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Comprehensive Psychiatry 54 (2013) 321 325

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Antisocial and borderline personality disorders revisited

Joel Paris, Marie-Pierre Chenard-Poirier, Robert Biskin
Institute of Community and Family Psychiatry, Department of Psychiatry, McGill University, Montreal, Canada

Abstract
Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) have an overlap in both symptoms and risk factors,
suggesting that they might reflect the same form of psychopathology, shaped by gender. However other lines of evidence point to the
presence of partly unique, albeit overlapping, trait dimensions, specifically affective instability which differentiates BPD from ASPD. Our
conclusion is that ASPD and BPD are separate disorders.
2013 Elsevier Inc. All rights reserved.

1. Defining disorders
Fifteen years ago, our research group [1] suggested that
ASPD and BPD could have a common base in personality
traits, and that their behavioral differences could be largely
attributable to gender. This review aims to update research
on these relationships, and to reconsider earlier conclusions.
To examine this question, we conducted a literature search.
Using the keyword antisocial personality disorder and
borderline personality disorder, we found 331 articles published
since 1950, but of these, only 31 were relevant to the issue of
differential diagnosis. The selection was augmented by including
papers that examine theoretical issues related to our question.
ASPD has a very large empirical literature. First described
in the early nineteenth century, terms such as psychopathy,
sociopathy, or dyssocial personality have also been used to
describe this clinical picture [2]. While dissocial personality is
the preferred term in the International Classification of
Diseases [3], psychopathy describes a more specific syndrome
emphasizing abnormal personality traits rather than criminal
and irresponsible patterns of behavior [4], and some of these
traits can be identified early in development [5].
In DSM-5 [6], patients must meet overall criteria for a
personality disorder: impairments in self and interpersonal
relationships, associated with pathological personality traits.
DSM-5 requires general overall criteria for a personality
disorder, with a characteristic trait profile marked by
antagonism (manipulativeness, deceitfulness, callousness,
Corresponding author.
E-mail address: joel.paris@mcgill.ca (J. Paris).
0010-440X/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.comppsych.2012.10.006

and hostility) and disinhibition (irresponsibility, impulsivity,

and risk-taking). The requirement in DSM-IV [7] that
conduct disorder beginning before the age of 15 must be
present has been removed, but predisposing traits are
assumed to be stable from childhood to adulthood.
Callousness, the hallmark of psychopathy [5], defined as
the absence of concern or guilt over painful experiences felt
or induced in others, is listed as a modifier in children with
conduct disorder. As before, a diagnosis of ASPD can only
be made in patients aged 18 or over.
BPD, which also has a large empirical literature, is
defined in DSM-5 by a personality trait profile consisting of
negative affectivity (emotional lability, anxiousness, separation insecurity, depressiveness) disinhibition (impulsivity
and risk-taking), and antagonism (hostility). Thus the last
two domains overlap both disorders, while negative
affectivity, particularly affective instability (also called
emotional lability or emotional dyresgulation), is more
unique to BPD. One does not usually see this feature in
ASPD, in which comorbidity for anxiety and depression may
be present, but emotions tend to be shallow [2]. In research,
these symptoms are often understood as reflecting affective
instability [8], also called emotional dysregulation [9], and
have been considered to be a core feature of BPD. Moreover,
antagonism takes a different form in BPD: instead of the
manipulativeness, deceitfulness, and callousness that characterize ASPD, one sees persistent anger in response to
slights. Finally, while disinhibition is common to both
disorders, it also presents differently: ASPD patients take
advantage of others, and are irresponsible, impulsive, and
risk-taking, but BPD patients, due to their interpersonal

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J. Paris et al. / Comprehensive Psychiatry 54 (2013) 321325

difficulties, often find themselves in abusive or violent

relationships, leading to higher rates of victimization [10].
There is no age requirement for BPD, and the definition
gives little weight to cognitive symptoms, chronic depersonalization, subdelusional paranoid trends, and auditory
hallucinations that have been shown to differentiate patients
with BPD from those with other forms of personality
disorder [11]. However, similar phenomena, transient and
stress-related, can be seen in ASPD [2]. In summary, while
there remains an overlap, the trait profiles described in DSM5, particularly the predominance of affective instability in
BPD, point to major differences between these disorders.

2. Epidemiological and clinical surveys

ASPD was the first personality disorder for which
epidemiological surveys measured community prevalence
[12,13]. However, prevalence has ranged greatly in different
studies [1418]. If the higher numbers, approaching 4%, are
correct, then ASPD would be one of the more common
mental disorders. While it presents less often in clinical
settings [19], it may be present as a comorbid diagnosis when
other complaints are prominent. In all studies, ASPD is about
five times as common in men as in women. Most
epidemiological studies of BPD [1014] have found BPD
to be less common than ASPD, with a prevalence of less than
1%, or no higher than 2% [20]. While one study [21] found a
much higher prevalence for BPD (over 6%), this probably
reflects an error in methodology, and re-analysis of the data
using more stringent criteria [20] produced a rate consistent
with other research.
The effects of gender are crucial for whether or not ASPD
and BPD are separate or similar disorders. While clinical
populations of BPD are largely female [10], community
studies, with one exception [17], have found an equal
prevalence of men and women [14]. This surprising finding
could be explained if men with BPD are less help-seeking
than women, and/or if they tend to have more subsyndromal features of the disorder [22]. It is also possible that a
failure to observe gender differences reflects a loose
definition of BPD. There are problems with the polythetic
DSM-IV criteria, in that many different combinations of
symptoms can produce the same diagnosis [23]. For this
reason, some researchers have developed a semi-structured
interview to identify a narrower range of patients with more
severe symptoms and problems in multiple domains [24].
Finally, in clinical samples of men with BPD, comorbidity
between ASPD and BPD is rare [25].
Both ASPD and BPD seem to have increased in
prevalence since the Second World War. There is good
support for cohort effects in ASPD, but the evidence for
increases in BPD is indirect [26], based on increases in
accompanying symptoms (parasuicide, youth suicide, and
substance abuse). Research shows cross-cultural differences
in the prevalence of ASPD: for example, Taiwan [27] and

Japan [28] have low rates, while Korea has a higher

prevalence [29]. Unfortunately, there have been no
systematic cross-cultural studies of that kind on BPD. It
has been hypothesized that this disorder is uncommon in
traditional societies, but is increasing in urban areas around
the world [26,30].

3. Risk factors
Like other mental disorders, ASPD and BPD can be
understood in a biopsychosocial model [31]. Genetic
factors account for approximately 40% of the variance in
both personality dimensions [32] and disorders [33].
Although twin studies have not been conducted on
ASPD, heritability has been established for criminality
[34], and for behavioral patterns and traits related to the
disorder [35]. In BPD, twin studies find that genetic factors
account for nearly half the variance [33]. However, the
nature of the vulnerabilities to both disorders is unknown:
while a relationship between impulsive and affective trait
dimensions with central serotonergic activity has been
suggested in BPD [36], no specific genetic polymorphisms
or biomarkers have been identified.
The psychosocial risk factors for ASPD and BPD clearly
overlap. In ASPD, paternal antisocial features, associated
with family dysfunction and parental inconsistency, are long
established risks [37]. Studies of psychological factors in
BPD strongly implicate parental psychopathology family
dysfunction, and psychological trauma, with similar risks in
males and females [38]. However, since these risk factors are
not specific to any mental disorder, their presence in both
ASPD and BPD cannot determine whether they should be
considered separate.

4. Outcome and treatment

A comprehensive study of ASPD outcome [39] found that
by late middle age, most patients no longer meet criteria, but
that many continue to suffer from severe interpersonal
problems and poor work histories. In general, impulsivity is
a trait that tends to burn out as people grow older [40].
Studies of the long-term outcome of BPD, both retrospective
[41], and prospective [42,43], paint a similar picture. Most
patients are no longer diagnosable by middle age, largely due
to reduced impulsivity, while many achieve stable employment, and about half eventually find a stable partner. While
both disorders have suicide rates ranging from 5% to 10%
[44], the overall prognosis of BPD is somewhat more
favorable, while that of ASPD is largely unfavorable. There
is also evidence for increased mortality in ASPD, associated
with risk-taking behaviors and the possibility of becoming a
victim of homicide [2]. These findings point to an essential
distinction between the two disorders.

J. Paris et al. / Comprehensive Psychiatry 54 (2013) 321325

Treatment results reflect these differences in outcome.

ASPD is difficult to treat [45,46], and there is little evidence
that any existing intervention helps. In contrast, clinical trials
show that specialized forms of psychotherapy are often
effective in BPD [46,47]. These findings, which must reflect
the traits underlying these diagnoses, point to separation
between the disorders.

5. Gender, personality, and psychopathology

How gender shapes personality and psychopathology
helps to explain some of the differences between patients
with ASPD or BPD. The most consistent and pervasive
difference affecting interpersonal behavior is in aggressiveness, so that men tend to be more assertive and dominant,
while women tend to be more focused on attachment [48].
These effects of gender on personality are seen in cultures all
over the world: in the Five-Factor Model, neuroticism,
agreeableness, conscientiousness, and extraversion are all
higher in women, while openness to experience is greater in
men [49]. These differences are likely to be intrinsic, and
they are supported by the strong relationship between
testosterone and aggression [50].
Gender differences are also apparent in the most basic
distinction in psychopathology: the distinction between
externalizing and internalizing symptoms [51]. These broad
spectra are sensitive to gender. In children, boys have a much
higher prevalence of externalizing disorders, such as conduct
disorder and attention deficit disorder, while girls are more
likely to develop internalizing disorders, such as anxiety and
mood disorders [52]. In adults, men have a higher rate of
substance abuse, differences that are robust in societies around
the world [53], while women have a higher rate of depression,
a difference that is cross-culturally consistent [54].
It has been suggested that some gender differences could
be artefactual, related to diagnostic criteria that provide
different weightings for internalizing and externalizing
psychopathology [55,56], but that conclusion seems unlikely
[57]. If gender differences are real for the prevalence of
depression and substance abuse, there is no reason to doubt
that they can be just as real in personality disorders.
Finally, while ASPD (and psychopathy) is uncommon in
females, some researchers have found an overlap between
scales measuring psychopathic and borderline features in
female prisoners and students samples [58,59]. However
these findings are based on self-report data in non-clinical
settings, and may not be generalizable to clinical populations. In BPD, while gender clearly shapes clinical
presentation, antisocial features are uncommon [60,61].

6. Diagnostic boundaries
The ultimate source of confusion in separating BPD and
ASPD lies in the way that DSM-IV criteria, the basis for most

323

current epidemiological studies, were written. Surveys

showing that BPD is common in untreated men suggest
that the current definition is too broad, or that it is not picking
up the severe psychopathology that brings patients to clinical
attention. Moreover, as is the case for so many other
categories in the manual, a diagnosis of BPD that requires
only 5 out of 9 listed criteria inevitably leads to heterogeneity.
It is possible that if more criteria (say 7 out of 9) had been
required, researchers would have observed sharper gender
differences in prevalence. Also, if the most characteristic
symptoms of BPD are specific to gender, a semi-structured
interview requiring symptoms in all domains [24] could make
these differences clearer. Research in clinical samples has
found that comorbidity in men with BPD reflects genderspecific patterns, particularly substance abuse [61]. Future
studies will be based on DSM-5, a system that focuses on
characteristic trait profiles. But while the DSM-5 definition of
BPD does not use the same cutoff points for diagnosis, it does
not escape the problem of heterogeneity.
The deeper problem is that in the absence of biological
markers, it is very difficult to say whether patients, male or
female, suffer from one specific mental disorder, and not
from another. Some of these problems may eventually be
illuminated by research, but we still know too little. For
example, while ASPD has a few established biological
markers, such as reduced prefrontal gray matter and
reduced autonomic activity [62], these features are only
consistent when symptomatology is severe. Biological and
genetic markers are even more inconsistent for BPD, with
little specificity [63,64]. In short, while these disorders
share risk factors, clinical outcome reflects the principle of
multifinality [65].

7. Conclusions
The strength of the research literature on ASPD and BPD
supported the retention of these categories in DSM-5, and
both diagnoses will continue to have an impact on practice.
Applying the DSM-5 view of personality disorders, which
focuses on trait profiles, the differences between these
disorders are rooted in trait dimensions shaped by gender.
For this reason, the influence of gender on symptoms is not
an artefact, but a factor that partly determines specific
psychopathological constellations.
In summary, several lines of evidence suggest that BPD
and ASPD are different disorders associated with unique
trait profiles. We therefore reject our earlier conclusion [1],
that ASPD and BPD are different aspects of the same
underlying psychopathology.
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