Personality and Mental Health

(2012)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI 10.1002/pmh.1203

Adult antisocial syndrome co-morbid with

borderline personality disorder is associated
with severe conduct disorder, substance
dependence and violent antisociality

MARK FREESTONE1,2, RICK HOWARD3, JEREMY W. COID1 AND SIMONE ULLRICH1, 1Barts
and The London School of Medicine and Dentistry, Queen Mary University of London, UK; 2North
East London Forensic Personality Disorder Service, UK; 3Division of Psychiatry and Institute of
Mental Health, University of Nottingham, Nottingham, UK

ABSTRACT
This study tested the hypothesis that syndromal adult antisocial behaviour (AABS) co-morbid with borderline
personality disorder (BPD) is a syndrome that emerges from severe conduct disorder (CD) in childhood and
adolescence and is strongly associated, in adulthood, with both violence and substance dependence. In a sample
of 8 580 community-resident adults screened for the presence of personality disorders, the following predictions
arising from this hypothesis were tested: first, that those with AABS co-morbid with BPD would, in comparison
with those showing AABS or BPD only, show a high level of antisocial outcomes, including violence; second,
that adjusting for co-morbid alcohol dependence would attenuate group differences in many of the antisocial
outcomes, and violence in particular; and third, that the AABS/BPD group would show both a high prev-
alence and a high severity of CD, and that adjusting for co-morbid CD would attenuate any association
found between AABS/BPD co-morbidity and violence. Results confirmed these predictions, suggesting that
AABS/BPD co-morbidity mediates the relationship between childhood CD and a predisposition to adult
violence. The triad of AABS/BPD co-morbidity, alcohol dependence and severe CD is likely associated with
the risk of criminal recidivism in offenders with personality disorder following release into the community.
Copyright © 2012 John Wiley & Sons, Ltd.

Introduction among British and American prisoners (Coid et al.,

Antisocial personality disorder (ASPD) and bor-
derline personality disorder (BPD) are highly co-
morbid among adult admissions to psychiatric
hospital (Becker, Grilo, Edell, & McGlashan,
2000). The prevalence of ASPD/BPD co-morbidity
is particularly high in forensic samples, for example
2009; Lewis, 2011), and has been reported to be
especially high (77%) in female prisoners who, in
the UK, meet criteria for ‘dangerous and severe
personality disorder’ (Duggan & Howard, 2009).
This selective co-occurrence of ASPD and BPD
likely reflects genetic and environmental influences
common to these disorders over and above

Copyright © 2012 John Wiley & Sons, Ltd. (2012)

DOI: 10.1002/pmh
Freestone et al.
influences shared by all Cluster B disorders (Torgersen
et al., 2008). Co-morbid borderline and psycho-
pathic traits in patients recruited as part of the
McArthur study were associated with violence
during a one-year study period (Newhill, Eack, &
Mulvey, 2009). Among the same sample, Newhill,
Vaughn, and DeLisi (2010) were able to identify
an antisocial subgroup of BPD individuals who were
characterized by a high felony conviction rate and a
history of childhood-onset conduct disorder. Among
treatment-seeking PD patients resident in the UK,
those showing a co-occurrence of ASPD and BPD
were more likely to have received a conviction for vi-
olence and a custodial sentence (Howard, Huband,
Duggan, & Mannion, 2008). In addition, patients
with ASPD/BPD co-morbidity showed high levels
of anger and impulsivity, suggesting deficient emo-
tional self-regulation as a mechanism through which
ASPD co-morbid with BPD is linked to violence.
Consistent with this, recent evidence suggests that
both ASPD and BPD are associated with impulsive
behaviour across a wide range of behavioural
domains, including physical aggression towards
others (Perry & Körner, 2011).
These results suggest that co-occurring ASPD/
BPD represents a critical pattern of co-morbidity that
increases the risk of violence. However, further clar-
ification is needed to determine whether this associ-
ation with violence is confounded by co-occurring
Axis I disorders, in particular by co-occurring child-
hood CD and alcohol abuse/dependence. In female
American prisoners with an ASPD diagnosis, the
degree of violence was associated with greater Axis
I co-morbidity, particularly early-onset substance
dependence (Lewis, 2011). The relationship
between childhood CD and adult antisocial
behaviour was found to be partially mediated
by early alcohol abuse (Howard, Finn, Jose, & Galla-
gher, 2012; Khalifa, Duggan, Lumsden, & Howard,
2012), suggesting that conduct disordered children
who become antisocial as adults do so, at least, in
part, as a result of their early alcohol abuse. Results
of a prospective study further indicated that indivi-
duals with CD as children who subsequently abused
alcohol in adolescence showed both frequent and
Copyright © 2012 John Wiley & Sons, Ltd.
hazardous drinking in early adulthood (Buchmann
et al., 2010), when alcohol use substantially increases
the risk of violence (Haggård-Grann, Hallqvist,
Långström, & Möller, 2006). Finally, evidence
suggests that when syndromal adult antisocial
behaviour (AABS; Black & Braun, 1998), defined
by the presence of the adult rather than the child
criteria for ASPD (APA, 1994), occurs concurrently
with BPD, it is associated with more severe, and
more prevalent, childhood CD than when it occurs
in the absence of co-occurring BPD (Howard,
Huband, & Duggan, 2012). Evidence further sug-
gests that antisocial syndromes, both with prior CD
(i.e. ASPD) and without prior CD (i.e. AABS),
identify a pernicious clinical profile of alcohol use
disorders among adults in the US population, al-
though associations with alcohol use disorders were
reported as more modest among those with AABS
than among those with ASPD (Goldstein et al.,
2007). Results from a study using the same adult sam-
ple indicated that early-onset CD, compared with
adolescent-onset CD, was associated with greater
psychiatric co-morbidity (both Axis I and Axis II dis-
orders) and identified a more violent form of ASPD
(Goldstein, Grant, Ruan, Smith, & Saha, 2006).
Taken together, evidence reviewed earlier sug-
gests the hypothesis that AABS/BPD co-morbidity
is an adult presentation of a syndrome that emerges
from severe (and possibly earlier) CD in childhood
and adolescence, and is strongly associated with
both violence (particularly alcohol-related vio-
lence) and substance abuse. This study tested this
hypothesis in a community-resident sample of
adults, among whom it was predicted that those
showing AABS with co-morbid with BPD, com-
pared with those showing AABS or BPD only,
would show a high level of antisocial outcomes,
particularly violence. It was further predicted that
adjusting for Axis I co-morbidity, particularly
co-morbid alcohol dependence, would attenuate
group differences in many of the antisocial out-
comes, and violence in particular. Lastly, it was
predicted that the AABS/BPD group would
show both a high prevalence and a high severity
of CD, and that adjusting for co-morbid CD
(2012)
DOI: 10.1002/pmh
 Adult antisocial syndrome with co-morbid borderline PD and violence
would attenuate any association found between
AABS/BPD co-morbidity and violence.
Method
Sample
The sample of 8 580 individuals was drawn from
those participating in the first phase of the British
National Survey of Psychiatric Morbidity, aged
16–74 years and living in private households in
England, Scotland or Wales in 2000 (Singleton,
Bumpstead, O’Brien, Lee, & Meltzer, 2001). The
sampling method utilized by this study has been
described elsewhere (Coid, Yang, Tyrer, Roberts,
& Ullrich, 2006; Ullrich & Coid, 2009).
Measures
Probable cases of PD within the sample were iden-
tified using the screening questionnaire of the
Structured Clinical Interview for DSM-IV
(APA, 1994) Personality Disorders (SCID-II; First
et al., 1997). Participants were also screened for a
range of Axis I mental disorders. The revised version
of the Clinical Interview Schedule (CIS-R; Lewis,
Pelosi, Araya, & Dunn, 1992) was used to obtain
the prevalence of common mental disorders in the
past week using the ICD-10 classification.
Participants screened positive for psychosis if any
two of the four criteria were currently present from
the Psychosis Screening Questionnaire (Bebbington
& Nayani, 1994). The Alcohol Use Disorders
Identification Test (AUDIT; Babor, de la Fuente,
Saunders, & Grant, 1992) was used to identify
alcohol misuse over the past year. An AUDIT score
of 20+ was considered to be indicative of alcohol
dependence (Babor, Higgins-Biddle, Saunders, &
Monteiro, 2001). A number of additional questions
were asked about participants’ use of drugs (Coid,
Yang, Tyrer et al., 2006). Positive responses to
any of five questions (two questions for cannabis)
regarding a series of different substances (cannabis,
amphetamines, cocaine, crack cocaine and heroin/
methadone) measuring drug dependence over the
Copyright © 2012 John Wiley & Sons, Ltd.
past year were combined to produce a single category
of ‘any’ drug dependence.
Participants were also asked a series of questions
relating to their lifetime antisocial behaviour, in-
cluding major financial crisis, homelessness, any
problems with the police or a court appearance
(as an adult), any violent acts in the past five years.
injury to themselves or another person due to vio-
lent behaviour, violence while intoxicated, number
of victim types and involvement in 5 or more vio-
lent incidents in the past five years.
Statistical analysis
In a first step, the sample dataset was subdivided
into five groups: (1) No PD: no evidence of any
PD; (2) Other PD: evidence of at least one PD that
did not include either AABS or BPD; (3) BPD:
those with BPD only; (4) AABS: those with AABS
only; and (5) AABS + BPD: those with co-morbid
AABS and BPD. To compare the five groups,
multiple logistic, ordinal and/or multinomial regres-
sions were carried out to calculate odds ratios
depending on the nature of the comparison variable.
Where continuous variables were under examina-
tion, contrast ANOVA was conducted. Initial
analyses were carried out unadjusted, then with
adjustments for significant demographic characteris-
tics and Axis I/Axis II mental disorders by entering
all relevant variables into the model simultaneously.
Weighted data were used throughout, and analyses
were conducted using SPSS v16 (IBM Corp, New
orchard Road, Armonk, New York 10504, USA).
Results
Prevalence
A total of 8 580 individuals completed the SCID-II
screen. The majority of those (n = 5916, 69%) did
not meet the criteria for any PD. The prevalence
of any PD other than AABS/BPD was 22.8%
(n = 1956), BPD occurred in 0.9% (n = 74) of the
sample, the criteria for AABS were fulfilled in
6.9% (n = 595) and the prevalence of co-morbid
AABS + BPD was 0.5% (n = 39). A majority of the
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DOI: 10.1002/pmh
Freestone et al.

latter (64.1%) met the full criteria for ASPD (i.e.
three or more of both child and adult criteria), in
contrast to only 37.0% of those with AABS only,
and this difference was significant (p = 0.01). A total
of 779 individuals (9.1%) met the criteria for CD
with 220 (2.6%) fulfilling AABS criteria as well.
Demographics
Those in the No PD group (M = 43.1, SD = 16.0)
and the Other PD group (M = 43.7, SD = 15.8)
were significantly older (p < 0.001) than those
with AABS/BPD (M = 32.5, SD = 10.2). No
significant age difference was found between
AABS + BPD and BPD only (M = 30.6, SD = 12.4)
and AABS only (M = 35.9, SD = 12.2).
As can be seen in Table 1, there were no signifi-
cant differences with respect to ethnicity, low
socio-economic status or lack of educational qualifi-
cations. Those with No PD, Other PD or BPD only
were less likely to be male than the ASPD + BPD ref-
erence group, but there were no gender differences
compared with AABS only. With regard to marital
status, significantly more individuals in the AABS +
BPD group were single compared with those with
No PD or Other PD, but they did not differ signifi-
cantly from those with BPD only or AABS only.
Adult antisocial and violent outcomes
Results of the comparison of the five groups
with regard to antisocial and violent outcomes in

Table 1: Demographic characteristics

n % OR 95% CI p

Ethnic minority group No PD 365 6.2 0.77 0.23 2.59 0.679

Other PD 155 8 1.06 0.32 3.56 0.926
BPD only 9 12.3 1.81 0.45 7.27 0.405
AABS only 39 6.6 0.84 0.24 2.91 0.778
AABS and BPD* 3 7.7 1.00
Male gender No PD 2809 47.5 0.42 0.21 0.83 0.012
Other PD 973 49.7 0.46 0.23 0.91 0.026
BPD only 23 31.5 0.22 0.09 0.50 <0.001
AABS only 453 76.3 1.50 0.74 3.02 0.262
AABS and BPD* 26 68.4 1.00
Single marital status No PD 1645 27.8 0.49 0.26 0.92 0.027
Other PD 550 28.1 0.50 0.26 0.94 0.032
BPD only 43 58.9 1.80 0.82 3.94 0.144
AABS only 276 46.4 1.09 0.57 2.11 0.788
AABS and BPD* 17 43.6 1.00
No educational qualifications No PD 1454 24.8 0.78 0.39 1.56 0.490
Other PD 602 30.9 1.06 0.53 2.12 0.870
BPD only 28 37.8 1.43 0.62 3.29 0.410
AABS only 120 20.3 0.60 0.29 1.24 0.170
AABS and BPD* 11 28.9 1.00
Low socio-economic status No PD 1160 20.6 1.49 0.71 3.12 0.295
Other PD 468 25.0 1.16 0.55 2.44 0.701
BPD only 24 35.8 0.69 0.28 1.68 0.415
AABS only 132 23.1 1.29 0.60 2.76 0.516
AABS and BPD* 10 28.6 1.00

Note: Logistic regression. OR, odds ratio; CI, confidence interval; PD, personality disorder; BPD, borderline personality disor-
der; AABS, syndromal adult antisocial behaviour.
*Reference group.

Copyright © 2012 John Wiley & Sons, Ltd. (2012)

DOI: 10.1002/pmh
 Adult antisocial syndrome with co-morbid borderline PD and violence
adulthood can be found in Table 2. Individuals
classified as AABS + BPD significantly more often
experienced a major financial crisis, became
homeless and/or had trouble with the police. They
were significantly more likely to have been violent
in the last five years, violent while intoxicated,
committed more than five violent acts within the
last five years and more frequently injured the
victim during the violent act. They were also more
frequently injured themselves during an incident
of violence than the No PD, Other PD and AABS
only groups, but no significant difference was
found in comparison with the BPD only group.
Having more than three victim types in violent
acts was more frequent in the AABS + BPD group
when compared with the No PD and Other PD
group, but no significant differences were found
in comparison with the BPD only and AABS
only groups.
Comparison of the three AABS/BPD groups
In order to avoid artificial inflation of odds and to
identify differences between the AABS only, BPD
only and co-morbid AABS + BPD groups, the No
PD and Other PD groups were excluded from
subsequent analyses. The analyses of antisocial and
violent outcomes were then repeated with only the
three AABS/BPD groups (controlling for all signifi-
cant demographic factors) and yielded similar
results: individuals with co-morbid AABS + BPD
showed significantly higher prevalence of all antiso-
cial and violent outcomes—except for more than
three victim types and/or a violent incident resulting
in injury to the perpetrator—compared with those
with AABS or BPD only.
Axis I co-morbid psychopathology. As can be seen
in Table 3, the AABS/BPD group demonstrated a
significantly higher prevalence of anxiety disorder,
conduct disorder, drug and alcohol dependence,
and a higher psychosis score in comparison with
the AABS only group. Compared with the BPD
only group, the AABS + BPD group showed a
higher prevalence of drug and alcohol dependence,
Copyright © 2012 John Wiley & Sons, Ltd.
and a higher score on the PSQ psychosis screen.
No significant differences were found regarding
conduct disorder, depressive or anxiety disorders.
Antisocial and violent outcomes: Adjustment for Axis
I pathology and other confounders. Significant
differences between the AABS + BPD and the
‘BPD only’ and ‘AABS only’ groups are outlined
in Table 4. After adjusting for demography and
co-morbid psychopathology, all the significant
associations shown in Table 2 disappeared, with
the following exceptions. First, the AABS + BPD
group demonstrated a significantly (p = 0.02)
higher prevalence of homelessness and a signifi-
cantly (p = 0.02) higher tendency to have injured
a victim in a fight compared with the BPD only
group (but not the AABS only group). Second,
the AABS + BPD group significantly more often
reported five or more violent incidents in the last
five years when compared with both the BPD only
(p = 0.02) and AABS only (p = 0.03) groups.
AABS only and AABS/BPD: Comparison of antiso-
cial PD criteria. The adult antisocial criteria of
deceitfulness (p = 0.02), impulsivity (p = 0.014)
and irritability/aggressiveness (p = 0.001) were
significantly more prevalent in the AABS + BPD
group, whereas recklessness and lack of remorse
were significantly (p = 0.001) more prevalent in
the AABS only group. Notwithstanding this
difference in the pattern of adult antisociality,
the two groups did not differ significantly in terms
of their total dimensional scores, with groups
having almost identical means: 3.32 and 3.39 for
AABS and AABS + BPD respectively.
In contrast, 10 out of 15 CD criteria demon-
strated a significantly higher prevalence in the
AABS + BPD group including bullying (p = 0.013),
fighting (p < 0.001), use of a weapon (p < 0.001),
physical cruelty to people (p = 0.001), stealing
while confronting a victim (p = 0.026), damage to
property (p < 0.001), breaking and entering
(p = 0.038), staying out at night (p < 0.001), telling
lies (p = 0.001) and running away from home
(p = 0.005). Comparison of the total dimensional
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Freestone et al.

Table 2: Antisocial and violent outcomes

n % OR 95% CI p

Major financial crisis No PD 509 8.7 0.09 0.05 0.18 <0.001

Other PD 277 14.2 0.16 0.08 0.31 <0.001
BPD only 15 20.5 0.37 0.16 0.87 0.023
AABS only 150 25.3 0.34 0.17 0.66 0.001
AABS and BPD* 19 48.7
Homelessness No PD 127 2.2 0.03 0.02 0.07 <0.001
Other PD 76 3.9 0.06 0.03 0.12 <0.001
BPD only 8 10.8 0.17 0.07 0.46 <0.001
AABS only 94 15.9 0.28 0.14 0.56 <0.001
AABS and BPD* 16 41.0
Trouble with the police No PD 382 6.5 0.06 0.031 0.124 <0.001
Other PD 181 9.3 0.09 0.045 0.181 <0.001
BPD only 14 19.2 0.30 0.121 0.741 0.009
AABS only 182 30.7 0.30 0.147 0.595 0.001
AABS and BPD* 21 55.3
Violence in past five years No PD 491 8.6 0.09 0.05 0.19 <0.001
Other PD 237 12.1 0.16 0.08 0.33 <0.001
BPD only 25 34.2 0.39 0.16 0.96 0.040
AABS only 208 35.1 0.39 0.19 0.81 .012
AABS and BPD* 22 56.4
Violent while intoxicated No PD 176 3 0.04 0.02 0.09 <0.001
Other PD 96 4.9 0.08 0.04 0.18 <0.001
BPD only 12 16.4 0.23 0.09 0.63 0.004
AABS only 119 20 0.24 0.11 0.51 <0.001
AABS and BPD* 18 46.2 1.00
Injured self when violent No PD 130 2.2 0.07 0.04 0.16 <0.001
Other PD 70 3.6 0.13 0.06 0.29 <0.001
BPD only 11 14.9 0.41 0.15 1.13 0.084
AABS only 88 14.8 0.38 0.17 0.82 0.014
AABS and BPD* 12 30.8 1.00
More than three victim types No PD 12 0.2 0.04 0.01 0.14 <0.001
Other PD 7 0.4 0.08 0.02 0.30 <0.001
BPD only 3 4.1 0.59 0.11 3.12 0.532
AABS only 18 3.0 0.39 0.11 1.37 0.140
AABS and BPD* 3 7.7 1.00
More than five violent incidents in last five years No PD 99 1.7 0.04 0.02 0.09 <0.001
Other PD 51 2.6 0.07 0.03 0.16 <0.001
BPD only 6 8.2 0.13 0.04 0.42 0.001
AABS only 67 11.3 0.20 0.09 0.45 <0.001
AABS and BPD* 13 34.2 1.00
Victim injured No PD 138 2.3 0.05 0.02 0.10 <0.001
Other PD 78 4.0 0.10 0.04 0.21 <0.001
BPD only 2 2.7 0.05 0.01 0.21 <0.001
AABS only 100 16.8 0.28 0.13 0.60 0.001
AABS and BPD* 15 39.5

Note: Logistic regression; adjustments were made for demography (age, gender and marital status). OR, odds ratio; CI,
confidence interval; PD, personality disorder; BPD, borderline personality disorder; AABS, syndromal adult antisocial behaviour.
*Reference group.

Copyright © 2012 John Wiley & Sons, Ltd. (2012)

DOI: 10.1002/pmh
 Adult antisocial syndrome with co-morbid borderline PD and violence

Table 3: Comparison of the three AABS/BPD groups: Axis I psychopathology

n % OR 95% CI p

Depressive disorder BPD only 17 23.3 2.24 0.70 7.23 0.176

AABS only 21 3.5 0.35 0.12 1.03 0.057
AABS and BPD* 11 28.2 1.00
Anxiety disorder BPD only 47 63.5 0.46 0.16 1.38 0.167
AABS only 139 23.4 0.10 0.04 0.26 <0.001
AABS and BPD* 33 84.6 1.00
Drug dependence BPD only 8 10.8 0.20 0.07 0.63 0.006
AABS only 62 10.4 0.25 0.10 0.61 0.002
AABS and BPD* 17 43.6 1.00
Alcohol dependence BPD only 2 2.7 0.10 0.02 0.49 0.005
AABS only 36 6.1 0.34 0.13 0.91 0.031
AABS and BPD* 14 36.8 1.00
Conduct disorder BPD only 30 40.5 0.55 0.22 1.41 0.213
AABS only 220 37.0 0.41 0.18 0.95 0.037
AABS and BPD* 25 64.1 1.00

M SD
Psychosis score BPD only 0.28 0.72 0.43 0.23 0.78 0.006
AABS only 0.09 0.37 0.36 0.21 0.61 <0.001
AABS and BPD* 0.54 0.79 1.00

Note: Multinomial regression (n/%), adjusted for gender and co-morbid psychopathology (including conduct disorder). OR,
odds ratio; CI, confidence interval; PD, personality disorder; BPD, borderline personality disorder; AABS, syndromal adult
antisocial behaviour.
*Reference group.

CD scores indicated that CD criteria were present to
a significantly (p < 0.001) greater extent in the
AABS + BPD group (mean score 4.8) than in the
AABS group (mean score 2.5).
Discussion
Results of this study provide further evidence that
adult antisocial syndrome co-occurring with
borderline pathology represents a constellation of
traits that is associated with adverse outcomes,
including a high risk for frequent and severe
violence. In showing that the association between
antisocial/borderline co-morbidity and many of the
antisocial outcomes examined was confounded by
Axis I disorders, particularly drug and alcohol use
and CD, the results further help clarify the nature
of the relationship between this constellation of
personality traits and antisocial outcomes, and
violence in particular. Compared with the AABS
only group, the group showing AABS with co-mor-
bid borderline pathology showed significantly
greater evidence of co-morbid Axis I disorders, par-
ticularly anxiety disorders, drug and alcohol depen-
dence, and childhood CD. CD was both more severe
and more prevalent, in terms of the number of crite-
ria met and the total dimensional score, in the
AABS/BPD co-morbid group than in the AABS
only group. This confirms findings reported for treat-
ment-seeking patients with personality disorder
(Howard, Huband & Duggan, 2012). Despite show-
ing a different pattern of adult antisocial behaviours,
as defined by ASPD adult criteria, the AABS/BPD
co-morbid and AABS alone groups did not differ
in the overall degree to which these adult antisocial
criteria were met, that is, their behaviour since age
15 years was antisocial to an equivalent degree. In
short, we have identified a syndrome characterized

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DOI: 10.1002/pmh
Freestone et al.

Table 4: Comparison of the three ASPD/BPD groups: antisocial and violent outcome

n % OR 95% CI p

Major financial crisis BPD only 15 20.5 0.51 0.20 1.30 0.159
AABS only 150 25.3 0.75 0.35 1.64 0.476
AABS and BPD* 19 48.7 1.00
Homelessness BPD only 8 10.8 0.27 0.09 0.82 0.020
AABS only 94 15.9 0.75 0.33 1.73 0.501
AABS and BPD* 16 41.0 1.00
Trouble with the police BPD only 14 19.2 0.42 0.16 1.15 0.092
AABS only 182 30.7 0.80 0.35 1.85 0.602
AABS and BPD* 21 55.3 1.00
Violence in past five years BPD only 25 34.2 0.89 0.35 2.27 0.813
AABS only 208 35.1 0.98 0.43 2.22 0.960
AABS and BPD* 22 56.4 1.00
Violent while intoxicated BPD only 12 16.4 0.77 0.27 2.16 0.615
AABS only 119 20 0.63 0.27 1.50 0.298
AABS and BPD* 18 46.2 1.00
Injured self while violent BPD only 11 14.9 1.03 0.35 2.99 0.959
AABS only 88 14.8 0.78 0.32 1.89 0.581
AABS and BPD* 12 30.8 1.00
More than three victim types BPD only 3 4.1 1.38 0.23 8.46 0.726
AABS only 18 3.0 1.28 0.30 5.44 0.736
AABS and BPD* 3 7.7 1.00
Five or more violent incidents in BPD only 6 24 0.25 0.08 0.80 0.020
last five years
AABS only 67 32.4 0.39 0.17 0.92 0.032
AABS and BPD* 13 61.9 1.00
Victim injured BPD only 2 2.7 0.09 0.02 0.43 0.002
AABS only 100 16.8 0.49 0.21 1.16 0.105
AABS and BPD* 15 39.5 1.00

Note: Logistic regression; adjusted for gender and co-morbid psychopathology (including conduct disorder). OR, odds ratio; CI,
confidence interval; PD, personality disorder; BPD, borderline personality disorder; AABS, syndromal adult antisocial
behaviour; ASPD, antisocial personality disorder.
*Reference group.

by antisocial/borderline co-morbidity that shows all
the hallmarks of the secondary psychopath type de-
scribed as showing the following triad: a high degree
of both adult and child antisocial behaviour, to-
gether with a high degree of adult BPD symptoms
(Blackburn, 2009).
In comparison with the AABS only group
(as well as with other groups), the AABS/BPD
co-morbid group showed poorer outcomes across
a wide range of antisocial outcomes; they showed
in particular a greater risk of violence in terms of
its frequency (number of violent incidents) and
its intensity (victim injured). However, when
Axis I disorders were controlled for, almost all
the differences in antisocial outcome disappeared,
suggesting that the majority of these differences
could be accounted for by co-morbid Axis I disor-
ders, in particular CD and alcohol dependence.
Importantly, CD was a significant confounder for
five out of six violence-related outcomes (the
exception was more than three victim types), and
alcohol dependence was a significant confounder
for four out of six violence-related outcomes. Excep-
tionally, frequent violence (five or more episodes in
five years) remained significantly higher in the
AABS/BPD co-morbid group even when Axis I

Copyright © 2012 John Wiley & Sons, Ltd. (2012)

DOI: 10.1002/pmh
 Adult antisocial syndrome with co-morbid borderline PD and violence
disorders were accounted for, although childhood
CD was still a significant confounder. Of particular
relevance to alcohol-related violence, being male,
alcohol dependent and having a history of CD all
independently contributed to the risk of being
violent when intoxicated (odds ratios were 2.96,
2.95 and 2.76 respectively).
Previous studies have shown that both CD and
alcohol abuse/dependence (particularly when this
starts in adolescence) contribute to the risk of
violence in adulthood (Buchmann et al., 2010;
Farrington, Ttofi, & Coid, 2009; Gustavson et al.,
2007; Wells, Horwood, & Fergusson, 2004). Results
of the current study suggest that AABS/BPD co-
morbidity mediates the relationship between child-
hood CD, adolescent alcohol abuse/dependence
and adult violence. More generally, they support
the hypothesis that AABS/BPD co-morbidity is
the adult presentation of a syndrome that emerges
from a developmental background of pathological
disinhibition in childhood and alcohol (and other
drug) abuse and dependence in adolescence. The
key explanatory mechanism underlying AABS/
BPD co-morbidity and its association with violence
is likely to be impulsiveness, particularly the dimen-
sion of impulsiveness described by Blackburn (2009)
as ‘hostile impulsivity’, reflecting emotional under-
control, belligerence and non-compliance. Consis-
tent with this, the trait-based ratings of personality
disorder proposed for DSM-5 explicitly recognizes
trait-level commonality, in the domains of hostility
and impulsivity, between ASPD and BPD (American
Psychiatric Association, 2011).
Limitations of the study
It can be argued that reliance on self-report when
assessing Axis I and Axis II mental disorders has
biased the prevalence rates because of answering
styles, such as social desirability. Being a cross-
sectional survey, this study relied on retrospective
assessment of symptoms and was therefore depen-
dent on interviewees being truthful in their
responses and accurate in their recollections.
Comparison of self-report and interview-derived
Copyright © 2012 John Wiley & Sons, Ltd.
diagnoses in the second phase of the survey,
however, indicated sufficient accuracy for the
self-reported PDs (Ullrich & Coid, 2009). Never-
theless, these analyses could not be carried out for
Axis I mental disorders. Furthermore, the
time span covered by these diagnoses differed
(currently for psychosis, week before the
interview for affective and anxiety disorders and
one year before the interview for alcohol and
drug-related disorders). This may affect the
comparability of our results with other studies
that used lifetime or present state diagnoses.
Because CD before age 15 years was assessed
retrospectively, the possibility that assessment of
CD symptoms was affected by recall bias cannot
be excluded, particularly because self-report of
recalled childhood behaviours can result in both
false-positive and false-negative errors (Rueter,
Chao, & Conger, 2000). Additionally, low preva-
lence rates of BPD in the sample under examina-
tion, and, therefore, a low rate of co-occurrence
of BPD with AABS, may limit the study’s power
to discriminate the characteristics of this specific
subgroup of personality pathology.
Another limitation of the study was its focus on
adult alcohol dependence, and its failure to assess
early-onset alcohol abuse and dependence. How-
ever, given the evidence that excessive alcohol use
in adolescence continues into young adulthood
(Buchmann et al., 2009), it can be inferred that a
large proportion of those in the present sample
who were alcohol dependent (37% of the AABS/
BPD co-morbid group compared with 6% of the
AABS only group) and engaged in alcohol-related
violence (46% of the AABS/BPD co-morbid group
compared with 20% of the AABS only group)
started abusing alcohol in adolescence.
Finally, in view of evidence that childhood CD
appears to identify a more polysymptomatic and
violent form of ASPD (Goldstein et al., 2006), it is
unfortunate that a distinction between childhood-
onset and adolescent-onset CD was not drawn in this
sample. Nonetheless, there appears to be an overlap
between the more severe pattern of CD symptom-
atology shown by Goldstein et al.’s early-onset CD
(2012)
DOI: 10.1002/pmh
Freestone et al.
group and the pattern shown by our AABS/BPD
group. This suggests that had we been able to
distinguish between early-onset and late-onset
CD, our co-morbid group would likely have been
characterized by a predominance of early-onset CD.
Implications
Prospective studies will be required to confirm the
hypothesis that AABS/BPD co-morbidity repre-
sents an adult syndrome that mediates the relation-
ship between, on the one hand, childhood CD and
adolescent alcohol abuse and, on the other hand, a
predisposition to adult violence. Results of this
study, moreover, suggest that individuals showing
the triad of antisocial/borderline co-morbidity,
co-morbid alcohol dependence and severe conduct
disorder might be at high risk of criminal (particu-
larly violent) recidivism after their release from
secure care into the community.
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Address Correspondence to: Rick Howard,
Institute of Mental Health, Forensic Psychiatry
Section, Sir Colin Campbell Building, Triumph
Road, Nottingham NG7 2TU, UK. Email:
Richard.howard@nottingham.ac.uk
(2012)
DOI: 10.1002/pmh