ershentment

ity diogy,ifica

and irresponsible patterns of behavior [4], and some of these be present, but emotions tend to be shallow [2]. In research,

Available online at www.sciencedirect.com

Comprehensive Psychiatry 54 (2traits can be identified early in development [5].In DSM-5 [6], patients must meet overall criteria for a

personality disorder: impairments in self and interpersonalrelationships, associated with pathological personality traits.DSM-5 requires general overall criteria for a personality

these symptoms are often understood as reflecting affectiveinstability [8], also called emotional dysregulation [9], andhave been considered to be a core feature of BPD. Moreover,antagonism takes a different form in BPD: instead of themanipulativeness, deceitfulness, and callousness that char-since 1950, but of these, only 31 were relevant to the issue ofdifferential diagnosis. The selectionwas augmented by includingpapers that examine theoretical issues related to our question.

ASPD has a very large empirical literature. First describedin the early nineteenth century, terms such as psychopathy,sociopathy, or dyssocial personality have also been used todescribe this clinical picture [2]. While dissocial personality isthe preferred term in the International Classification ofDiseases [3], psychopathy describes a more specific syndromeemphasizing abnormal personality traits rather than criminal

BPD, which also has a large empirical literature, isdefined in DSM-5 by a personality trait profile consisting ofnegative affectivity (emotional lability, anxiousness, sepa-ration insecurity, depressiveness) disinhibition (impulsivityand risk-taking), and antagonism (hostility). Thus the lasttwo domains overlap both disorders, while negativeaffectivity, particularly affective instability (also calledemotional lability or emotional dyresgulation), is moreunique to BPD. One does not usually see this feature inASPD, in which comorbidity for anxiety and depression mayAntisocial and borderline pJoel Paris, Marie-Pierre C

Institute of Community and Family Psychiatry, Depar

Abstract

Antisocial personality disorder (ASPD) and borderline personalsuggesting that they might reflect the same form of psychopatholpresence of partly unique, albeit overlapping, trait dimensions, specconclusion 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 thatASPD and BPD could have a common base in personalitytraits, and that their behavioral differences could be largelyattributable to gender. This review aims to update researchon these relationships, and to reconsider earlier conclusions.

To examine this question, we conducted a literature search.Using the keyword antisocial personality disorder andborderline personality disorder, we found331 articles publisheddisorder, with a characteristic trait profile marked byantagonism (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.2012.10.006onality disorders revisitedard-Poirier, Robert Biskinof Psychiatry, McGill University, Montreal, Canada

sorder (BPD) have an overlap in both symptoms and risk factors,shaped by gender. However other lines of evidence point to thelly affective instability which differentiates BPD from ASPD. Our

and hostility) and disinhibition (irresponsibility, impulsivity,and risk-taking). The requirement in DSM-IV [7] thatconduct disorder beginning before the age of 15 must bepresent has been removed, but predisposing traits areassumed to be stable from childhood to adulthood.Callousness, the hallmark of psychopathy [5], defined asthe absence of concern or guilt over painful experiences feltor induced in others, is listed as a modifier in children withconduct disorder. As before, a diagnosis of ASPD can onlybe made in patients aged 18 or over.

013) 321325www.elsevier.com/locate/comppsychacterize ASPD, one sees persistent anger in response toslights. Finally, while disinhibition is common to bothdisorders, it also presents differently: ASPD patients takeadvantage of others, and are irresponsible, impulsive, andrisk-taking, but BPD patients, due to their interpersonal

DSM-IV criteria, in that many different combinations of

account for nearly half the variance [33]. However, thenature of the vulnerabilities to both disorders is unknown:

to reduced impulsivity, while many achieve stable employ-ment, and about half eventually find a stable partner. While

322 J. Paris et al. / Comprehensive Psychiatry 54 (2013) 321325symptoms can produce the same diagnosis [23]. For thisreason, some researchers have developed a semi-structuredinterview to identify a narrower range of patients with moresevere symptoms and problems in multiple domains [24].Finally, in clinical samples of men with BPD, comorbiditybetween ASPD and BPD is rare [25].

Both ASPD and BPD seem to have increased inprevalence since the Second World War. There is goodsupport for cohort effects in ASPD, but the evidence forincreases in BPD is indirect [26], based on increases inaccompanying symptoms (parasuicide, youth suicide, andsubstance abuse). Research shows cross-cultural differencesin the prevalence of ASPD: for example, Taiwan [27] anddifficulties, often find themselves in abusive or violentrelationships, leading to higher rates of victimization [10].There is no age requirement for BPD, and the definitiongives little weight to cognitive symptoms, chronic deper-sonalization, subdelusional paranoid trends, and auditoryhallucinations that have been shown to differentiate patientswith BPD from those with other forms of personalitydisorder [11]. However, similar phenomena, transient andstress-related, can be seen in ASPD [2]. In summary, whilethere remains an overlap, the trait profiles described in DSM-5, particularly the predominance of affective instability inBPD, point to major differences between these disorders.

2. Epidemiological and clinical surveys

ASPD was the first personality disorder for whichepidemiological surveys measured community prevalence[12,13]. However, prevalence has ranged greatly in differentstudies [1418]. If the higher numbers, approaching 4%, arecorrect, then ASPD would be one of the more commonmental disorders. While it presents less often in clinicalsettings [19], it may be present as a comorbid diagnosis whenother complaints are prominent. In all studies, ASPD is aboutfive times as common in men as in women. Mostepidemiological studies of BPD [1014] have found BPDto be less common than ASPD, with a prevalence of less than1%, or no higher than 2% [20]. While one study [21] found amuch higher prevalence for BPD (over 6%), this probablyreflects an error in methodology, and re-analysis of the datausing more stringent criteria [20] produced a rate consistentwith other research.

The effects of gender are crucial for whether or not ASPDand BPD are separate or similar disorders. While clinicalpopulations of BPD are largely female [10], communitystudies, with one exception [17], have found an equalprevalence of men and women [14]. This surprising findingcould be explained if men with BPD are less help-seekingthan women, and/or if they tend to have more subsyn-dromal features of the disorder [22]. It is also possible that afailure to observe gender differences reflects a loosedefinition of BPD. There are problems with the polytheticboth disorders have suicide rates ranging from 5% to 10%[44], the overall prognosis of BPD is somewhat morefavorable, while that of ASPD is largely unfavorable. Thereis also evidence for increased mortality in ASPD, associatedwith risk-taking behaviors and the possibility of becoming avictim of homicide [2]. These findings point to an essentialdistinction between the two disorders.while a relationship between impulsive and affective traitdimensions with central serotonergic activity has beensuggested in BPD [36], no specific genetic polymorphismsor biomarkers have been identified.

The psychosocial risk factors for ASPD and BPD clearlyoverlap. In ASPD, paternal antisocial features, associatedwith family dysfunction and parental inconsistency, are longestablished risks [37]. Studies of psychological factors inBPD strongly implicate parental psychopathology familydysfunction, and psychological trauma, with similar risks inmales and females [38]. However, since these risk factors arenot specific to any mental disorder, their presence in bothASPD and BPD cannot determine whether they should beconsidered separate.

4. Outcome and treatment

A comprehensive study of ASPD outcome [39] found thatby late middle age, most patients no longer meet criteria, butthat many continue to suffer from severe interpersonalproblems and poor work histories. In general, impulsivity isa 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. Mostpatients are no longer diagnosable by middle age, largely dueJapan [28] have low rates, while Korea has a higherprevalence [29]. Unfortunately, there have been nosystematic cross-cultural studies of that kind on BPD. Ithas been hypothesized that this disorder is uncommon intraditional societies, but is increasing in urban areas aroundthe world [26,30].

3. Risk factors

Like other mental disorders, ASPD and BPD can beunderstood in a biopsychosocial model [31]. Geneticfactors account for approximately 40% of the variance inboth personality dimensions [32] and disorders [33].Although twin studies have not been conducted onASPD, heritability has been established for criminality[34], and for behavioral patterns and traits related to thedisorder [35]. In BPD, twin studies find that genetic factors

effective in BPD [46,47]. These findings, which must reflect

settings, and may not be generalizable to clinical popula-

attention. Moreover, as is the case for so many other

from another. Some of these problems may eventually be

323J. Paris et al. / Comprehensive Psychiatry 54 (2013) 321325tions. In BPD, while gender clearly shapes clinicalpresentation, antisocial features are uncommon [60,61].

6. Diagnostic boundaries

The ultimate source of confusion in separating BPD andASPD lies in the way that DSM-IV criteria, the basis for mostthe traits underlying these diagnoses, point to separationbetween the disorders.

5. Gender, personality, and psychopathology

How gender shapes personality and psychopathologyhelps to explain some of the differences between patientswith ASPD or BPD. The most consistent and pervasivedifference affecting interpersonal behavior is in aggressive-ness, 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 allover the world: in the Five-Factor Model, neuroticism,agreeableness, conscientiousness, and extraversion are allhigher in women, while openness to experience is greater inmen [49]. These differences are likely to be intrinsic, andthey are supported by the strong relationship betweentestosterone and aggression [50].

Gender differences are also apparent in the most basicdistinction in psychopathology: the distinction betweenexternalizing and internalizing symptoms [51]. These broadspectra are sensitive to gender. In children, boys have a muchhigher prevalence of externalizing disorders, such as conductdisorder and attention deficit disorder, while girls are morelikely to develop internalizing disorders, such as anxiety andmood disorders [52]. In adults, men have a higher rate ofsubstance abuse, differences that are robust in societies aroundthe 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 couldbe artefactual, related to diagnostic criteria that providedifferent weightings for internalizing and externalizingpsychopathology [55,56], but that conclusion seems unlikely[57]. If gender differences are real for the prevalence ofdepression and substance abuse, there is no reason to doubtthat they can be just as real in personality disorders.

Finally, while ASPD (and psychopathy) is uncommon infemales, some researchers have found an overlap betweenscales measuring psychopathic and borderline features infemale prisoners and students samples [58,59]. Howeverthese findings are based on self-report data in non-clinicalTreatment results reflect these differences in outcome.ASPD is difficult to treat [45,46], and there is little evidencethat any existing intervention helps. In contrast, clinical trialsshow that specialized forms of psychotherapy are oftenilluminated by research, but we still know too little. Forexample, while ASPD has a few established biologicalmarkers, such as reduced prefrontal gray matter andreduced autonomic activity [62], these features are onlyconsistent when symptomatology is severe. Biological andgenetic markers are even more inconsistent for BPD, withlittle specificity [63,64]. In short, while these disordersshare risk factors, clinical outcome reflects the principle ofmultifinality [65].

7. Conclusions

The strength of the research literature on ASPD and BPDsupported the retention of these categories in DSM-5, andboth diagnoses will continue to have an impact on practice.Applying the DSM-5 view of personality disorders, whichfocuses on trait profiles, the differences between thesedisorders are rooted in trait dimensions shaped by gender.For this reason, the influence of gender on symptoms is notan artefact, but a factor that partly determines specificpsychopathological constellations.

In summary, several lines of evidence suggest that BPDand ASPD are different disorders associated with uniquetrait profiles. We therefore reject our earlier conclusion [1],that ASPD and BPD are different aspects of the sameunderlying psychopathology.

References

[1] Paris J. Antisocial and borderline personality disorders: two separatediagnoses or two aspects of the same psychopathology? ComprPsychiatry 1997;38:237-42.categories in the manual, a diagnosis of BPD that requiresonly 5 out of 9 listed criteria inevitably leads to heterogeneity.It is possible that if more criteria (say 7 out of 9) had beenrequired, researchers would have observed sharper genderdifferences in prevalence. Also, if the most characteristicsymptoms of BPD are specific to gender, a semi-structuredinterview requiring symptoms in all domains [24] couldmakethese differences clearer. Research in clinical samples hasfound that comorbidity in men with BPD reflects gender-specific patterns, particularly substance abuse [61]. Futurestudies will be based on DSM-5, a system that focuses oncharacteristic trait profiles. But while the DSM-5 definition ofBPD does not use the same cutoff points for diagnosis, it doesnot escape the problem of heterogeneity.

The deeper problem is that in the absence of biologicalmarkers, it is very difficult to say whether patients, male orfemale, suffer from one specific mental disorder, and notcurrent epidemiological studies, were written. Surveysshowing that BPD is common in untreated men suggestthat the current definition is too broad, or that it is not pickingup the severe psychopathology that brings patients to clinical

324 J. Paris et al. / Comprehensive Psychiatry 54 (2013) 3213252008;31:405-20.[20] Trull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ. Revised NESARC

personality disorder diagnoses: gender, prevalence, and comorbiditywith substance dependence disorders. J Personal Disord 2010;24:412-26.

[21] Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, etal. Prevalence, correlates, disability, and comorbidity of DSM-IVborderline personality disorder. J Clin Psychiatry 2008;65:948-58.

[22] Zanarini MC, Frankenburg FR, Reich DB, Silk KR, Hudson JI,McSweeney LB. The subsyndromal phenomenology of borderlinepersonality disorder: a 10-year follow-up study. Am J Psychiatry2007;164:929-35.

[23] Skodol AE, Clark LA, Bender DS, Krueger RF, Morey LC, Verheul R,et al. Proposed changes in personality and personality disorderassessment and diagnosis for DSM-5 part I: description and rationale.Personal Disord Theory Res Treat 2011;2:4-22.

[24] Zanarini MC, Gunderson JG, Frankenburg FR. The revised diagnosticinterview for borderlines: discriminating BPD from other axis IIdisorders. J Personal Disord 1989;3:10-8.

[25] Paris J, Zweig-Frank H, Guzder J. Risk factors for borderlinepersonality in male outpatients. J Nerv Ment Dis 1994;182:375-80.

[26] Paris, J, Lis, E (in press): Can sociocultural and historical mechanismsinfluence the development of borderline personality disorder?Transcult Psychiatry.disorders in clinical settings. Psychiatr Clin North Am[2] Lykken DT. The antisocial personalities. Berkley, CA: PsychologyPress; 1995.

[3] World Health Organization. International classification of diseases,10th edition: mental disorders. Geneva: WHO; 1993.

[4] Hare RD, Hart SD, Harpur TJ. Psychopathy and the DSM-IV criteriafor antisocial personality disorder. J Abnorm Psychol 1991;100:391-8.

[5] Rutter M. Psychopathy in childhood: is it a meaningful diagnosis? Br JPsychiatry 2012;200:191-6.

[6] American Psychiatric Association. Diagnostic and statistical manual ofmental disorders, 5th ed, www.dsm-5.org. [in press].

[7] American Psychiatric Association. Diagnostic and statistical manual ofmental disorders, 3rd ed., text revision. Washington, DC: AmericanPsychiatric Publishing; 2000.

[8] Koenigsberg H. Affective instability: toward an integration ofneuroscience and psychological perspectives. J Personal Disord2010;24:60-82.

[9] Gunderson JG, Linehan MM. Cognitive behavioral therapy forborderline personality disorder. New York: Guilford; 1993.

[10] Gunderson JG, Links P. Borderline personality disorder: a clinicalguide2nd ed. . Washington, DC: American Psychiatric Press; 2007.

[11] Zanarini MC, Gunderson JG, Frankenburg FR. Cognitive features ofborderline personality disorder. Am J Psychiatry 1990;147:57-63.

[12] Robins LN, Regier DA, editors. Psychiatric disorders in America. NewYork: Free Press; 1991.

[13] Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M,Eshleman S. Lifetime and 12-month prevalence of DSM-III-Rpsychiatric disorders in the United States. Results from the NationalComorbidity Survey. Arch Gen Psychiatry 1994;51:8-19.

[14] Paris J. Estimating the prevalence of personality disorders. J PersDisorders 2010;24:405-11.

[15] Coid J, Yang M, Tyrer P, Roberts A, Ullrich S. Prevalence andcorrelates of personality disorder in Great Britain. Br J Psychiatry2006;188:423-33.

[16] Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IVpersonality disorders in the National Comorbidity Survey Replication.Biol Psychiatry 2007;62:553-6.

[17] Torgersen S, Kringlen E, Cramer V. The prevalence of personalitydisorders in a community sample. Arch Gen Psychiatry 2001;58:590-6.

[18] Samuels J, Eaton WW, Bienvenu OJ, Nestadt G, Brown CH, Costa PJ.Prevalence and correlates of personality disorders in a communitysample. Br J Psychiatry 2002;180:536-42.

[19] Zimmerman M, Chelminkis I, Young D. The frequency of personality[27] Hwu HG, Yeh EK, Change LY. Prevalence of psychiatric disorders inTaiwan defined by the Chinese Diagnostic Interview Schedule. ActaPsychiatr Scand 1989;79:136-47.

[28] Sato T, Takeichi M. Lifetime prevalence of specific psychiatricdisorders in a general medicine clinic. Gen Hosp Psychiatry1993;15:224-33.

[29] Lee KC, Kovac YS, Rhee H. The national epidemiological study ofmental disorders in Korea. J Korean Med Sci 1987;2:19-34.

[30] Millon T. Borderline personality disorder: a psychosocialepidemic. In: Paris J, editor. Borderline personality disorder: etiologyand treatment. Washington, DC: American Psychiatric Press; 1993.p. 197-210.

[31] Engel GL. The clinical application of the biopsychosocial model. Am JPsychiatry 1980;137:535-44.

[32] Jang KL, Livesley WJ, Vernon PA, Jackson DN. Heritability ofpersonality traits: a twin study. Acta Psychiatr Scand 1996;94:438-44.

[33] Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J. A twinstudy of personality disorders. Compr Psychiatry 2000;41:416-25.

[34] Brennan PA, Mednick SA. Genetic perspectives on crime. ActaPsychiatr Scand 1993;87:19-26.

[35] Rhee S, Waldman I. Genetic and environmental influences onantisocial behavior: a meta-analysis of twin and adoption studies.Psychol Bull 2002;128:490-529.

[36] Siever LJ, Davis KL. A psychobiological perspective on thepersonality disorders. Am J Psychiatry 1991;148:1647-58.

[37] Robins L. Deviant children grown up. Baltimore: Williams andWilkins; 1966.

[38] Zanarini MC. Childhood experiences associated with the developmentof borderline personality disorder. Psychiatr Clin North Am2000;23:89-101.

[39] Black DW, Baumgard CH, Bell SE. A 1645 year follow-up of 71 menwith antisocial personality disorder. Compr Psychiatry 1995;36:130-40.

[40] Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC.Psychiatric aspects of impulsivity. Am J Psychiatry 2001;158:1783-93.

[41] Paris J, Zweig-Frank H. A 27-year follow-up of patients withborderline personality disorder. Compr Psychiatry 2001;42:482-7.

[42] Gunderson JG, Stout RL, McGlashan TH, Shea T, Morey LC, GriloCM, et al. Ten-year course of borderline personality disorder:psychopathology and function from the collaborative longitudinalpersonality disorders study. Arch Gen Psychiatry 2011;68:827-37.

[43] Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Time toattainment of recovery from borderline personality disorder andstability of recovery: a 10-year prospective follow-up study. Am JPsychiatry 2010;167:663-7.

[44] Paris J. Personality disorders over time. Washington DC: AmericanPsychiatric Press; 2003.

[45] Gibbon S, Vollm BA, Duggan C, Khalifa N, Stoffers J, Huband N, etal. Pharmacological and psychological interventions for antisocialpersonality disorder results of two Cochrane reviews. Eur PsychiatrRev 2011;4(1):52-8.

[46] Kendall T, Pilling S, Tyrer P, Duggan C. Borderline and antisocialpersonality disorders: summary of NICE guidance. BMJ 2009:338,http://dx.doi.org/10.1136/bmj.b93.

[47] Paris J. Effectiveness of differing psychotherapy approaches in thetreatment of borderline personality disorder. Curr Psychiatry Rep2010;12:56-60.

[48] Feingold A. Gender differences in personality: a meta-analysis.Psychol Bull 1994;116:429-56.

[49] Costa PT, Terracciano A, McCrae RR. Gender differences inpersonality traits across cultures: robust and surprising findings. JPers Soc Psychol 2001;81:322-31.

[50] Baghaei F, Rosmond R, Landen M, Westberg L, Hellstrand M, HolmG, et al. Phenotypic and genotypic characteristics of women in relationto personality traits. Int J Behav Med 2003;10:365-78.

[51] Krueger RF. The structure of common mental disorders. Arch GenPsychiatry 1999;56:921-6.

[52] Achenbach TM, McConaughy SH. Empirically based assessment ofchild and adolescent psychopathology: practical applications. 2nd ed.Thousand Oaks, CA: Sage; 1997.

[53] Helzer JE, Canino GJ, editors. Alcoholism in North America, Europe,and Asia. New York: Oxford University Press; 1992.

[54] Weissman MM, Klerman GL. Gender and depression. TrendsNeurosci 1985;8:416-20.

[55] Anderson KG, Sankis LM, Widiger TA. Pathology versus statisticalinfrequency: potential sources of gender bias in personality disordercriteria. J Nerv Ment Dis 2001;189:661-8.

[56] Skodol AE, Bender DS. Why are women diagnosed borderline morethan men? Psychiatr Q 2003;74(4):349-60.

[57] Paris J. Gender differences in personality traits and disorders. CurrPsychiatry Rep 2004;6(1):71-4.

[58] Hicks BM, Vaidyanathan U, Patrick CJ. Validating female psychop-athy subtypes: differences in personality, antisocial and violentbehavior, substance abuse, trauma, and mental health. Personal DisordTheory Res Treat 2010;1:38-57.

[59] Sprague J, Javdani S, Sadeh N, Newman JP, Verona E.Borderline personality disorder as a female phenotypic expression

of psychopathy. Personal Disord Theory Res Treat 2012;3:127-39.

[60] Zlotnick C, Rothschild L, Zimmerman M. The role of gender in theclinical presentation of patients with borderline personality disorder.J Personal Disord 2002;16:277-82.

[61] Johnson DM, Shea MT, Yen S. Gender differences in borderlinepersonality disorder: findings from the Collaborative LongitudinalPersonality Disorders Study. Compr Psychiatry 2003;44:284-92.

[62] Raine A, Lencz T, Bihrle S, Lacasse L, Colleti P. Reduced prefrontalgray matter volume and reduced autonomic activity in antisocialpersonality disorder. Arch Gen Psychiatry 2000;57:119-27.

[63] New AS, Goodman M, Triebwasser J, Siever LJ. Recent advances inthe biological study of personality disorders. Psychiatr Clin North Am2008;31:441-61.

[64] Livesley WJ, Jang K. Behavioral genetics of personality disorder.Annu Rev Clin Psychol 2008;4:247-74.

[65] Beauchaine TP, Klein DN, Crowell SE, Derbidge C, Gatzke-Kopp L.Multifinality in the development of personality disorders: a biology sex environment interaction model of antisocial and borderline traits.Dev Psychopathol 2009;21(3):735-70.

325J. Paris et al. / Comprehensive Psychiatry 54 (2013) 321325

Antisocial and borderline personality disorders revisited1. Defining disorders2. Epidemiological and clinical surveys3. Risk factors4. Outcome and treatment5. Gender, personality, and psychopathology6. Diagnostic boundaries7. ConclusionsReferences