Nature and Prevalence of Violent Behavior in Individuals with Borderline Personality Disorder

Background and purpose: The treatment and management of individuals with severe personality disorders, particularly borderline personality disorder (BPD), continues to be a significant challenge for social workers and other providers in the mental/behavioral health care system. Despite the fact that self-harm, interpersonal problems and dysregulated behavior, including aggression, are all considered hallmark characteristics of BPD, little is known about the nature and prevalence of violence toward others among this population. This is important because it has implications for the development of targeted strategies to effectively treat such individuals in the context of community-based services.

Methods: Employing a longitudinal, multi-site sample of 801 individuals recruited from inpatient services (220 met diagnostic criteria for BPD), this study examined (1) the extent to which having BPD elevates risk for violence in the community in the context of other well established risk markers for violence over time, (2) the clinical and demographic characteristics of individuals with BPD who report involvement in violence, and (3) the nature and targets of the violent acts involving such individuals in the community. Reliable and valid instruments measuring the presence of BPD, psychopathy, criminal history, violent behavior and substance abuse were administered along with collection of standard demographic data. Violence data were collected and triangulated every 10 weeks from arrest records, collateral informants, and client self-report over a one-year period, and multivariate logistic regression models examined the degree to which a diagnosis of BPD contributed to increased risk of violent behavior.

Results: Seventy-three percent of BPD subjects (N=160) engaged in violence during the one-year study period, and a series of logistic regression models showed that having BPD was a significant predictor of engaging in future violence. Reported violence was mostly characterized by disputes with significant others and involved hitting, pushing, grabbing or shoving. Violent persons with BPD also frequently exhibited co-morbid antisocial personality disorder (ASPD) and elevated levels of psychopathy, and the results of a series of path models indicated that the shared variance between BPD, ASDP, and psychopathy was a substantial contributor to the prognostic association between BPD and violence.

Conclusions and implications: Our findings show a majority of individuals with BPD engage in interpersonal violence, primarily toward family, friends/acquaintances, and commonly evidence co-morbidity with ASPD and elevated levels of psychopathy. Individuals with BPD who engage in repetitive violence may not receive adequate psychiatric care for their BPD symptoms and, instead, may end up involved in the criminal justice system, where their mental health needs are even less likely to be met and their problems become an increasing burden to society. It will be important that future social work research efforts begin to identify the mechanisms that elevate risk for violence in such individuals, and develop appropriate psychosocial intervention strategies aimed at reducing frequency of violence in this population. Existing evidence-based treatments addressing reduction of self-harm in BPD could be appropriately modified to focus on reducing interpersonal violence, as well as self-harming behavior, and thus more comprehensively serve to improve the lives of individuals with BPD.