Borderline Personality Disorder and Psychopathy: What’s the Difference?

By Carrie Barron

What’s the difference between these two common and often-confused conditions?

Borderline Personality Disorder is characterized by instability in identity, mood, and feelings of security. In the DSM 5, it is a Cluster B personality disorder, which captures disorders marked by dramatic or unpredictable behaviors. This is as opposed to Cluster A, which captures disorders marked by odd behaviors and Cluster C which captures disorders marked by anxiety.

Here is a list of criteria for Borderline Personality Disorder, or BPD:

• An intense fear of abandonment, separation, or rejection
• Precarious yet intense relationships with “black and white” thinking – idealizing someone one moment and devaluing them the next
• Fluctuating, unstable identity with inconsistent goals and values. Seeing the self as overly flawed or nonexistent
• Bouts of paranoia and poor reality testing lasting from that last up to a few hours
• Impulsive and risky behavior, including gambling, reckless driving, unsafe sex, spending sprees, binge eating, drug abuse or self-destructive behaviors such as quitting a good job or relationship
• Suicidal threats or behavior or self-injurious actions in fear of separation or rejection
• Sweeping mood swings from joy to irritability, shame or anxiety
• Feeling empty
• Moments of intense anger, biting sarcasm or physical fights

While treatments depend on the individual, recommended options include Dialectical Behavioral Therapy, Cognitive Behavioral Therapy, Transference Focused Psychotherapy and Mentalization-based Psychotherapy. These are all manual-based, evidence-based treatments.

A good outcome using any of these treatments depends on the therapeutic relationship and rapport as well as the experience and skill of the therapist. The goal is for the person to get better at managing affect and feelings, integrating the good and bad into one person instead of splitting into a value-devalue pattern, and developing a sense of continuity in personal identity as well as in relations with others.

Psychopathy is not a formal diagnosis but a condition that can accompany other disorders or stand alone as    a character type. One way to assess it is with the revised Psychopathy Checklist (PCL-Revised) developed by forensic psychologist Dr. Robert D. Hare. An experienced researcher or clinician is best suited to conduct the interview and assess the condition, as gradations of symptoms are involved. Assessing each trait isn’t just a straightforward yes or no.

The descriptive traits on the PCL-Revised include:

• Superficial
• Grandiose
• Deceitful
• Lacks remorse
• Lacks empathy
• Doesn’t accept responsibility
• Impulsive
• Poor behavioral controls
• Lacks goals
• Irresponsible
• Adult antisocial behavior
• Adolescent antisocial behavior

There are challenges to treating psychopathy. Containment, such as clear limit setting, rather than a true cure may be a more realistic goal.  It is difficult to create a conscience in a remorseless person, but you might be able to uncover a conscience. If the diagnosis looks like psychopathy, but actually is something else, such as narcissism, the prognosis could be better. Someone may exhibit psychopathic traits under extreme stress or if their grandiosity is excessive, but if the stress abates and the grandiosity is treated, psychopathic traits may abate and a sense of morality, ethics and even empathy might emerge. An extremely skilled diagnostician is essential as the interventions and prognoses are different for psychopathy and narcissism as well as borderline personality disorder.

Overall, when we compare borderline personality disorder and psychopathy, there is a wildness common to both. The gestalt difference is that someone with BPD often feels out of control and victimized while the psychopath is more able to regulate his or her affect and derives a sense of power from the ability to manipulate, deceive and control others.

Both are at risk for hard falls because the behaviors can lead to painful consequences.

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Carrie Barron, M.D., is director of Creativity for Resilience at Dell Medical School and an associate professor in the Department of Medical Education. She is also a board-certified psychiatrist, psychoanalyst, and Positive Psychology Coach.