European Psychiatry 24 (2009) 464–469

Original article
Impulsivity, personality and bipolar disorder
M. Lewis b, J. Scott a, S. Frangou b,*
a
Section of Psychological Treatments, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
b
Section of Neurobiology of Psychosis, PO66 Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
Received 4 January 2007; received in revised form 15 February 2009; accepted 23 March 2009
Available online 29 September 2009

Abstract
Background: Increased impulsivity is a diagnostic feature of mania in bipolar disorder (BD). However it is unclear whether increased impulsivity
is also a trait feature of BD and therefore present in remission. Trait impulsivity can also be construed as a personality dimension but the
relationship between personality and impulsivity in BD has not been explored. The aim of this study was to examine the relationship of impulsivity
to clinical status and personality characteristics in patients with BD.
Methods: We measured impulsivity using the Barratt Impulsiveness Scale (BIS-11) and personality dimensions using Eysenck Personality
Questionnaire in 106 BD patients and demographically matched healthy volunteers. Clinical symptoms were assessed in all participants using the
Clinical Global Impressions Scale, the Montgomery-Asberg Depression Rating Scale and the Young Mania Rating Scale. Based on their clinical
status patients were divided in remitted (n = 36), subsyndromal (n = 25) and syndromal (n = 45).
Results: There was no difference in BIS-11 and EPQ scores between remitted patients and healthy subjects. Impulsivity, Neuroticism and
Psychoticism scores were increased in subsyndromal and syndromal patients. Within the BD group, total BIS-11 score was predicted mainly by
symptoms severity followed by Psychoticism and Neuroticism scores.
Conclusions: Increased impulsivity may not be a trait feature of BD. Symptom severity is the most significant determinant of impulsivity measures
even in subsyndromal patients.
# 2009 Elsevier Masson SAS. All rights reserved.

Keywords: Impulsivity; Personality; Mood disorders; Depression; Mania

1. Introduction Two recent studies reported that BD patients judged

Impulsivity can be conceptualised as a predisposition
towards rapid, unplanned actions without regard to conse-
quences [20]. As impulsive behaviour is one of the diagnostic
criteria for mania [1] the concept of impulsivity is particularly
relevant to bipolar disorder (BD). It is unclear, however,
whether increased impulsivity occurs in depression as well and
whether it persists as a trait characteristic during periods of
remission.
Studies of patients with unipolar or bipolar depression
suggest that increased impulsivity is strongly related to
symptom severity [5,17]. In addition, tryptophan depletion in
unaffected first degree relatives of BD patients has been
associated both with increased impulsivity but also with
lowering of mood [26].
* Corresponding author. Tel.:/fax: +020-7848-0903.
E-mail address: s.frangou@iop.kcl.ac.uk (S. Frangou).
0924-9338/$ – see front matter # 2009 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.eurpsy.2009.03.004
‘‘euthymic’’ scored similarly to manic patients on the Barratt
Impulsiveness Scale (BIS-11), suggesting that impulsivity is
a trait feature of this disorder [30,31]. However, patients
were described as having ‘‘a wide range of depressive
symptoms’’ which raises doubt about their ‘‘euthymic’’
status.
The present study had two main objectives:
 to revisit the question of impulsivity as a trait characteristic of
BD. To examine this we compared BIS-11 scores between
healthy volunteers and BD patients with variable levels of
psychopathology, ranging from remitted to syndromal.
Furthermore, we explored the relationship of impulsivity
to personality dimensions, which are considered trait
features, using the Eysenck Personality Questionnaire
(EPQ). Psychoticism incorporates the idea of poor impulse
control and we hypothesised that, if impulsivity is indeed a
trait feature of BD, then both the Psychoticism and BIS-11
scores should be higher in remitted patients;
 M. Lewis et al. / European Psychiatry 24 (2009) 464–469
 to examine the effect of manic and depressive symptoms on
the level of impulsivity in BD patients. Our initial hypothesis
was that impulsivity would be increased in patients regardless
of symptom polarity.
2. Method
2.1. Subjects
Patients with bipolar disorder type 1 (BD1) or II (BDII),
aged between 18 and 70 years, were recruited from secondary
care services by advertisement. The diagnosis of BD was
established using the Structured Clinical Interview for Axis 1
DSM-IV disorders [11]. Patients with current substance
dependence or concomitant CNS disorders were excluded.
Comparison subjects were also recruited through advertisement
and were considered for inclusion if they had no personal
history of physical or psychiatric disorders and had never
received treatment for psychological problems. The study was
approved by our local ethics committee. Written informed
consent was obtained from all participants after complete
description of the protocol.
2.2. Assessments
Demographic variables assessed were age, gender and
education. Participants completed the EPQ [7]. This 90-item
questionnaire assesses the orthogonal global personality traits
of Psychoticism (scored 0 to 25), Extraversion (scored 0 to 21)
and Neuroticism/Stability (score 0 to 23). In the EPQ, unlike its
precursors the Maudsley Personality Inventory [6] and the
Eysenck Personality Inventory, items relating to impulsivity are
included in Psychoticism and not Extraversion, which mainly
focuses on sociability [9]. Apart from impulsivity, Psychoti-
cism also incorporates non-conformity and emotional coldness
while the Neuroticism/Stability dimension measures levels of
emotional stability. Those with high scores are seen as
generally nervous and prone to sadness, anxiety and emotional
fluctuations. The EPQ also includes a ‘‘Lies’’ dimension
(scored 0 to 21), which reflects a tendency to dissimulation
(‘‘faking good’’).
Impulsivity was assessed with the BIS-11 based on the
principal-component analysis of the scale by Patton et al. [23].
BIS-11 is a 30-item questionnaire of statements about one’s self
rated on a scale of 1 (rarely/never) to 4 (almost always/always).
It consists of Attentional (rapid shifts in attention/impatience
with complexity), Motor (acting impetuously) and Non-
Planning (absence of weighing up long-term consequences
of actions) subscales.
In all participants, symptomatology was rated on the
Montgomery-Asberg Depression Rating Scale (MADRS) [21]
and the Young Mania Rating Scale (YMRS) [32]. BD patients
were further assessed on:
 clinical history, including length of illness, number and type
of episodes in the preceding year and current medication;
 the Clinical Global Impressions Scale (CGI) [12].
465
BD patients were categorised in three groups based on CGI
scores to reflect current levels of illness (syndromal, subsyn-
dromal and remitted). The ‘‘syndromal’’ group comprised
patients with a CGI score of less than or equal to 3 (‘‘mildly
unwell’’ and above). The ‘‘subsyndromal’’ group included
patients with a CGI score of 2 and YMRS and MADRS scores of
less than 13. Remission was defined as a score of 1 on the CGI and
a score of less than or equal to 9 on the MADRS [33] and less than
or equal to 6 on the YMRS [19].
2.3. Statistical analysis
Comparisons of personality and impulsivity measures
between groups (volunteers, remitted, subsyndromal and
syndromal patients) were performed using analysis of
covariance with total MADRS and YMRS scores are
covariates. Significant results were followed-up with Bonfer-
roni post-hoc comparisons. Pearson’s or Spearman’s correla-
tions were used to examine relationships between variables; the
level of statistical significance was set at p  0.01 to
compensate for multiple testing.
Predictors of impulsivity in the BD sample were investigated
using hierarchical stepwise multiple regression analyses with
the BIS-11 subscales as dependent variables. Each analysis
included four sub-sets of variables (blocks) decided a priori as
follows: block 1 = demographic details (age, gender, educa-
tion); block 2 = clinical history (length of illness, number of
admissions); block 3 = MADRS and YMRS total scores; block
4 = EPQ Neuroticism, Extraversion and Psychoticism scores.
Threshold for entry into the model was set at p  0.01.
Symptom scores were entered before personality measures, as
even low levels of depression are known to affect personality
ratings [4,14,16,18]. Diagnostic tests on the final models
showed the residuals to be normally distributed and homo-
scedastic.
3. Results
3.1. Subjects
A hundred and six BD patients (78 women, 28 men) and 30
healthy volunteers participated in this study. Only 10 patients
had BDII and they were equally distributed across the three
patient subgroups. The mean age  S.D. of the patients and
controls were 50.0  10.0 and 48.6  10.5 years respectively.
Educational levels were high, with 42.5% of patients and 46.7%
of controls having a college or other higher degree. The clinical
characteristics of the BD sample are presented in Table 1.
There were no significant differences between the total
sample of BD patients and controls on age (t134 = 0.68;
p = 0.49), gender (x2 = 0.15; p = 0.43) or education status
(x2 = 0.17; p = 0.42). Similarly, none of the three BD
subgroups differed from each other or from the controls on
any of these demographic variables.
We avoided categorising episodes into depressive, manic or
mixed since most patients present with a mixture of symptoms
[3] and opted for a dimensional approach instead.
466 M. Lewis et al. / European Psychiatry 24 (2009) 464–469

Table 1
Clinical characteristics of the bipolar disorder groups.
Remitted BD cases Sub-syndromal BD cases Syndromal BD cases p Significant pairwise
(n = 36) (n = 25) (n = 45) comparisons *
Current symptoms
MADRS mean (range) 3.0 (0–9) 7.9 (1–13) 19.8 (0–35) < 0.001 s > ss > r
YMRS mean (range) 1.1 (0–6) 3.6 (0–12) 10.6 (0–30) < 0.001 s > ss > r
Clinical history
Previous year
Mean number episodes (range) 0.8 (0–4) 1.3 (0–4) 2.5 (0–10) < 0.001 r, ss < s
Number of cases without episode (%) 24 (67) 7 (28) 3 (6.7) < 0.001 r > ss > s
Lifetime
Illness duration (years): Mean (range) 22.9 (4–50) 25.4 (5–47) 25.7 (4–45) ns
History of psychosis: No. (%) 29 (81) 23 (92) 32 (70) ns
Mean number of admissions (range) 3.6 (0–11) 6.4 (0–23) 4.2 (0–20) ns
BD: bipolar disorder; BIS-11: Barratt Impulsiveness Scale; EPQ: Eysenck Personality Questionnaire; MADRS: Montgomery-Asberg Depression Rating Scale;
YMRS: Young Mania Rating Scale. Letters indicate group: r: remitted BD; ss: subsyndromal BD; s: syndromal BD.
*
All p values < 0.01.

3.2. EPQ personality and BIS-11 impulsivity scores
The mean scores of the remitted, subsyndromal, syndromal
and comparison groups on the EPQ and BIS-11 are given in
Table 2. There were no significant differences in dissimulation
(Lie) or Extraversion scores between controls and any BD sub-
group. Remitted patients did not differ from controls on any EPQ
dimension while Psychoticism and Neuroticism scores increased
incrementally the higher the levels of current symptomatology.
There were no differences in Attentional, Motor, Non-
Planning Impulsivity or BIS-11 total scores between remitted
patients and controls but we observed a significant incremental
increase across all subscale scores between remitted and
symptomatic BD subgroups.
3.3. Correlates of impulsivity in BD
In the total BD sample (n = 106), the BIS-11 total score
correlated positively with Psychoticism (Spearman’s rho = 0.40;
p = <0.001) and Neuroticism (Spearman’s rho = 0.50; p <
0.001) but not Extraversion (Spearman’s rho = –0.15; p = 0.13).
Of the demographic variables, only education appeared relevant
being negatively correlated with the Attentional and Non-
Planning, but not the Motor subscale scores. Of the clinical
variables only current manic and depressive symptom scores
showed (positive) correlations with impulsivity.
3.4. Predictors of impulsivity in BD patients
The results of the regression analyses are shown in Table 3.
Current depressive symptom ratings were the strongest
predictor of impulsivity in the BD sample. MADRS scores
explained around a quarter of the variance in total BIS-11
scores. Psychoticism added between 7 and 10% to the variance
explained in the models predicting Motor, Non-Planning and
BIS-11 total scores but contributed little to Attentional
Impulsivity. Educational attainment, by contrast, contributed
just over 10% to the amount of variance explained for
Attentional, Non-Planning and total BIS-11 scores, but had no
impact on Motor Impulsivity. Neuroticism explained 6% of the
variance in Attentional Impulsivity and 4% in the BIS-11 total
score.

Table 2
Participants’ mean BIS-11 and EPQ scores and standard deviation.
Mean (S.D.) Controls Remitted BD cases Sub-syndromal BD cases Syndromal BD cases F df p Significant pairwise
(n = 30) (n = 36) (n = 25) (n = 45) comparisons *
BIS-11
Attentional 14.5 (2.8) 14.6 (3.1) 17.0 (3.2) 19.2 (3.7) 17.5 135 < 0.001 c, r < s
Motor 22.8 (4.3) 20.2 (3.3) 23.1 (3.2) 25.4 (5.3) 9.5 135 < 0.001 r<s
Non-Planning 23.5 (5.2) 23.9 (4.4) 26.1 (3.4) 28.5 (6.0) 8.0 135 < 0.001 c, r < s
Total 60.8 (10.0) 58.7 (8.2) 66.0 (8.0) 73.0 (12.2) 16.0 135 < 0.001 c, r < s
EPQ
Neuroticism 9.8 (5.3) 13.3 (5.0) 16.2 (4.5) 19.0 (3.1) 28.0 135 < 0.001 c < ss
c, r < s
Extraversion 12.8 (6.0) 11.6 (4.7) 9.7 (4.6) 10.2 (5.4) 2.2 135 0.09
Psychoticism 3.0 (3.4) 3.0 (1.7) 3.3 (2.1) 4.8 (3.4) 3.5 135 0.03 r<s
Lies 8.8 (3.5) 10.3 (3.7) 10.0 (3.9) 9.3 (4.2) 1.0 135 0.39
BD: bipolar disorder; BIS-11: Barratt Impulsiveness Scale; EPQ: Eysenck Personality Questionnaire. Letters indicate group: c: controls; r: remitted BD; ss:
subsyndromal BD; s: syndromal BD.
*
All p values < 0.01.
 M. Lewis et al. / European Psychiatry 24 (2009) 464–469 467

Table 3
Predictors of BIS-11 scores in the bipolar disorder sample (n = 106).
Variables retained in stepwise multiple regression model B r2 p
Attentional impulsivity Education –0.77 0.13 0.001
MADRS 0.12 0.26 0.001
Neuroticism 0.24 0.06 0.001
Psychoticism 0.30 0.04 0.006
total r2 = 0.49 < 0.001
Motor impulsivity MADRS 0.12 0.11 0.01
Psychoticism 0.58 0.10 < 0.001
total r2 = 0.22 < 0.001
Non-Planning impulsivity Education –1.18 0.13 0.001
MADRS 0.18 0.16 < 0.001
Psychoticism 0.52 0.07 0.001
total r2 = 0.36 < 0.001
BIS-11 Total Education –1.80 0.10 0.01
MADRS 0.33 0.24 0.002
Psychoticism 1.39 0.10 < 0.001
Neuroticism 0.60 0.04 0.006
total r2 = 0.48 < 0.001
BIS-11: Barratt Impulsiveness Scale; MADRS: Montgomery-Asberg Depression Rating Scale.

4. Discussion healthy controls was 56.1  8.2 which is again remarkably

4.1. Impulsivity as a trait feature of BD
We found no differences between remitted BD patients and
healthy volunteers in any subscale or in the total BIS-11 score.
Both subsyndromal and syndromal BD groups had higher
impulsivity scores on all BIS-11 subscales compared to
remitted patients and healthy volunteers. This contrasts with
studies by Swann et al. [30,31] where the BIS-11 scores of
‘‘euthymic’’ patients were found to be similar to those of manic
inpatients. The mean subscale and total BIS-11 scores of our
controls and that of Swan et al. [31] are nearly identical
(mean  S.D., BIS-11 total score in Swann et al. = 59.9  9.3;
this study = 60.8  10.0). It is therefore unlikely that our
contrasting results are due to differences in the administration
of the scale but are probably attributable to the clinical features
of the patient samples. Our criteria for remission were a CGI
score of 1 and MADRS and YMRS scores that were equal or
below the mean scores of these scales in studies of healthy
controls [33]. Swann et al. [31] defined ‘‘euthymia’’ as the
absence of an acute mood episode meeting DSM-IV criteria in
the preceding 6 months, a definition that would allow the
inclusion of patients with subsyndromal symptoms. Indeed the
authors report ‘‘a wide range of depressive symptoms’’ in their
sample but give no details. The total BIS-11 score of the
‘‘euthymic’’ patients in the study of Swan et al. was higher
(77.1  13.8) than that obtained in our syndromal group
(73.0  12). This is perhaps a reflection of the different
sampling frame of the two studies; patients in the Swan et al.
study came from specialist clinics that may attract more
complex and co-morbid cases than those found in secondary
care settings such as ours. Peluso et al. [24] also reported
increased BIS-11 scores in ‘‘euthymic’’ BD patients compares
to healthy controls; in their study the mean total score for
similar to the score for healthy participants in the present study.
Their ‘‘euthymic’’ group however has a mean Hamilton
Depression Rating Scale of 8.8, which is above the conven-
tional cut-off for euthymia.
Since even residual mood symptoms are associated with
higher BIS-11 scores we suggest that in studies of impulsivity
in BD wide definitions of remission should be avoided.
Our results also suggest that in BD impulsivity scores are
higher in depression, as well as mania, a finding consistent
with that of Corruble et al. [5] who also found high
impulsivity scores in depression. Impulsivity ratings appeared
to reduce as depressive symptoms remitted with successful
treatment [5].
4.2. EPQ measures and clinical phases in BD
We found no differences between remitted BD patients and
controls in any personality dimension. Apart from Extraver-
sion, which showed no association with clinical status, both
Psychoticism and Neuroticism scores were increased in
subsyndromal and syndromal patients.
Our results regarding Extraversion are consistent with other
studies which also reported no significant differences between
remitted BD patients and controls [2,13,18,25,28] and the
absence of an effect of symptom levels also supports earlier
views that Extraversion may not be significantly affected by
mood [18].
Neuroticism scores were increased in subsyndromal and
syndromal but in remitted patients. In contrast, two studies from
the National Institute of Mental Health (NIMH) collaborative
programme on the psychobiology of depression reported
increased scores in the Neuroticism scale of the Maudsley
Personality Inventory (MPI) between remitted BD patients and
controls [15,28]. In both studies remission was defined by the
468 M. Lewis et al. / European Psychiatry 24 (2009) 464–469
schedule for affective disorders and schizophrenia [29] which
allows for the presence of symptoms below the cut-off of a full
episode. Therefore it is likely that subsyndromal patients were
included and this may explain the higher levels of neuroticism
observed. Since symptoms at the time of the personality
assessments were not quantified in either study, it is not possible
to know. Finally, this is the first study to report on psychoticism
in BD. Psychoticism scores were generally low and although
they tended to increase with higher levels of symptomatology
this did not reach statistical significance.
4.3. Impulsivity, personality and symptoms
Current symptoms were by far the best predictors of
Attentional, Motor and Non-Planning Impulsivity in our BD
sample. MADRS scores explained about 17 to 26% of the
variance. Manic symptoms did not make an independent
contribution over and above that of depressive symptoms.
Scores however were low (mean of 5.9  7.6) and co-varied
with depressive symptoms. Of the EPQ dimensions, Neuroti-
cism and Psychoticism explained between 4 to 6% and 7 to 10%
of the variance respectively.
Psychoticism predicted impulsivity scores across all the
subscales making its largest contribution to motor and BIS-11
total scores indicating that impulsivity, as argued by Eysenck, is
a component of Psychoticism [8].
4.4. Methodological issues
Although the EPQ and the BIS-11 are widely used in
psychiatric research their application in BD may require special
consideration.
Close examination of the EPQ items suggests the possibility
that the experience of repeated and chronic mood symptoms
may influence the way BD patients respond to some of the
questions. We highlight two such questions here to illustrate our
point. In item 84 of the EPQ subjects are asked: ‘‘Are you
sometimes bubbling over with energy and sometimes very
sluggish?’’. Item 68 asks: ‘‘Have you ever wished you were
dead?’’. BD patients may have difficulties separating aspects of
their behaviour can be directly attributed to their illness or are
part of their ‘‘normal’’ personality.
The BIS-11 Attentional Impulsivity scale was designed to
measure rapid shifts in attention and impatience with
complexity, a pattern commonly seen in manic patients
[22,27]. In contrast, depressed patients have problems shifting
attentional focus [22,27]. The observed correlation of Atten-
tional Impulsivity scores with depressive symptoms suggests
that this subscale of the BIS-11 detects general attentional
dysfunction without being informative about its nature.
An obvious drawback of the BIS-11 data is that they are
based on self-report. It is therefore important to examine the
relationship of this scale with objective measures obtained by
formal cognitive testing and we plan to focus on this in future
studies. Finally, the study sample comprised primarily of
female BD patients; although male and female patients in our
study did not differ in any measure of clinical status, personality
trait or impulsivity scores the inclusion of male patients in
further studies will be helpful in ensuring the generalisability of
our findings.
In summary we found that impulsivity may not be a trait
feature of BD but may fluctuate depending on symptoms.
Remitted BD patients did not show abnormalities in any
personality dimension measured by the EPQ whereas
Neuroticism and Psychoticism scores were increased in
syndromal and sub-syndromal patients. Therefore the clinical
status of patients needs to be clearly and rigorously defined in
all future studies in this field. We are currently engaged in a
longitudinal follow-up of these patients that will allow us to
describe better the relationship between impulsivity, person-
ality and changes in symptom severity or polarity.
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