognitive
consequences of anxiety, such as the inability to control one's thoughts
(e.g., feeling as though thoughts are racing out of control; Capron et al.,
2012c). Conceptual similarities between ASCC and symptoms of BPD
such as emotional and cognitive dysregulation are highly apparent. Not
surprisingly, research has begun to focus on the role that ASCC might
play in BPD. In a study comparing clinical outpatients diagnosed with
BPD to those without, Gratz et al. (2008) reported a large between-
group difference in self-reported ASCC. ASCC has also been correlated
to FFM facets associated with BPD diagnosis, such as anxiousness,
angry hostility, depressiveness, self-consciousness, vulnerability to
stress, and straightforwardness (Cox et al., 1999).
Despite ASCC being linked to suicide ideation and BPD diagnosis,
no research has examined the relationship between ASCC and suicide
ideation in those diagnosed with BPD. This is particularly surprising
given the accumulation of research across multiple samples that
demonstrate the importance of ASCC in the prediction of suicide-
related outcomes. It is also surprising given that ASCC includes
elements of affective instability, a prospective predictor of suicide
ideation in those with BPD (Links et al., 2007). Anxiety sensitivity has
been linked to elevated panic symptoms (McNally, 2002), an important
correlate of suicide ideation and attempts (Katz et al., 2011; Goodwin
and Roy-Byrne, 2006; Yaseen et al., 2013). Additionally, ASCC shares
strong conceptual similarities to the fears of dying, losing control, and
feelings of derealisation which are important predictors of suicide
ideation in those experiencing panic and depression symptoms (Yaseen
et al., 2013; Rappaport et al., 2014). Several studies have found
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Psychiatry Research 246 (2016) 432–437
associations between elevated ASCC and suicide ideation (Capron
et al., 2013a; Schmidt et al., 2001), suicide attempt history (Capron
et al., 2012b), and suicide risk in adult clinical outpatients. Results
from Capron et al. (2012b) also demonstrated that ASCC predicted
suicide ideation intensity above and beyond a diagnosis of Major
Depressive Disorder (MDD). Similarly, in community samples, ASCC
has been shown to predict suicidality (combined endorsement of
experiencing suicide ideation and intentional self-harm) in Air Force
cadets undergoing the stress of basic training (Capron et al., 2012a),
cigarette smokers (Capron et al., 2012b), increased suicide risk
(Oglesby et al., 2015), and suicide ideation in Russian adults (Capron
et al., 2013b). Taken together, this research indicates that the
experience of ASCC may play an important role in the etiology and
maintenance of suicide ideation in a variety of populations and across
differing mental health diagnoses.
The investigation of how ASCC influences suicide ideation in those
suffering from BPD is a logical extension of both the BPD and anxiety
sensitivity literatures. The current study is the first to empirically
investigate the role of maladaptive FFM personality traits associated
with BPD and the experience of anxiety sensitivity and suicide ideation.
We explored the potential relationships between ASCC, suicide idea-
tion, and maladaptive levels of personality traits associated with BPD
in a sample of undergraduate students oversampled for elevated BPD
symptoms. Specifically, it was hypothesized that FFM traits associated
with BPD would have an indirect effect on suicide ideation through
increased ASCC. Increased levels of each maladaptively high FFM facet
would be individually related to higher levels of ASCC and thus, higher
levels of suicide ideation. The propensity to fear the inability to control
thoughts (ASCC) is likely influenced by stable FFM facets that comprise
emotional dysregulation (e.g., vulnerability to stress, impulsivity, and
anxiousness). Thus, it is hypothesized that these personality facets
relate to increased suicide ideation through their relationship to ASCC.
2. Method
2.1. Participants
Participants were 131 students (74.8% female, 25.2% male) from a
large Midwestern state university. Participant ages ranged from 18 to
53, with a mean age of 19.70 years. The majority of participants
(79.0%) self-identified as being Caucasian, 6.6% as bi-racial or multi-
racial, 5.3% as African American, 3.8% as Hispanic or Latino/Latina,
3.1% as American Indian/Alaska Native, 2.3% Asian American, and 1%
as other. Percentages do not total to 100% as participants were allowed
to identify with more than one ethnicity. Due to oversampling recruit-
ment procedures utilized (see Section 2.3 below), the prevalence of
suicide ideation in the current sample was higher in comparison to
research utilizing convenience samples from the university (e.g.,
Tucker and Wingate, 2014). Almost a quarter of participants
(22.10%, N=29) indicated suicide ideation in the two weeks prior to
completing the study and 43.50% of participants (N=57) endorsed five
or more BPD symptoms on a screener measure of BPD symptoms (see
description of McLean Screening Instrument for Borderline Personality
Disorder below (MSI-BPD; Zanarini et al., 2003)).
2.2. Materials and procedure
2.2.1. Demographics questionnaire
Demographic information included questions about ethnicity, age,
and sex.
2.2.2. Anxiety Sensitivity Index 3 - cognitive concerns subscale (ASI-
3; Taylor et al., 2007)
The ASI-3 is an 18 item measure of the physical, cognitive, and
social consequences of anxiety. For the current study, only the
cognitive concerns subscale was administered as ASCC has been
R.P. Tucker et al.
integrated as an important element of theoretical models of the
development of suicide ideation (Norr et al., 2016). Additionally,
research has failed to find a relationship between suicide ideation
and physical and social anxiety sensitivity concerns (Capron et al.,
2012b). The cognitive concerns subscale consists of six items assessing
anxiety regarding the cognitive consequence of anxiety, such as
experiencing difficulty focusing and thinking clearly (e.g., “When my
thoughts seem to speed up, I worry that I might be going crazy”).
Participants are asked to respond on a 5 point likert-type scale ranging
from 1 (very little) to 5 (very much). In the current study, internal
consistency was excellent (α=0.90).
2.2.3. Hopelessness Depression Symptom Questionnaire – Suicidality
Subscale (HDSQ-SS; Metalsky and Joiner, 1997)
The Hopelessness-Depression Symptom Questionnaire Suicidality
Subscale (also referred to as the Depressive Symptom Inventory -
Suicidality Subscale in some research reports) is a 4-item self-report
measure of suicide ideation in the previous two weeks (e.g. “I am not
having thoughts about suicide” to “I am having thoughts about suicide
but have little or no control over these thoughts”). Participants are
asked to respond to questions using a four point Likert-type scale.
Response anchors vary for each question. Higher total score of the
HDSQ-SS indicates higher levels of suicide ideation. In the current
study, internal consistency was excellent (α=0.93).
2.2.4. Five-Factor Borderline Inventory (FFBI; Mullins-Sweatt et al.,
2012)
The FFBI is a 120-item self-report instrument that assesses
maladaptive FFM personality traits associated with BPD (anxious
uncertainty, dysregulated anger, despondence, self-disturbance, beha-
vioral dysregulation, affective dysregulation fragility, dissociative ten-
dencies, distrust, manipulativeness, oppositional tendencies, and rash-
ness). The FFBI includes 12 subscale scores that are correlated with
respective facets of the gold standard self-report measure of the FFM
(Revised NEO Personality Inventory; NEO PI-R; Costa and McCrae,
1992) that are associated with BPD. In particular, the 12 FFBI scales
are taken from the domains neuroticism (anxious uncertainty, dysre-
gulated anger, despondence, self disturbance, behavioral dysregulation,
affective dysregulation, fragility), openness to experience (dissociative
tendencies), agreeableness (distrust, manipulativeness, oppositional),
and conscientiousness (rashness) domains. The FFBI has been shown
to have strong convergent and divergent validity with established
measures of BPD, including the McLean Screening Instrument for
Borderline Personality Disorder (MSI-BPD; Zanarini et al., 2003) and
the borderline subscale of measures such as the Personality Assessment
Inventory (Morey, 1991) and the Schedule for Nonadaptive and
Adaptive Personality (Clark, 1993). Internal consistencies in the
current study ranged from α=0.80 (self-disturbance) to α=0.91 (de-
spondence) in the present sample.
2.2.5. McLean Screening Instrument for Borderline Personality
Disorder (MSI-BPD; Zanarini et al., 2003)
The MSI-BPD is a ten-item screener questionnaire for symptoms of
BPD that correspond to the BPD symptom criteria in the DSM-IV-TR
(APA, 2000). Participants are asked to indicate the presence of each
symptom of BPD using a yes or no response format. Research indicates
that a cut-off score of five demonstrates adequate specificity in the
prediction of BPD diagnosis (Zanarini et al., 2003). The MSI-BPD was
utilized as a screening measure in the current study to assist in
recruiting individuals elevated in maladaptive personality traits asso-
ciated with BPD. The measure was re-administered during data
collection to determine general levels of BPD symptoms in the sample
and demonstrated good reliability (α=0.91).
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Psychiatry Research 246 (2016) 432–437
2.3. Procedure
As the experience of BPD symptoms are likely not normally
distributed across the general college population, oversampling proce-
dures were used through the university's research pool to recruit
participants endorsing elevated levels of BPD symptoms. Specifically,
the MSI-BPD was completed by all participants in the university
research pool via a pre-screen study administered at the beginning of
each semester. All students who were over the age of 18 and endorsed
an MSI-BPD total score of five or above were contacted to participate in
the study. A smaller portion (approximately ten percent) of students
who were 18 and older and scored below a five were recruited for
participation.1 The score outlined above was selected as a conservative
estimate of BPD traits as the DSM-5 (APA, 2013) requires the presence
of five or more symptoms to warrant a BPD diagnosis. Additionally,
research has demonstrated adequate specificity for the use of a cut-off
score of 5 in detecting BPD (Zanarini et al., 2003). Recruited
participants received an email invitation to complete study measures
via an online survey system. Upon clicking on the invitation, partici-
pants first read an informed consent sheet that detailed study
procedures, and clicked a button on their screen to indicate consent
to participate. Following participation, information regarding local and
national counseling resources was provided to all participants. They
were encouraged to utilize these resources if they felt distressed after
completing the study. Subjects received class credit for participating.
This study was approved by Oklahoma State University's Human
Research and Compliance Office.
2.4. Analytical strategy
Descriptive statistics and frequency analyses were conducted in
order to examine the prevalence of maladaptive personality traits
associated with BPD, suicide ideation, and ASCC in the current sample.
As suicide ideation displayed both significant positive skew and
kurtosis (skew=2.59, kurtosis=6.91), a logarithmic transformation
was used to improve the normality of the distribution. Since the
logarithmic transformation significantly improved normality
(skew=1.74, kurtosis=1.50), the transformed variable of suicide idea-
tion was used in all analyses. Bivariate correlations were conducted in
order to examine simple relationships between study variables. As
FFBI subscales were expected to demonstrate collinearity, a linear
regression was conducted to determine what FFBI subscales predict
suicide ideation when considered together. Non-parametric bootstrap-
ping procedures with 5000 bootstrapping samples were conducted
using PROCESS with 95% bias corrected confidence intervals.
PROCESS is a statistical macro used to test indirect effects utilizing a
bootstrapping approach (Hayes, 2013). Indirect effects are interpreted
as meaningful and significant if the confidence interval for the effect
does not bound zero. The procedure utilized in the present study is in
line with the recommendations of Hayes (2013) in testing the hypoth-
esis that personality maladaptive traits associated with BPD would
have an indirect effect on suicide ideation through increased ASCC. In
each indirect effect analysis, the personality trait of interest served as
the predictor variable, ASCC served as the mediator, and suicide
ideation in the past two weeks (HDSQ-SS total score) served as the
outcome variable.
3. Results
Means, standard deviations, and bivariate correlation coefficients of
study variables are presented in Table 1. As hypothesized, ASCC was
1
Data was collected over the course of three semesters. Over 2000 students completed
the MSI-BPD per semester (average across all three semesters equaled 2309). Over the
course of these three semesters, 16.46% (N=380) of these students indicated an MSI-
BPD score of five or more.
R.P. Tucker et al. Psychiatry Research 246 (2016) 432–437

Table 1 Table 2
Means, standard deviations, and correlation coefficients of FFBI traits and total score, Indirect effects of maladaptive personality traits on suicide ideation through ASCC.
ASCC, and suicide ideation.
Indirect Effects Effect SE 95% BC CI Kappa 95% BC CI
M SD ASCC Suicide Ideation Estimate Squared For k2
(k2)
Neuroticism
Anxious/Uncertainty 33.16 10.32 0.44*** 0.33*** Anxious/ 0.0040 0.0014 L=0.0017 0.1376 L=0.0621
Dysregulated Anger 26.27 9.49 0.38*** 0.33*** Uncertainty U=0.0070 U=0.2295
Despondence 28.76 10.25 0.47*** 0.65***
Self-Disturbance 27.60 8.39 0.50*** 0.53*** Dysregulated 0.0038 0.0014 L=0.0016 0.1233 L=0.0544
Behavioral Dysregulation 24.99 7.55 0.44*** 0.45*** Anger U=0.0073 U=0.2176
Affective Dysregulation 25.82 9.77 0.54*** 0.58***
Fragility 24.39 8.63 0.46*** 0.66*** Despondence 0.0018 0.0011 L=−0.0002 0.0762 L=0.0069
U=0.0044 U=0.1705
Openness To Experience
Dissociative Tendencies 26.25 8.35 0.51*** 0.46*** Self-Disturbance 0.0033 0.0017 L=0.0005 0.0983 L=0.0150
U=0.0072 U=0.1997
Agreeableness
Distrust 28.23 8.74 0.33*** 0.48*** Behavioral 0.0044 0.0018 L=0.0013 0.1148 L=0.0372
Manipulativeness 20.45 6.94 0.30*** 0.29** Dysregulation U=0.0086 U=0.2077
Oppositional 22.54 6.56 0.21* 0.18*
Affective 0.0022 0.0015 L=−0.0004 0.0769 L=0.0057
Self-Conscientiousness Dysregulation. U=0.0053 U=0.1784
** *
Rashness 23.49 8.30 0.27 0.28
ASCC 10.44 5.19 – 0.41*** Fragility 0.0021 0.0012 L=0.0000 0.0769 L=0.0088
Suicide Ideation 0.14 0.29 0.41*** – U=0.0050 U=0.1722

FFBI=Five Factor Borderline Inventory; ASCC=Anxiety Sensitivity Cognitive Concerns. Dissociative Tend. 0.0041 0.0019 L=0.0010 0.1158 L=0.0290
* U=0.0083 U=0.2207
p < 0.05.
**
p < 0.01.
*** Distrust 0.0030 0.0013 L=0.0010 0.0992 L=0.0348
p < 0.001.
U=0.0063 U=0.1887

positively correlated to all maladaptive personality traits, ranging from
a small effect, r=0.21, p < 0.05 for oppositional to large effects, r=0.54,
p < 0.001 for affective dysregulation. All maladaptively high facets of
neuroticism (anxious uncertainty, dysregulated anger, despondence,
self disturbance, behavioral dysregulation, affective dysregulation,
fragility) were correlated to ASCC with effect sizes ranging from
medium to large. Dissociative tendencies were strongly associated to
ASCC. Facets of distrust, manipulativeness, oppositional, and rashness
were positively correlated to ASCC with small to moderate effect sizes.
All maladaptive personality traits were positively correlated to
suicide ideation, ranging from a small effect, r=0.18, p < 0.05 for
oppositional to large effects, r=0.66, p < 0.001 for fragility. When
analyzed together in one block of a linear regression analysis, despon-
dence (β=0.31, t(118) =2.18, p=0.031), affective dysregulation
(β=0.47, t(118)=3.50, p=0.001), and fragility (β=0.75, t(118)=5.51,
p < 0.001) remained significant positive predictors of suicide ideation.
3.1. Indirect effect analyses
Bootstrapping analyses indicated that all but three subscales of the
FFBI (despondence, affect dysregulation, and fragility) had indirect
effects on suicide ideation through increased ASCC (see Table 2 for a
summary of these results). Effect size ranged from k2=0.0762 for
despondence to k2=0.1376 for anxious/uncertainty. Preacher and
Kelley (2011) suggest that k2 is a meaningful measure of indirect effect
size that range from 0 to 1. A k2 value indicates the percentage of the
maximum value that an indirect effect accounted for (e.g., an indirect
effect with k2=0.1376 can be interpreted as the indirect effect being
13.76% of the maximum value it could have been).
4. Discussion
The current study investigated the influence of ASCC on suicide
ideation in the context of maladaptive personality traits associated with
BPD and it fills an important gap in the ASCC and BPD literatures. This
study examined the simple relationships between maladaptively high
FFM personality traits associated with BPD (FFBI traits) and ASCC.
This study also hypothesized that these FFBI traits would have indirect
Manipulativeness 0.0045 0.0020 L=0.0015 0.1077 L=0.0378
U=0.0096 U=0.2147
Oppositional 0.0036 0.0018 L=0.0008 0.0829 L=0.0193
U=0.0078 U=0.1696
Rashness 0.0035 0.0015 L=0.0012 0.1000 L=0.0376
U=0.0072 U=0.1919
Dissociative Tend.=Dissociative Tendencies; ASCC=Anxiety Sensitivity Cognitive Con-
cerns; BPD=Borderline Personality Disorder; BC=bias corrected; 5000 bootstrap
samples; L=Lower estimate of confidence interval; U=Upper level of confidence interval.
effects on suicide ideation through increased ASCC.
Correlation analyses indicated that ASCC was positively related to
all 12 maladaptive personality traits associated with BPD symptoms as
measured by the FFBI. All maladaptively high facets of neuroticism
were correlated to ASCC. These correlations were moderate to large in
effect size (Cohen, 1988). The relationship between ASCC and mala-
daptively high neuroticism facets is in line with research linking anxiety
sensitivity to the specific facets of neuroticism - specifically anxiety,
anger/hostility, depressiveness, self-consciousness, and vulnerability
(Cox et al., 1999). Although these maladaptively high neuroticism
facets were closely related to ASCC, the moderate to strong effect sizes
indicate that these constructs are likely distinct, yet highly related
constructs. This suggests that stable maladaptive neuroticism facets
may underlie the fearful response to mental incapacitation as this
response style is likely comprised of multiple elements of neuroticism
(e.g., anxiousness, impulsivity, and vulnerability to stress). Results also
indicated that other maladaptive traits assessed by the FFBI (i.e.,
distrust, manipulativeness, oppositional, and rashness) were positively
correlated with ASCC, but to a lesser degree than all facets of
neuroticism. Taken together, correlation analyses indicate that those
who are elevated in maladaptive personality traits associated with BPD,
especially neuroticism traits, are highly susceptible to experiencing
distress when experiencing mental incapacitation and perceived un-
controllable thoughts.
ASCC may be influenced by maladaptive personality traits and, in
turn, increase the likelihood of experiencing suicide ideation. Indirect
effect analyses indicated that maladaptive personality traits had

435
R.P. Tucker et al.
indirect effects on suicide ideation through increased ASCC except for
the traits of despondence, fragility, and affect dysregulation. It may be
that maladaptively high levels of most maladaptive traits increase the
propensity to react with fears of going crazy or being mentally-ill when
thoughts seem uncontrollable or the mind wanders. This increase in
cognitive reactance (ASCC) may then in turn increase the susceptibility
for suicide ideation as death by suicide may be viewed as relief from the
intense fears of going crazy and losing control. Models that propose
ASCC as an amplifier of suicide ideation have been examined in adults
and adolescents (Capron et al., 2014, 2015, 2016).
Although the majority of maladaptive personality traits were related
to suicide ideation through increased ASCC, this relationship was not
found for the traits of despondence, fragility, and affect dysregulation.
This result is interesting as when all FFBI traits were analyzed together
in their prediction of suicide ideation, only these three traits remained
positive predictors. These FFBI traits were moderately correlated to
ASCC and suicide ideation, but were not related to increased suicide
ideation through increased ASCC. It may be that the relationship
between these maladaptive personality traits and suicide ideation are
mediated by other predictors of suicide in those suffering from BPD,
such as depression symptoms, thwarted belongingness, and perceived
burdensomeness (Rogers and Joiner, 2016; Black et al., 2004).
Additionally, other ASCC like cognitions experienced during panic
attacks, such as catastrophic thoughts of dying may influence this
relationship as the presence of these thoughts are prominent predictors
of suicidality in those suffering from depression (Yaseen et al., 2013). It
is important to note however, that the 95% confidence intervals for
these indirect effect analyses neared significance and the effect sizes for
these models were only slightly lower than significant indirect effect
analyses for other traits. Future research should attempt to better
understand the close relationships between these traits, ASCC, and
suicide ideation to better understand how they collectively influence
suicide risk.
One limitation to the current study is the use of a college sample.
Participants were largely female, Caucasian, in late adolescence, and is
likely of a higher socio-economic status in comparison to the general
population, which inhibits generalizability. Although this study over-
sampled for participants with BPD symptoms in order to increase the
severity of the sample, the use of college students as participants may
have resulted in a less-severe sample than a community or clinical
sample and study results may not generalize to those diagnosed with
BPD. However, given that BPD symptoms onset in young adulthood
(APA, 2013), capturing data regarding personality disorders in college
age participants is important. Although the current study likely
captures data regarding authentic psychopathology via the recruitment
procedure and age of participants, future research should replicate and
extend study findings in clinical samples of adults to corroborate or
disconfirm the generalizability of the current findings. Future research
should also assess psychopathology via the use of a semi-structured
clinical interview as opposed to self-report measures in order to get a
clearer representation of symptomatology.
The current study used a cross-sectional design with a trait-based
measure of ASCC, which limits the interpretation of the temporal
relationship between study variables. Additionally, significant indirect
effects do not prove causality; therefore future studies should utilize
experimental or longitudinal designs to determine temporal prece-
dence. The current study hypothesizes that maladaptive FFM traits
increase risk for suicide ideation through the experience of increased
ASCC. Although it stands to reason that basic, stable personality traits
such as anxiousness, impulsivity, and vulnerability to stress influence
the propensity to respond to mental incapacitation with fear and thus
increase suicide risk, the current study cannot rule out the possibility
that ASCC influences the development of FFM traits associated with
BPD. The use of Ecological Momentary Assessment (EMA) and a state
measure of ASCC may indicate, in-real time, how fears of cognitive
anxiety symptoms influence suicide ideation in individuals suffering
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Psychiatry Research 246 (2016) 432–437
from BPD. EMA is a methodological technique that collects informa-
tion about symptoms and/or behaviors either as they occur or shortly
afterward and can be used virtually anywhere (Moskowitz and Young,
2006). This work would be in-line with research in the BPD literature
utilizing EMA (for a review see Santangelo et al. (2014)) as well as the
recommendation of Davidson et al. (In press) that Suicidologists utilize
EMA designs more actively to better understand suicide risk and
reduce concerns of recall bias. However, it should be noted that anxiety
sensitivity has been shown to be stable over time unless treated (Maller
and Reiss, 1992).
Although the current study has limitations that should be carefully
considered, these results have important clinical implications. The
current study, along with past research, indicates that ASCC may be an
important treatment target for reducing distress in those with BPD
(Gratz et al., 2008). Future research may benefit from determining
whether the explicit targeting of ASCC during the treatment of BPD is
efficacious. Anxiety Sensitivity Amelioration Training (ASAT) or
Cognitive Anxiety Sensitivity Treatment (CAST), which combine psy-
choeducation about anxiety sensitivity and interoceptive exposure
techniques, have been shown to longitudinally reduce anxiety sensitiv-
ity and ASCC (Schmidt et al., 2014, 2007). It may be that incorporating
either of these brief interventions into evidence-based interventions for
BPD would incrementally enhance the treatment of suicidality in those
diagnosed with BPD.
References
American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental
Disorders 4th ed., text rev. Author, Washington, DC.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental
Disorders 5th ed. Author, Washington, DC.
Black, D.W., Blum, N., Pfohl, B., Hale, N., 2004. Suicidal behavior in borderline
personality disorder: prevalence, risk factors, prediction, and prevention. J. Pers.
Disord. 18 (3), 226.
Brodsky, B.S., Malone, K.M., Ellis, S.P., Dulit, R.A., Mann, J.J., 1997. Characteristics of
borderline personality disorder associated with suicidal behavior. Am. J. Psychiatry
154, 1715–1719.
Capron, D.W., Cougle, J.R., Ribeiro, J.D., Joiner, T.E., Schmidt, N.B., 2012a. An
interactive model of anxiety sensitivity relevant to suicide attempt history and future
suicidal ideation. J. Psychiatr. Res. 46 (2), 174–180.
Capron, D.W., Fitch, K., Medley, A., Blagg, C., Mallott, M., Joiner, T., 2012b. Role of
anxiety sensitivity subfactors in suicidal ideation and suicide attempt history.
Depress. Anxiety 29 (3), 195–201.
Capron, D.W., Gonzalez, A., Parent, J., Zvolensky, M.J., Schmidt, N.B., 2012c. Suicidality
and anxiety sensitivity in adults with HIV. AIDS Patient Care ST 26 (5), 298–303.
http://dx.doi.org/10.1089/apc.2011.0429.
Capron, D.W., Norr, A.M., Macatee, R.J., Schmidt, N.B., 2013a. Distress tolerance and
anxiety sensitivity cognitive concerns: testing the incremental contributions of affect
dysregulation constructs on suicidal ideation and suicide attempt. Behav. Ther. 44,
349–358.
Capron, D.W., Kotov, R., Schmidt, N.B., 2013b. A cross-cultural replication of an
interactive model of anxiety sensitivity relevant to suicide. Psychiatr. Res. 205 (1–2),
74–78. http://dx.doi.org/10.1016/j.psychres.2012.08.006.
Capron, D.W., Lamis, D.A., Schmidt, N.B., 2014. Test of the depression distress
amplification model in young adults with elevated risk of current suicidality.
Psychiatry Res. 219, 531–535.
Capron, D.W., Allan, N.P., Ialongo, N.S., Leen-Feldner, E.W., Schmidt, N.B., 2015. The
depression distress amplification model in adolescents: a longitudinal examination
of anxiety sensitivity cognitive concerns, depression and suicidal ideation. J. Adol.
41, 17–24.
Capron, D.W., Bujarski, S.J., Gratz, K.L., Anestis, M.D., Fairholme, C.P., Tull, M.T., 2016.
Suicide risk among male substance users in residential treatment: evaluation of the
depression–distress amplification model. Psychiatry Res. 237, 22–26.
Clark, L.A., 1993. The Schedule for Nonadaptive and Adaptive Personality (SNAP).
University of Minnesota Press, Minneapolis, MN.
Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences, 2nd ed. Lawrence
Earlbaum Associates, Hillsdale, NJ.
Costa, P.T., McCrae, R.R., 1992. NEO PI-R Professional Manual. Psychological
Assessment Resources, Inc, Odessa, FL.
Costa, P.T., McCrae, R.R., 1995. Domains and facets: hierarchical personality assessment
using the revised NEO personality inventory. J. Pers. Assess. 64 (1), 21–50.
Cox, B.J., Borger, S.C., Taylor, S., Fuentes, K., Ross, L.M., 1999. Anxiety sensitivity and
the five-factor model of personality. Behav. Res. Ther. 37 (7), 633–641.
Davidson, C.L., Anestis, M.D., Gutierrez, P.M., 2016. Ecological momentary assessment
is a neglected methodology in suicidology. Arch. Suicide Res., (in press).
DeShong, H.L., Tucker, R.P., Wingate, L.R., O’Keefe, V.M., Mullins-Sweatt, S.N.,, 2016b.
Suicidal ideation and interpersonal suicide risk: The role of personality traits.
R.P. Tucker et al.
Psychiatr. Res., (in press).
Goodwin, R.D., Roy-Byrne, P., 2006. Panic and suicidal ideation and suicide attempts:
results from the national comorbidity survey. Depress. Anxiety 23 (3), 124–132.
Gratz, K.L., Tull, M.T., Gunderson, J.G., 2008. Preliminary data on the relationship
between anxiety sensitivity and borderline personality disorder: the role of
experiential avoidance. J. Psychiatr. Res. 42 (7), 550–559.
Hayes, A.F., 2013. Introduction to Mediation, Moderation, and Conditional Process
Analysis: A Regression-Based Approach. Guilford Press, New York, NY.
Katz, C., Yaseen, Z.S., Mojtabai, R., Cohen, L.J., Galynker, I.I., 2011. Panic as an
independent risk factor for suicide attempt in depressive illness: findings from the
national epidemiological survey on alcohol and related conditions (NESARC). J. Clin.
Psychiatr. 72 (12), 1628–1635.
Kullgren, G., Renberg, E., Jacobsson, L., 1986. An empirical study of borderline
personality disorder and psychiatric suicides. J. Nerv. Ment. Dis. 174 (6), 328–331.
Links, P.S., Eynan, R., Heisel, M.J., Barr, A., Korzekwa, M., McMain, S., Ball, J.S., 2007.
Affective instability and suicidal ideation and behavior in patients with borderline
personality disorder. J. Pers. Disord. 21 (1), 72–86.
Maller, R.G., Reiss, S., 1992. Anxiety sensitivity in 1984 and panic attacks in 1987. J.
Anxiety Disord. 6 (3), 241–247.
Metalsky, G.I., Joiner, T.E., Jr., 1997. The hopelessness depression symptom
questionnaire. Cogn. Ther. Res. 21, 359–384.
McCrae, R.R., Costa, P.T., 1987. Validation of the five-factor model of personality across
instruments and observers. J. Pers. Soc. Psychol. 52 (1), 81–90. http://dx.doi.org/
10.1037/0022-3514.52.1.81.
McNally, R.J., 2002. Anxiety sensitivity and panic disorder. Biol. Psychiatry 52 (10),
938–946.
Morey, L.C., 1991. Personality Assessment Inventory. Routledge, Odessa, FL.
Moskowitz, D.S., Young, S.N., 2006. Ecological momentary assessment: what it is and
why it is a method of the future in clinical psychopharmacology. J. Psychiatr.
Neurosci. 31 (1), 13.
Mullins-Sweatt, S.N., Edmundson, M., Sauer-Zavala, S., Lynam, D.R., Miller, J.D.,
Widiger, T.A., 2012. Five-factor measure of borderline personality traits. J. Pers.
Assess. 94, 475–487.
Norr, A.M., Allan, N.P., Macatee, R.J., Capron, D.W., Schmidt, N.B., 2016. The role of
anxiety sensitivity cognitive concerns in suicidal ideation: A test of the Depression-
Distress Amplification Model in clinical outpatients. Psychiat. Res. 238, 74–80.
Oglesby, M.E., Capron, D.W., Raines, A.M., Schmidt, N.B., 2015. Anxiety sensitivity
cognitive concerns predict suicide risk. Psychiatry Res. 226, 252–256.
Preacher, K.J., Kelley, K., 2011. Effect size measures for mediation models: quantitative
strategies for communicating indirect effects. Psychol. Methods 16, 93–115.
Rappaport, L.M., Moskowitz, D.S., Galynker, I., Yaseen, Z.S., 2014. Panic symptom
clusters differentially predict suicide ideation and attempt. Compr. Psychiatr. 55 (4),
762–769.
Rogers, M.L., Joiner, T.E., Jr, 2016. Borderline personality disorder diagnostic criteria as
risk factors for suicidal behavior through the lens of the interpersonal theory of
suicide. Arch. Suicide Res., 1–14.
Runeson, B., Beskow, J., 1991. Borderline personality disorder in young swedish
suicides. J. Nerv. Ment. Dis. 179 (3), 153–156.
Santangelo, P., Bohus, M., Ebner-Priemer, U., 2014. Ecological momentary assessment
437
Psychiatry Research 246 (2016) 432–437
in borderline personality disorder: a review of recent findings and methodological
challenges. J. Pers. Disord. 28 (4), 555–576. http://dx.doi.org/10.1521/
pedi_2012_26_067.
Schmidt, N.B., Capron, D.W., Raines, A.M., Allan, N.P., 2014. Randomized clinical trial
evaluating the efficacy of a brief intervention targeting anxiety sensitivity cognitive
concerns. J. Consult. Clin. Psychol. 82 (6), 1023–1033.
Schmidt, N.B., Eggleston, A.M., Woolaway-Bickel, K., Fitzpatrick, K.K., Vasey, M.W.,
Richey, J.A., 2007. Anxiety sensitivity amelioration training (ASAT): a longitudinal
primary prevention program targeting cognitive vulnerability. J. Anxiety Disord. 21
(3), 302–319. http://dx.doi.org/10.1016/j.janxdis.2006.06.002.
Schmidt, N.B., Woolaway-Bickel, K., Bates, M., 2001. Evaluating panic-specific factors in
the relationship between suicide and panic disorder. Behav. Res. Ther. 39 (6),
635–649.
Soloff, P.H., Chiappetta, L., 2012. Prospective predictors of suicidal behavior in
borderline personality disorder at 6-year follow-up. Am. J. Psychiatr. 169 (5),
484–490. http://dx.doi.org/10.1176/appi.ajp.2011.11091378.
Taylor, S., Zvolensky, M.J., Cox, B.J., Deacon, B., Heimberg, R.G., Ledley, D.R.,
Cardenas, S.J., 2007. Robust dimensions of anxiety sensitivity: development and
initial validation of the anxiety sensitivity index-3. Psychol. Assess. 19 (2), 176–188.
http://dx.doi.org/10.1037/1040-3590.19.2.176.
Tucker, R.P., Wingate, L.R., 2014. Basic need satisfaction and suicidal ideation: a self-
determination theory perspective on interpersonal suicide risk and suicidal thinking.
Arch. Suicide Res. 18 (3), 282–294.
Turner, B.J., Dixon-Gordon, K.L., Austin, S.B., Rodriguez, M.A., Rosenthal, M.Z.,
Chapman, A.L., 2015. Non-suicidal self-injury with and without borderline
personality disorder: differences in self-injury and diagnostic comorbidity. Psychiatr.
Res. 230 (1), 28–35.
Venta, A., Ross, E., Schatte, D., Sharp, C., 2012. Suicide ideation and attempts among
inpatient adolescents with borderline personality disorder: frequency, intensity and
age of onset. Pers. Ment. Health 6 (4), 340–351. http://dx.doi.org/10.1002/
pmh.1202.
Yaseen, Z.S., Chartrand, H., Mojtabai, R., Bolton, J., Galynker, I.I., 2013. Fear of dying in
panic attacks predicts suicide attempt in comorbid depressive illness: prospective
evidence from the national epidemiological survey on alcohol and related conditions.
Depress. Anxiety 30 (10), 930–939.
Yen, S., Shea, M.T., Sanislow, C.A., Grilo, C.M., Skodol, A.E., Gunderson, J.G., Morey,
L.C., 2004. Borderline personality disorder criteria associated with prospectively
observed suicidal behavior. Am. J. Psychiatr. 161 (7), 1296–1298. http://dx.doi.org/
10.1176/appi.ajp.161.7.1296.
Zeng, R., Cohen, L.J., Tanis, T., Qizilbash, A., Lopatyuk, Y., Yaseen, Z.S., Galynker, I.,
2015. Assessing the contribution of borderline personality disorder and features to
suicide risk in psychiatric inpatients with bipolar disorder, major depression and
schizoaffective disorder. Psychiatr. Res. 226 (1), 361–367.
Zanarini, M.C., Vujanovic, A.A., Parachini, E.A., Boulanger, J.L., Frankenburg, F.R.,
Hennen, J., 2003. A screening measure for BPD: the McLean screening instrument
for borderline personality disorder (MSI-BPD). J. Pers. Disord. 17, 68–573.
Zisook, S., Goff, A., Sledge, P., Shuchter, S.R., 1994. Reported suicidal behavior and
current suicidal ideation in a psychiatric outpatient clinic. Ann. Clin. Psychiatr. 6 (1),
27–31.