Does Borderline Personality Disorder Overlap With Psychopathy?

No, no it does not... and yet here we are...

I know, I know, I have spoken about this before, which you can see here:

Psychopathy, Borderline Personality Disorder, And Borderline Psychopathy...

but it seems to come up a lot, and it is usually brought up by people who aren’t familiar with what is being spoken about when this conflation is discussed. Because this tends to be the case I found a study that specifically addresses this so we can take a look at it, and debunk it properly.

This is the text that we will be talking about today:

Borderline Personality Disorder with Psychopathic Traits: A Critical Review

Once again, I have not read this study and my reactions will be in the moment of my writing. Shall we then?

Background

Borderline personality disorder has been related to personality traits such as antisocial traits, impulsivity or neuroticism. However, little attention has been given to psychopathic traits and the role they play on the disorder.

I can’t wait to see how “psychopathic traits” are going to be defined. Anyone want to bet that they will be the factor two traits from the PCL-R? That’s what I’m betting. A quick reminder for those of you who aren’t as entrenched in the world of psychopathy and bad information, the PCL-R is a list that was misappropriated by Robert Hare from someone else’s work, had a copyright slapped on it shortly after that person’s death, and is now sold as the “gold-standard” when it comes to diagnosing psychopathy. There are too many issues with the checklist and Robert Hare himself to summarize in this post, but if you want to know what they are, let me know and I will link you the posts.

I don’t know that I will go through every single part of this article, but we shall see as we go.

Background

Borderline personality disorder has been related to personality traits such as antisocial traits, impulsivity or neuroticism. However, little attention has been given to psychopathic traits and the role they play on the disorder.

I can’t wait to find out how they are defining “psychopathic traits.

Objective

To review the relationship between psychopathic traits and borderline personality disorder.

You… you already said that part…

Methods

A review of scientific literature between 1980 and 2017 was carried out. Papers were in English and had to relate psychopathic traits to borderline personality disorder. A total of 52 articles were included in the study. After full text revision, eighteen papers were selected for review.

Oh yay… a meta-analysis… my favorite…

Results

This review suggests an association between borderline personality disorder and the factor 2 of the concept of "psychopathy", but not between BPD and factor 1. Previous literature is not conclusive about the influence of gender on psychopathic features present on BPD patients.

*head on desk* So this is garbage is what you’re saying. I mean, I guess good on you for outright making that clear before I dove into this argument, but it’s still garbage. You wasted your time. Well done.

All right, being more fair to this paragraph, what does it actually say? It states that they took the factor two traits of the PCL-R *who didn’t see that coming* and then looked to see how often those traits present in BPD studies. The factor two traits from the PCL-R have nothing to do with psychopathy. They have to do with antisocial behavior. That’s it and that’s all. There is nothing about antisocial behavior that is correlated with any one type of person. Most people who are antisocial are neurotypical, and most psychopaths are not antisocial. So, where does this leave us?

It leaves us looking at fifty-two studies about BPD that are looking to see how often people with BPD have an overlap with antisocial personality disorder. Here’s my question though. Where were these studies done? I ask this question because researchers have a very nasty habit of concentrating solely on incarcerated cohorts when it comes to studies on psychopathy, so I am not inclined to give them the benefit of the doubt when it comes to BPD regarding whether or not they are studying real people and not criminals.

If they are focusing on a criminal population, spoiler alert, likely almost all of the study participants will be antisocial in nature. I mean… they are in prison for a reason, right? Right. I’m guessing that they aren’t going to address the cohorts of these studies, both because there were fifty-two of them, and also because it would make their precious meta-analysis an obvious waste of time instead of a more subtle one.

Oh oh oh, aaaannnndddd they outright say:

This review suggests an association between borderline personality disorder and the factor 2 of the concept of "psychopathy", but not between BPD and factor 1.

Crap as it is, the PCL-R itself makes the distinction between what factors one and two are looking at. Factor one (even though it is a crap checklist that is not good for identifying psychopathy) is directly associated with “psychopathic traits” and factor two has to do with antisocial traits. In other words, the meta-analysis demonstrates that BPD and psychopathy have no overlap. It would be great if they weren’t using the PCL-R to demonstrate this, but all the same, they have at least debunked that myth.

Now, I could just quit here, but that isn’t exactly being thorough now, would it? In fairness, however, 

Keywords

Borderline personality disorder, Psychopathy, Antisocial personality disorder, Impulsivity, Aggressiveness

Abbreviations

BPD: Borderline Personality Disorder; F1: Factor 1 of Psychopathy; F2: Factor 2 of Psychopathy; APD: Antisocial Personality Disorder; PCL-R: Hare Psychopathy Checklist-Revised; FFM: Five Personality Factor Model; PTSD: Post-Traumatic Stress Disorder; PPD: Psychopathic Personality Disorder; CAPP: Comprehensive Assessment of Psychopathic Personality; CABP: Comprehensive Assessment of Borderline Personality; BPI: Borderline Personality Inventory; LSRP: Levenson Self-Report Psychopathy Scale; DBT: Dialectic Behavioral Therapy; PID-5: Personality Inventory for DSM-5

Wow… that’s a lot. In case you are wondering what something means, you can refer back to the handy dandy list up above. Let’s see how we are defining terms:

Borderline Personality Disorder (BPD) is described as a severe mental condition characterized by high affective instability, impulsive behaviors, autolytic attempts, or unstable interpersonal relationships [1]. Previous literature on BPD has focused mainly on symptoms of mood and anxiety and self-injurious behavior [2,3] but relatively little is known about the association between borderline personality disorder and psychopathic traits.

Well, based on your own description, there won’t be any. None of what is described above is remotely similar to psychopathy. However, based on the quality of the definition of psychopathy that is to follow, I am not certain how good of a definition of BPD this is either. Keep in mind, I am no expert in BPD. I know very little about it so I am in no way stating that this definition is accurate or representative of BPD at all.

Now for psychopathy:

Psychopathy is a mental condition characterized by a deficit of emotional processing, interpersonal relationships and self-regulation. Individuals with psychopathic traits engage in callous and manipulative behavior with others and exhibit antisocial and impulsive behaviors [4]. The predominant model of psychopathy during the last two decades has been the two-factor model [5], from which most self-report measures of psychopathy have been constructed.

“Psychopathy is a mental condition”- nope

“characterized by a deficit of emotional processing:-yes

“interpersonal relationships”- nope. Relationships are a choice. Having them or not comes down to the individual, however, describing the relationships with the term “deficit” means to define “normal relationships” as those that neurotypicals have. Those are not normal to us. Nothing about our relationships is deficient at all to us.

“and self-regulation”- Nope. Again, this is a choice, and to decide that all psychopaths have self-regulation issues just because you all can’t drag yourselves out of the prison system and away from criminals long enough to evaluate the normative psychopaths in the population doesn’t mean that you are correct about that assumption.

“Individuals with psychopathic traits engage in callous and manipulative behavior with others and exhibit antisocial and impulsive behaviors”

No. To all of that. Callousness in psychopathy has to do with not having the same emotional experiences as neurotypicals. We aren’t being mean to you because we don’t share your feelings on whatever matter. We don’t feel those things, nor do we think that your emotions on the situation are particularly helpful or valuable. That’s our opinions, we are allowed to have them. You don’t have to agree with us and generally, neurotypicals don’t agree with us. However, being in the majority doesn’t make you correct.

Manipulation is human nature and it is everywhere. We don’t engage in any more manipulation than neurotypicals do. We learn it from neurotypicals, we experience it from neurotypicals, we tolerate it from neurotypicals when it doesn’t work and it almost never does, and we are very aware of how commonplace it is in every single human interaction there is and ever will be in this world. However, somehow when we do it, we’re evil. When we make mention of how often neurotypicals do it, they’re offended by the suggestion.

Antisocial and impulsive behaviors are exactly that, they are behaviors and behavior is a choice. Psychopaths might be impulsive before learning to get that nonsense under control, but antisocial tendencies are not hardwired into psychopathy. That is an environmental aspect that tends to come from crappy childhoods, just like it does with all the other non-psychopaths who are also antisocial.

This is getting long guys. I haven’t even gotten into the methodology of the meta-analysis, so this might end up being a three part series. It depends on how many more tangents they are going to send me on. We will see…

Factor 1 (F1) is related to the interpersonal and affective components of psychopathy, such as a lack of remorse or guilt, manipulative, egocentric and grandiose attitude, and/or a lack of empathy. On the other hand, factor 2 (F2) refers to impulsive-antisocial behaviors, such as the susceptibility to boredom, difficulties for planning, irresponsibility, aggression and delinquency [5].

Love it, they outright admit that factor one has to do with psychopathy, and factor two has to do with ASPD. Now, if only they would admit that the PCL-R is garbage, we could all go home. Actually, I am home, so yay me.

Psychopathy has traditionally been linked to the diagnosis of Antisocial Personality Disorder (APD), but recent research suggests that APD is related only to certain aspects of Factor 2 of psychopathy

That is a very convoluted way of stating:

Factor one-psychopathy

Factor two-antisocial personality disorder

Psychopathy has traditionally been linked to the diagnosis of Antisocial Personality Disorder (APD), but recent research suggests that APD is related only to certain aspects of Factor 2 of psychopath

Do I need to repeat myself? Seems like I already rephrased this for you, but here we are again with exactly the same point. Right, we got it. Factor one has to do with psychopathy, factor two has to do with antisocial personality disorder, and the PCL-R is a stupid checklist that belongs in the trash. We’re all caught up, okay?

Stanlenheim and Von Knorring [7] suggested that borderline personality disorder was even closer to psychopathy than antisocial personality disorder, since APD is mainly limited to behavioral alterations, whereas BPD presents affective and interpersonal deficits in the same line as psychopathy.

You see, this is what happens when too many drugs are used by researchers when doing their work. That is the only explanation for anyone thinking to themselves, “You know how BPD has unstable and intense emotions that fluctuate based on the interpersonal relationships that the person is in? That is like… exactly like psychopathy which has completely missing or extremely muted emotions and no ability to connect to, bond to, or care what other people think. You know?”

I have no idea who those two people are who proposed such nonsense, but I am pretty sure I have a rolled-up newspaper around here somewhere with their names on it. Time for smackings and wackings. Moving on.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) [1] APD shares the domains of the Personality Inventory for DSM-V (PID-5) [8] disinhibition and antagonism with psychopathy but does not include interpersonal efficacy, emotional resilience and intrinsic temperament elements despite of many authors consider as the characteristics of psychopathy [9].

This is a very wordy way of saying, antisocial personality disorder overlaps with criminal psychopaths because criminal psychopaths usually have antisocial personality disorder (as almost all criminals do, go figure) but antisocial personality disorder lacks significant characteristics of psychopathy… Yeah, because they’re different. Not a little bit different. More like duck≠atom bomb different. I don’t know why we needed all those words to say that, but I guess it makes everyone feel smarter for having read them. Yay us.

Other studies [10], correlate BPD with factor 2 of psychopathy. Research focused on psychopathy factors suggest that BPD traits are more strongly associated with F2 traits than with F1 traits [11,12]. This relationship may be due to the symptoms shared between the secondary psychopath and patient with BPD, such as impulsivity, emotional instability and reactive aggression [13].

I really cannot wait to find out where these studies were conducted. Again, I am wondering about prison. I mean, it would make sense. After all:

As currently construed, the diagnosis of antisocial personality disorder grossly over-identifies people, particularly those with offence histories, as meeting the criteria for the diagnosis. For example, research shows that between 50% and 80% of prisoners meet the criteria for a diagnosis of antisocial personality disorder, yet only approximately 15% of prisoners would be expected to be psychopathic, as assessed by the PCL-R. As such, the characteristics and research findings drawn from the psychopathy research may not be relevant for those with antisocial or dissocial personality disorder.

Fifty to eighty percent of all prisoners qualify for a diagnosis of ASPD, so if you are doing a study on prisoners, there is an extremely high chance, regardless of the neural make-up, they will also have ASPD. If you are looking at something like autism, or BPD, or NPD, and are trying to view them without any contaminants, prison is not the place to do so. Sure, you might be able to figure out how often one of those diagnoses also tend to be antisocial, but the antisocial traits should not be considered a part of the diagnosis as a whole, but rather a behavioral addendum.

Besides, preliminary research suggests that the presence of high scores in PCL Revised (PCL-R, [4]) may increase the risk of suffering BPD in women, but not in men

Hmm, I wonder how they are defining, “suffering”.

According to this, Rogers, et al. [15] observed a greater comorbidity between psychopathy and BPD in women than in men.

Translation with correction- There is a greater occurrence of antisocial personality disorder, or at least the traits of it, in women than in men. Not psychopathy, ASPD, or in this case, APD, which I am not sure why they have decided to change the acronym for it, but whatever. I will likely use both because I am more accustomed to writing ASPD, it’s a habit, and I type fast.

This is why some researchers have argued that psychopathy represents a feminine phenotypic expression of personality disorder [16].

I have to wonder what the chances of females being diagnosed with BPD over males, and if males get diagnosed with something else when in reality they have BPD. I wonder this because as BPD tends to be related to high emotional states, and that is something more traditionally associated with women, that this is probably going to influence how often men are actually diagnosed with it. I would guess in the prison system, men are not routinely diagnosed with BPD. Men in prisons aren’t exactly the sharing and caring types, so getting them to talk about emotional instability might be a challenge.

Just my opinion, however.

Basically, if there is a reason that females that have borderline personality disorder are more likely to behave in an antisocial manner, that’s interesting, but that does not mean that they are remotely psychopathic. It means that the root cause of their behavior is likely the BPD, and it demonstrates why ASPD is such a garbage diagnosis. If you are basing a diagnosis on the behavior, not the source, you are pointing to the flames not the fuel. That’s dumb. Anyone with two brain cells to rub together can see that it’s dumb, and yet, again, here we are.

Neurological and cognitive similarities have also been described for both syndromes, psychopathy and BPD, with functional abnormalities observed at the prefrontal level and in the amygdala, associated with such features as reactive aggression, disinhibition and affective intensity [17].

This is not true. I looked at the study and wow, is it a mess. They use the PCL-R, again. They define psychopathy solely based on the PCL-R. They cite older research where more current research debunked it. They define things based on behavior, not neurology, despite claiming that their study is about the neurological similarities. Let’s look at a sample of where they drew this nonsense from:

The PCL-R consists of 20 items falling broadly into two dimensions: Factor 1 items are predominantly emotional or interpersonal traits such as deception, remorselessness, shallow affect and callousness, whereas Factor 2 items assess behavioural manifestations of the disorder such as criminality, violence and dysfunctional lifestyle (Box 1). Characteristics from both these factors are needed for a diagnosis of psychopathy to be made. Although many consider the first dimension to differentiate psychopathy from other personality disorders (Reference KiehlKiehl 2006), there is considerable overlap between a number of these traits, not only between psychopathy and antisocial/dissocial personality disorder, but also between psychopathy and other DSM-IV Cluster B disorders (Table 1), including borderline, histrionic and narcissistic personality disorders. This supports the view that psychopathy comprises a ‘higher order’ collection of disordered personality traits from many categories (Reference Blackburn, Strack and MillonBlackburn 2005).

This paragraph is a hot mess if you understand the massive issues with the PCL-R. I might have to include the links for the uninitiated, but for those of you that have already read them, and are aware of the enormous problems with this checklist, this paragraph likely looks to you like it does to me. Rife with cognitive dissonance. I have made the case many times, oh what the hell, might as well stick them here:

Systems Need to be Challenged

The PCL-R's Significant Limitations, Overreaches,...

Personality and Conduct

regarding just how bad the PCL-R is as an entity. Here’s the deal though, I am not the only one making this case. Many researchers are making it as well. I discussed that in the links above, as well as Robert Hare’s response to this very valid criticism. The case is not only substantial enough to question the use of the PCL-R in general, but to also remove it from use and reconsider things from scratch. This is not just my argument, but certainly it is the one that I am making based on the evidence, but it is the argument of many people that have seen the serious issues with the checklist.

Now, if you know that there is massive criticism about the accuracy of something like the PCL-R, but ignore it and continue to use it, you will end up with paragraphs like that one. The argument is that factor two is the manifestation of factor one, but more people with factor two don’t have factor one traits, only some people do, but those people are psychopaths, but the whole checklist is for diagnosing psychopaths, so if you have any of the traits, you are a psychopath, or have an overlap with psychopathy, even if the actual diagnosis that you have, BPD, NPD, HPD, etc could never overlap with psychopathy because the emotional capacity is not something that a psychopath is capable of.

Now, keep in mind, it is agreed that psychopaths have missing and muted emotions. That we are ‘cold’ emotionally, cannot bond, feel love, trust, empathy, and so on. All of the personality disorders listed:

borderline, histrionic and narcissistic personality disorders

can feel those things, and can feel them deeply in most cases. They also all have deep emotional experiences. Not some of them, all of them. Psychopaths do not. So, the argument that they are making is that psychopathy is a malleable thing that bends and stretches to unrecognizable shapes in order to accommodate the argument that BPD, HPD, and NPD can overlap with psychopathy or have high psychopathic traits. Instead of saying, hey, this literally doesn’t make logical sense, these things can’t overlap one another based on our own definitions, maybe there is a problem with this checklist tool that we are using to try to make this argument, they instead just say, here is a bunch on stuff, lumped together, contradicting one another, but it’s all the same.

No.

Do better.

This is unacceptable from people that spent a lot of time in school supposedly learning critical thinking. If this is the conclusion that they have arrived at, and they think that this makes sense, they need to get into the MRI machine themselves, because I think that their brain has gone on vacation without them.

Also, the PCL-R is used only in prisons, and it is not meant to be a diagnostic tool, but rather a screening tool.

Also also, as fifty to eighty percent of all prisoners qualify for a diagnosis of ASPD, then it should be that you rule out the traits for ASPD when it comes to these evaluations, as ASPD is behavioral only, and concentrate on the fuel of the fire, because that is how you ascertain how to put it out or at least understand its patterns, not the other way around.

Also also also, when you state:

Although many consider the first dimension to differentiate psychopathy from other personality disorders (Reference KiehlKiehl 2006), there is considerable overlap between a number of these traits, not only between psychopathy and antisocial/dissocial personality disorder, but also between psychopathy and other DSM-IV Cluster B disorders (Table 1), including borderline, histrionic and narcissistic personality disorders.

That should tell you that the checklist is trash and you need to start over. Honestly, this argument is like saying,

“Well, in my mind chicken eggs and engine blocks are really different. We have studied them, mapped them both, and generally understand what the makings of each are. However, there is a tool that everyone in the chicken egg/engine block field uses that speaks about the overlap not only between chicken eggs and engine blocks, but clouds too. It goes against everything that we know about all three except some very basic things, like there is water involved in all of these things somewhere, but everyone accepts that this tool is a good one, and who am I to question that?”

Seriously? Is this a backbone thing, or a “I don’t want to lose my grant money” thing? There is no way that they aren’t able to see the contradictions in their own argument, right? Good lord, I don’t know if it’s better that they can see it, but prefer the money or not getting yelled at, or they can’t see it because their brain cells aren’t holding hands.

All right, so we can dismiss the idea that the neurological findings stated anything at all. The people that they threw into that fMRI machine were probably all neurotypical. Actually, that is the last thing I will do to lend any sort of benefit of the doubt to this so-called “study” that says that there is a neurological similarity between totally different things. I will look at their cohort. Before I do, let me guess. They will be:

All male

Between 18-65

All criminals

A small number, under one hundred and fifty

Included will be those that have drug and alcohol dependency issues

Head injuries

Let’s see how accurate I was…

Oh my, this isn’t a study, this is a “discussion” of previous studies, and they outright admit when it comes to the imaging of people with BPD:

A number of MRI studies report structural differences of the amygdala in people with borderline personality disorder compared with healthy controls. However, the direction of these differences varies between studies, with reduced volume (Reference Weniger, Lange and SachsseWeniger 2009), increased (Reference Minzenberg, Fan and NewMinzenberg 2008) and decreased (Reference Soloff, Nutche and GoradiaSoloff 2008) grey matter concentration, and no volumetric difference (Reference New, Hazlett and BuchsbaumNew 2007) being variously reported. Lack of consistency among these findings may arise from methodological differences between studies, including use of mixed- v. single-gender cohorts (for discussion of further limitations see Reference Minzenberg, Fan and NewMinzenberg 2008).

that they do not have anything to report. The studies that they have done came back with no consistency. There is no usable data, because they have not found that there is a consistent result unlike what they find in psychopathy. The amygdala in people with BPD is either larger, smaller, or not different than that of a neurotypical. That means that your “discussion” has nothing to say. You cannot compare consistent measurements that have been demonstrated in psychopathy to completely inconsistent contradictory data when it comes to BPD. It makes me wonder why they would even cite this “discussion” as it invalidates their claims in this meta-analysis. I can’t imagine that they didn’t read it, which means that they did, but saw no issue with putting this out. It makes me think that they didn't think anyone else was going to read it.

By the way, the paragraph immediately preceding the one where they admit that the results weren’t valuable stated, as fact, that there were results that showed differences in the brain of people with BPD. The exact differences that they, one paragraph later, remove the validity of. It seems to me that if there are differences in the brain for people with BPD, it would do them more favors to actually find consistency prior to making statements than it is to state something, only to have it be refuted by the information you are drawing from.

For something to be considered relevant it should be repeatable. Brains can change based on abuse, and different people might have different changes. Something else that I have found are clinicians stating that they don’t know if the brain being different in someone with BPD is the cause or the result of the BPD. Frankly, it doesn’t sound like they have successfully demonstrated that it has anything to do with it in the first place. If there aren’t consistent findings, how are they certain that it doesn’t have different roots? In one study, the cohort was tiny, eight people, and half of those have overlaps with things like having a major depressive disorder, which also apparently changes the brain. Another had ten in their cohort. This is not a large enough cohort to arrive at any conclusions at all. Why are studies formulated so poorly?