Antisocial Personality Disorder + Borderline Personality Disorder - DSM-5

Diagnostic Criteria [ASPD]

A) pervasive pattern of disregard for + violation of others’ rights since age 15, shown by 3+ symptoms:

1. failing to conform to legal social norms, shown by repeated acts that’re grounds for arrest

2. deceitfulness, indicated by repeated lying, use of aliases, or conning others for personal gain / pleasure

3. impulsivity / failure to plan ahead

4. irritability + aggressiveness, shown by repeated physical fights / assaults

5. reckless disregard for safety of self / others

6. consistent irresponsibility, shown by repeated failure to sustain consistent work behaviour / honour financial obligations

7. lack of remorse, indicated by indifference or rationalisation of having hurt, mistreated, or stolen from another

B) individual is 18+

C) evidence of conduct disorder w/ onset before 15

D) antisocial behaviour doesn’t happen exclusively during course of schizophrenia or bipolar disorder

Diagnostic Features [ASPD]

• behaviours characteristic of conduct disorder fall in 4 categories: aggression to people + animals, destruction of property, deceitfulness / theft, serious violation of rules

• aggressive acts to defend self / others don’t count for a4

Associated Features [ASPD]

• may have inflated / arrogant self-evaluation

• lack of empathy, inflated self-eval, + superficial charm are frequently predictive of reoffense in prison / forensic settings

• more likely to die prematurely from natural causes + suicide than general population

Prevalence [ASPD]

• median prev. of 3.6%

• highest prev. (70+%) found in men w/ most severe alcohol use disorders in forensic settings

• prev. may be higher in samples affected by adverse socioeconomic + sociocultural factors

Development + Course [ASPD]

• has chronic course but may become less obvious or remit as a person ages, often by 40

  • tends to be most evident wrt criminal behaviour, but likely decrease in full spectrum of antisocial behaviour

Risk Factors [ASPD]

• environmental: child abuse / neglect, unstable / erratic parenting, inconsistent parental discipline increases likelihood of conduct disorder developing into ASPD

• genetic: more common in first-degree relatives of people w/ ASPD. those relatives also have increased risk for somatic symptom disorder + substance use disorder 

  • substance use disorder + ASPD more common in male relatives; somatic symptom disorder more common in female relatives

Sex + Gender-Related Diagnostic Issues [ASPD]

• 3x more common in men than women

• women w/ ASPD more likely to have experienced childhood + adult adverse experiences (eg: sexual abuse)

• variations in clinical presentation: men more often irritable / aggressive + show reckless disregard for safety of others

• men more often have comorbid substance use disorder; women more often have comorbid mood / anxiety disorders

• may be underdiagnosed in woman due to the emphasis on aggressive items in the definition of conduct disorder

Differential Diagnoses [ASPD]

note: not given to people under 18 + requires evidence of conduct disorder before 15; people 18+ are only diagnosed w/ conduct disorder if ASPD criteria aren’t met

• substance use disorders

• schizophrenia + bipolar disorders

• other personality disorders

• criminal behaviour not associated w/ a mental disorder

Differential Diagnosis: Substance Use Disorders [ASPD]

if antisocial behaviour is associated w/ substance use, ASPD shouldn’t be diagnosed unless signs of antisocial personality were alsopresent in childhood + continued into adulthood. if substance use + antisocial behaviour both started in childhood + continued into adulthood, both disorders should be diagnosed if criteria are met, even tho some antisocial acts may be the consequence of substance use disorder

Differential Diagnosis: Schizophrenia + Bipolar Disorders [ASPD]

antisocial behaviour that only happens during the course of schizophrenia or bipolar disorder shouldn’t be diagnosed as ASPD

Differential Diagnosis: Other Personality Disorders [ASPD]

may have overlap in some features — important to distinguish personality disorders by differences in characteristic features. if a patient has perosnality features meeting criteria for 1+ personality disorders in addition to ASPD, all can be diagnosed

• narcissistic personality disorder: share tendency to be tough-minded, glib, superficial, exploitative, + lack empathy. NPD doesn’t include impulsivity, aggression, deceit, or tend to have a background of conduct disorder as a kid or criminal behaviour as an adult. ASPD may not be as a needy of admiration + envy of others

• histrionic personality disorder: share impulsivity, superficiality, excitement-seeking, recklessness, seductivity, + manipulation, but HPD tends to involve more exaggeration in emotions + doesn’t tend to engage in antisocial behaviours. HPD manipulation is usually to gain nurturance, vs ASPD manipulation for power or material gain

• borderline personality disorder: overlap in manipulation, but BPD manipulation is usually to gain nurturance, vs ASPD manipulation for power or material gain. ASPD also tends to be less emotionally unstable + more aggressive than BPD

• paranoid personality disorder: antisocial behaviour may be present in PPD but isn’t usually motivated by desire for personal gain or to exploit others. usually out of desire for revenge

Differential Diagnosis: Criminal Behaviour Not Associated W/ a Mental Disorder [ASPD]

antisocial behaviour can happen outside of any disorder. criminal behaviour undertaken for gain but not accompanied by personality traits characteristic of a disorder (including ASPD) can be coded as “adult antisocial behaviour”

Comorbidity [ASPD]

• may experience: dysphoria, tension, inability to tolerate boredom, depressed mood

• associated w/ anxiety disorders, mood disorders, substance use disorders, somatic symptom disorder, gambling disorder

• often meet criteria for other personality disorders (esp. BPD, HPD, + NPD)

• likelihood of development increases if onset of conduct disorder is before 10, w/ comorbid ADHD

Diagnostic Criteria [BPD]

pervasive pattent of instability in interpersonal relationships, self-image, + affects, + marked impulsivity beginning by early adulthood + present in a variety of contexts, indicated by 5+ symptoms:

1. frantic efforts to avoid real / imagined abandonment (not including behaviour from criterion 5)

2. pattern of unstable + intense interpersonal relationships w/ alternating extremes of idealisation / devaluation

3. identity disturbance: marked + persistent unstable self-image / sense of self

4. impulsivity in 2+ areas that could be self-damaging (eg: substance abuse, reckless driving, binge-eating, spending, sex — NOT including behaviour from criterion 5)

5. recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

6. emotional instability due to mood reactivity (ie: intense episodic moods usually lasting a few hours + rarely more than a few days)

7. chronic feelings of emptiness

8. inappropriate, intense anger or difficulty controlling anger

9. transient, stress-related paranoid ideation or severe dissociative symptoms

Associated Features [BPD]

• pattern of sabotaging self just before goal is acheived

• psychotic-like symptoms during periods of stress in some people

• feeling more security w/ transitional objects than in relationships

• suicide may happen, especially if comorbid depressive or substance use disorders are present

• deaths from other causes (eg: accidents, illness) are more than 2x as common as suicide deaths

• common pattern of job loss, interrupted education, separation / divorce

• physical + sexual abuse, neglect, parental loss, + hostile conflict all more common in childhood histories

Prevalence [BPD]

• est. between 1.4 - 2.7%

• 6% in primary care settings, 10% in outpatient mental health clinics, + 20% in inpatient

Development + Course [BPD]

• usually thought of as adult-onset disorder, but adolescents age 12 - 13 can meet full criteria

  • not yet known what percent of adults entering treatment had early onset

• frequently thought of as poor symptomatic course that tends to improve somewhat in 30s + 40s, but more recent studies found stable remissions of 1 - 8 yrs to be v. common

• impulsive symptoms remit fastest; affective symptoms much slower

• recovery from BPD (ie: simultaneous symptomatic remission + good psychosocial functioning) is harder + less stable over time

• lack of recovery assoc. w/ supporting self on disability benefits + poor physical health

Risk Factors [BPD]

• environmental: assoc. w/ high rates of childhood abuse + neglect. sexual abuse rates are higher in inpatient than outpatient, suggesting that history of sexual abuse is a risk factor for the severity of BPD as well as for development. however, childhood sexual abuse isn’t necessary or sufficient on its own for development of BPD

• genetic: 5x more common in first-degree relatives. those relatives also have increased risk for substance use disorders, anxiety disorders, depressive + bipolar disorders, + ASPD

Sex + Gender-Related Diagnostic Issues [BPD]

• more common in women than men in clinical settings, but community samples show no difference in prev.

  • women may seek help at higher rates

• clinical presentation seems similar — men may show more externalising symptoms while women show more internalising symptoms

Association w/ Suicidality [BPD]

• impulsive + antisocial behaviours associated w/ higher suicide risk

• longitudinal study of personality disorders over 24 years: 6% of BPD pts died by suicide, vs 1.4% of other PD patients

• recurrent suicidal behaviour is a defining characteristic, but attempts tend to decline over time

Differential Diagnoses [BPD]

• depressive + bipolar disorders

• separation anxiety disorder

• other personality disorders

• personality change due to another medical condition

• substance use disorder

• identity problems

Differential Diagnosis: Depressive + Bipolar Disorders [BPD]

often comorbid, so both should be diagnosed if criteria for both are met — but depressive + bipolar episodes can look like the cross-sectional presentation of BPD, so an additional diagnosis of BPD should be avoided until establishing that pattern of behaviour had early onset + longstanding course

Differential Diagnosis: Separation Anxiety Disorder [BPD]

overlap in fear of abandoment by loved ones, but BPD has additional issues surrounding identity, self-direction, interpersonal functioning, + impulsivity

Differential Diagnosis: Other Personality Disorders [BPD]

may have overlap in some features — important to distinguish personality disorders by differences in characteristic features. if a patient has personality features meeting criteria for 1+ personality disorders in addition to BPD, all can be diagnosed

• histrionic personality disorder: overlap in attention-seeking, manipulative behaviour, + rapidly shifting emotions. BPD differentiated by self-destructiveness, angry disruptions in close relationships, + chronic feelings of deep emptiness + loneliness

• schizotypal personality disorder: may overlap in paranoid ideas + illusions. in BPD they’ll be more brief, interpersonally reactive, + responsive to external structuring

• narcissistic personality disorder + paranoid personality disorder: overlap in angry reactions to minor stimuli. NPD + PPD will have relatively stable self-image + relative lack of physical self-destructiveness, repetitive impulsivity, + intense abandonment concerns

• antisocial personality disorder: both characterised by manipulative behaviour. BPD manipulation seeks care + comfort from caretakers while ASPD manipulation seeks material gains / power

• dependent personality disorder: both characterised by fear of abandonment. BPD reacts w/ feelings of emotional emptiness, rage, + demands; DPD reacts w/ appeasement + submissiveness, + seeks replacement realtionship to provide care + support. DPD tends to lack pattern of unstable + intense relationships

Differential Diagnosis: Personality Change Due to Another Medical Condition [BPD]

emerging traits will be the direct physiological consequence of another medical condition

Differential Diagnosis: Substance Use Disorder [BPD]

must be distinguished from symptoms that develop in assoc. w/ persistent substance use

Differential Diagnosis: Identity Problems [BPD]

should be distinguished from identity problems, which is identity concern related to a developmental phase + doesn’t qualify as a mental disorder. adolescents + young adults w/ identity problems (esp. when combined with substance use) may appear to have BPD — situations characterised by emotional instability, existential dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, + competing social pressures

Comorbidity [BPD]

• depressive + bipolar disorders

• substance use disorders

• anxiety disorders (esp. panic disorder + social anxiety disorder)

• eating disorders (esp. bulimia + binge-eating disorder)

• PTSD

• ADHD

• other personality disorders

Psychotherapy Treatments [BPD]

• DBT: gold-standard. emotion regulation, distress tolerance, interpersonal effectiveness, mindfulness

• mentalisation-based therapy (MBT): improved understanding of own + others’ mental states

• transference-focused psychotherapy (TFP): psychodynamic. identity integration, uses therapist-patient relationship

• schema therapy (ST): targets maladaptive schemas; integration of CBT + attachment / emotion work

• general psychiatric management (GPM): psychoeducation, case management, crisis planning; effective + widely used

Psychopharmacology Treatments [BPD]

• adjunctive only

• mood stabilisers: target impulsivity, anger, mood instability

• SSRIs / SNRIs: target comorbid depression / anxiety, not core BPD symptoms

• atypical antipsychotics: target affective instability, cognitive-perceptual symptoms, severe impulsivity

• benzos are typically avoided due to potential disinhibition, dependence, worsening impulsivity

Interventions + Programs [BPD]

• DBT-based partial hospitalisation programs (PHPs): structured intensive treatment, decrease self-harm + crises

• DBT intensive outpatient programs (IOPs): skills-focused, strong evidence that decreases suicidal behaviours

• crisis + safety interventions: safety planning interventions (SPI), chain analysis, lethal means reduction

• short-term hospitalisation: only for acute suicidality / severe self-harm; longer stays are usually unhelpful

• emerging interventions (early research): rTMS, ketamine for comorbid treatment-resistant depression, MDMA-assisted therapy (experimental)