Abstract
Objective
Borderline personality disorder (BPD) is highly prevalent among incarcerated populations; however, research has yet to examine whether prisoners diagnosed with BPD experience greater interpersonal dysfunction and institutional misconduct while incarcerated.
Procedure
This study drew from a sample of 184 male and female prisoners diagnosed with major depressive disorder (MDD) in a randomized trial of depression treatment. The presence of a BPD diagnosis (n = 69) was analyzed as a predictor of disciplinary incidents/infractions (i.e., fights, arguments with staff, disciplinary infractions, isolation), time spent in isolation, and types of aggression and victimization experiences during incarceration.
Results
There was a trend suggesting prisoners with BPD were about twice as likely as those without BPD to report disciplinary incidents/infractions (OR = 1.76 [.93, 3.32], p = .075). Having a BPD diagnosis was unrelated to time in isolation and overall aggression and victimization. However, prisoners with BPD were more likely than those without BPD to perpetrate and be victimized by psychological aggression. Due to high rates of antisocial personality disorder (ASPD) in the sample as a whole (72%), additional analyses compared outcomes across prisoners with no BPD or ASPD diagnosis, BPD diagnosis only, ASPD diagnosis only, and comorbid BPD and ASPD. Prisoners with comorbid BPD and ASPD were no more likely than prisoners with ASPD only to report disciplinary incidents/infractions, but were significantly more likely than those with ASPD only to report perpetrating and being victimized by psychological aggression.
Conclusions
Among prisoners with MDD, those with a BPD diagnosis have increased risk of psychological aggression and disciplinary infractions during incarceration.
Keywords: borderline personality disorder, aggression, victimization, institutional misconduct, prison
1. Introduction
Borderline personality disorder (BPD) is a psychiatric disorder characterized by instability in affect regulation, cognition, impulse control, and interpersonal relationships, and is associated with significant functional impairment [1]. For instance, suicide attempts are among the most salient indicators of BPD [2, 3] and 75% of those with the disorder will attempt suicide at least once during their lifetimes [4, 5]. BPD is characterized by impulsivity that often prompts engagement in significant health risk behaviors. Indeed, people with BPD engage in high rates of risky illicit behaviors, often leading to criminal justice system involvement [6, 7]. National studies have found that between 2.7 and 5.9% of adults meet criteria for BPD [8, 9], however, rates of BPD are markedly higher among men and women in the criminal justice system [10]. Up to 30% of prisoners meet full diagnostic criteria, and around 93% meet at least one criterion for BPD [11]. Despite research documenting the high prevalence of BPD among incarcerated populations, little research has examined how individuals with BPD adjust to and behave during incarceration.
1.1. Institutional Misconduct among People with BPD
There is reason to believe that people with BPD may be at a greater risk for institutional misconduct (i.e., disciplinary infractions and the resulting punishments such as segregation or isolation) during incarceration. Due to the severity of the disorder, people with BPD may experience emotional and behavioral dysregulation that prompts engagement in disruptive, rule-breaking behaviors. Certain prisoner characteristics such as younger age, history of substance use, and history of violence and victimization, have been found to be associated with institutional misconduct [12]. However, the role of specific mental health disorders in institutional misconduct has rarely been considered. The few studies that have examined the association between personality psychopathology and institutional misconduct have used self-report personality assessments. Studies have shown that the borderline features scale on the Personality Assessment Inventory (i.e., BOR) is positively correlated with number of disciplinary infractions during incarceration [13, 14]. Further, a meta-analysis showed that the BOR scale was moderately predictive of institutional misconduct across studies [15]. Research has yet to investigate the risk of engaging in institutional misconduct among people diagnosed with BPD (as opposed to individuals who endorse some BPD features on a self-report scale), limiting our understanding of the risk associated with this specific disorder.
Prisoners with BPD may also be at higher risk of experiencing interpersonal difficulties during incarceration compared to prisoners without BPD. In particular, prisoners with BPD may be more likely to perpetrate and be victimized by psychological or physical forms of aggression. Instances of violence and victimization are common in correctional settings. Up to one-third of male inmates report perpetrating physical violence during incarceration [16]. In addition, 43% of incarcerated men report knowing that a sexual assault occurred and 16% report witnessing a sexual assault within their correctional facility [17]. With regard to BPD, studies suggest a well-documented association between BPD and intimate partner violence perpetration [18–25] and victimization [22, 23, 26] in community samples. BPD traits, including impulsivity [24] and emotion dysregulation [27] are associated with violence against family members and friends. Aggression and victimization experiences involving other inmates or staff during incarceration have the potential to prompt serious consequences such as disciplinary infractions that lengthen the prison sentence. However, research has yet to examine aggression and victimization experiences during incarceration among prisoners with BPD.
1.2. Comorbidity with Antisocial Personality Disorder
In addition to examining the risk of aggression, victimization, and institutional misconduct associated with a BPD diagnosis, the comorbidity of BPD and ASPD diagnoses may also be important to consider. There is ample research suggesting a strong positive association between the antisocial features scale of the Personality Assessment Inventory (i.e., ANT) and institutional misconduct [14, 15]. However, the BOR scale predicts unique variance in institutional misconduct above the ANT scale [14]. Individuals with comorbid BPD and ASPD may have more severe behavioral difficulties compared to individuals with either disorder alone, especially among forensic samples [28]. For instance, one study showed that forensic patients with comorbid BPD and ASPD returned to the justice system more quickly than those with BPD alone or ASPD alone [29]. Secondary analyses examining the risk of institutional misconduct associated with comorbid BPD and ASPD, in relation to each disorder alone, will provide additional information about diagnostic risk.
1.3. Present Study
Given the elevated prevalence of BPD among inmates and the lack of research examining how people with BPD adjust to incarceration, research is needed to understand the risk associated with incidents of institutional misconduct as well as other behavioral difficulties that may ultimately contribute to institutional misconduct (i.e., aggression toward others and victimization experiences) among people diagnosed with BPD. Further, the comorbidity BPD and ASPD needs to be considered when examining institutional misconduct and behavioral difficulties during incarceration. The present study examined associations among BPD diagnosis, aggression towards others, victimization experiences, and institutional misconduct during incarceration in a sample of 184 male and female prisoners. We hypothesized that prisoners with a BPD diagnosis would report (a) heightened aggression towards others, (b) increased victimization experiences, and (c) increased disciplinary incidents/infractions during incarceration, compared to prisoners without a BPD diagnosis.
2. Methods
2.1. Participants and Procedures
This secondary analysis uses data from the baseline (i.e., pre-treatment) assessment of a randomized controlled trial [30], which assessed the effects of interpersonal psychotherapy (IPT) for major depressive disorder (MDD) among women and men in prison. A sample of 184 male and female prisoners was recruited from five minimum and medium security prisons in Rhode Island and Massachusetts. Potential participants were recruited through flyers or announcements made in the prison residential areas describing the depression treatment study. Participants privately volunteered for the initial assessment. Study staff conducted screening and consent procedures individually and privately. Staff read the consent form out loud and emphasized the voluntary nature of study participation. There were no legal incentives for participation. Participants received compensation for completing follow-up assessments (U.S. $10 per assessment). The studies followed ethical guidelines for research with prisoners under institutional ethics review board approval.
All participants met criteria for current primary (non-substance-induced) MDD as determined by the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I; [31]) after at least 4 weeks of incarceration. Participants who met SCID-I lifetime criteria for bipolar disorder or a primary psychotic disorder were excluded. Participants were required to expect to be at their current facility for at least 6 months so that study follow-ups could take place in prison. All assessments took place in prison and included structured interviews and self-report measures administered by research assistants (RAs) with a BA or MA. All research assistants were trained in interviewer administered instruments at Brown University’s Clinical Assessment and Training Unit and were supervised by the senior author JJ and by a clinical interviewing trainer.
2.2. Measures
2.2.1. BPD diagnosis
The presence of BPD was determined at baseline (i.e., entry into the study during incarceration) by the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II; [31]), which aligns with the diagnostic criteria for BPD in the DSM-IV.
2.2.2. ASPD diagnosis
The presence of antisocial personality disorder (ASPD) was assessed at baseline using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II; [31]), which aligns with the diagnostic criteria for ASPD in the DSM-IV.
2.2.3. Institutional misconduct
We analyzed two variables capturing institutional misconduct in the past 6 months. For the first variable, we used four dichotomous items from the adapted Life Events Questionnaire (LEQ; [32]), modified to capture events in a prison context. These items asked whether participants 1) got into any fights in prison, 2) got into any arguments with prison staff, 3) had any disciplinary action taken against them by the prison, and 4) had been put in isolation in the past 6 months. A positive response to any of these items was coded as a 1 on a dichotomous variable of disciplinary incidents/infractions. For the second variable, we examined the number of weeks participants reported spending in isolation/punishment in the past 6 months using a calendar-based interview method [33]. Among those who reported spending time in isolation (n = 71), we analyzed the number of weeks capturing time spent in isolation. We relied on self-report for institutional misconduct because our experience has been that this information is accurate, and sometimes more accurate, than institutional records. For example, studies often find a high correlation between self-reported and official records of arrest, sometimes with self-report including more information than is officially documented [34].
2.2.4. Aggression and victimization during incarceration
Aggression and victimization during incarceration were assessed using an adapted version of the Conflict Tactic Scale-2 (CTS-2; [35]). The CTS-2 was designed to capture tactics a participant has used (and the frequency of usage) during conflict with a partner (i.e., aggression scale), as well as to capture the tactics that a partner has used against a participant (i.e., victimization scale). Adaptations were made for the study to ask about incidents in relationships with anyone (inside or outside the prison) over the past 3 months, rather than only with romantic partners. Further, the original CTS-2 aggression and victimization scales each have 5 subscales, but the subscale assessing sexual violence was omitted due to the sensitive nature of these questions in a correctional setting; the adapted aggression and victimization scales used in this study each had 4 rather than 5 subscales (see next paragraph for subscale creation), with a total of 32 aggression items and 32 victimization items. To create the overall aggression and victimization scales, all items capturing aggression toward others were averaged to create a total score (aggression α = .91) and all items capturing victimization experiences were averaged to create a total score (victimization α = .88).
Four subscales of the CTS-2 were analyzed for the aggression and victimization scales. Within the overall aggression scale, subscales included psychological aggression (example item: “I insulted or swore at someone;” subscale α = .84), negotiation (example item: “I showed someone I cared even though we disagreed” [reverse coded]; subscale α = .86), physical assault (example item: “I pushed or shoved someone;” subscale α = .94), and injury (example item: “Someone had physical pain that still hurt the next day because of a fight with me;” subscale α = .93). Within the overall victimization scale, parallel subscales included psychological aggression (example item: “Someone insulted or swore at me;” subscale α = .79), negotiation (example item: “Someone showed care for me even though we disagreed” [reverse coded]; subscale α = .84), physical assault (example item: “Someone pushed or shoved me;” subscale α = .93), and injury (example item: “I felt physical pain that hurt the next day because of a fight with someone;” subscale α = .90). Items within each subscale were averaged to create 4 aggression and 4 victimization subscale scores.
2.2.5. Demographics/Covariates
Age, gender, number of months served on the current sentence, and prison location (state) were assessed with a demographic questionnaire.
2.3. Data Analysis Plan
Data were analyzed in SPSS and Mplus. Because we anticipated that certain model outcomes would be correlated (i.e., CTS-2 victimization and aggression scales, CTS-2 subscales), we ran path models in order to correlate those outcomes. In one path model, we examined the association of BPD diagnosis with aggression and victimization (correlated). In another path model, we examined the association of BPD diagnosis with the four CTS-2 aggression subscales (correlated), and another with the four CTS-2 victimization subscales (correlated). We ran a logistic regression to examine the relationship between BPD diagnosis and disciplinary incidents/infractions, and a regular regression to examine the relationship between BPD diagnosis and time spent in isolation (among those who spent time in isolation). Finally, to examine the risk of institutional misconduct, aggression, and victimization experiences during incarceration for individuals with comorbid BPD and ASPD, we ran logistic regressions (for dichotomous outcomes) and one-way ANCOVA’s with Bonferroni correction (for continuous outcomes) comparing prisoners with no BPD or ASPD diagnosis, those with a BPD diagnosis only, those with an ASPD diagnosis only, and those with both a BPD and ASPD diagnosis.
Variables thought to be related to aggression, victimization, and institutional misconduct were examined as potential covariates. These included gender [36, 37] months served on the current sentence (a measure of the length of participants’ current incarceration), the state the prison was located in, and age. We used one-way ANOVAs and chi-square analyses to examine whether aggression, victimization, and institutional misconduct variables varied by state. There were no significant between-group differences in aggression (F(1) = .42, p = .519) victimization (F(1) = .20, p = .656) time spent in isolation (F(1) = 2.39, p = .124), or any of the CTS-2 subscales among states and chi square analyses showed no significant differences in disciplinary incidents/infractions (χ 2 = 3.63, p = .057) by state. Therefore, state was ultimately not included as a covariate. In addition, months served on the current sentence and gender were unrelated to all outcomes and were excluded. There was a main effect of age on several outcomes examined and it was retained as a covariate in the final model.
All variables were analyzed as observed variables. Missing data (< 2%) were handled using Full Information Maximum Likelihood, which uses model information to estimate parameters [38, 39]. The Maximum Likelihood Robust estimator was used due to use of dichotomous outcomes as well as to correct standard error bias that can result from higher than normal kurtosis in some of the CTS-2 subscales [40]. A significance level of .10 was used due to the small sample of individuals diagnosed with BPD in this study.
3. Results
Univariate statistics of study variables are presented in Table 1 and sample descriptives split by BPD diagnosis are presented in Table 2. A total of 37.7% (n = 69) of the sample had a BPD diagnosis. The only significant difference in sample descriptives by BPD diagnosis was that those with BPD were more likely than those without to be diagnosed with ASPD (see Table 2). Of the 69 prisoners diagnosed with BPD, 88% (n = 61) had a comorbid diagnosis for ASPD, whereas 62% of the 114 prisoners without BPD met criteria for ASPD.
Table 1.
Sample descriptives (n = 184)
| n (%) | M (SD) | Possible Range |
Actual Range |
Skew | Kurtosis | |
|---|---|---|---|---|---|---|
| Demographics | ||||||
| Age | -- | 39.3 (10.4) | 18-- | 20–61 | .001 | −.92 |
| Sex (Female) | 66 (35.9%) | -- | 0–1 | 0–1 | .59 | −1.67 |
| Race (Caucasian) | 116 (63%) | -- | 0–1 | 0–1 | −.55 | −1.72 |
| Hispanic (1) | 34 (18.5%) | -- | -- | 0–1 | −1.63 | 0.66 |
| State (Massachusetts) | 111 (60.3%) | -- | -- | -- | -- | |
| Diagnosis a | ||||||
| BPD | 69 (37.7%) | -- | 0–1 | 0–1 | .51 | −1.76 |
| ASPD | 132 (72.1%) | -- | 0–1 | 0–1 | −1.00 | −1.02 |
| BPD ASPD Comorbidity | -- | -- | 0–3 | 0–3 | −.62 | −1.03 |
| No BPD or ASPD | 43 (23.5%) | -- | -- | -- | -- | -- |
| BPD Only (1) | 8 (4.4%) | -- | -- | -- | -- | -- |
| ASPD Only (1) | 71 (38.8%) | -- | -- | -- | -- | -- |
| BPD and ASPD | 61 (33.3%) | -- | -- | -- | -- | -- |
| CTS-2 Scales | ||||||
| Aggression Overall | -- | 26.29 (18.92) | 0–160 | 0–143 | .75 | 2.63 |
| Negotiation | -- | 14.87 (7.58) | 0–48 | 0–35 | .33 | −.32 |
| Psych. Aggression | -- | 9.40 (8.47) | 0–36 | 0–45 | 1.61 | 1.32 |
| Physical Assault | - | 1.54 (6.09) | 0–72 | 0–54 | 2.76 | 7.34 |
| Injury | .48 (2.87) | 0–36 | 0–28 | 4.97 | 25.84 | |
| Victimization Overall | -- | 23.64 (16.66) | 0–160 | 0–129 | .39 | 1.86 |
| Negotiation | -- | 13.36 (7.47) | 0–36 | 0–35 | .38 | −.28 |
| Psych. Aggression | -- | 8.28 (7.29) | 0–48 | 0–40 | 1.49 | 3.10 |
| Physical Assault | -- | 1.19 (5.11) | 0–72 | 0–47 | 3.04 | 9.61 |
| Injury | -- | .53 (2.93) | 0–36 | 0–30 | 4.54 | 21.84 |
| Misconduct b | ||||||
| Disciplinary Incidences/ | 81 (44.5%) | -- | 0–1 | 0–1 | .22 | −1.97 |
| Infractions (1) | ||||||
| Time Spent in Isolation | 71 (39.0%) | 5.61(6.23) | 0-- | 0–34 | 2.16 | 5.69 |
Note. 1 person was missing data on diagnosis (n = 183)
2 participants were missing data on institutional misconduct (n = 182). The presence of any institutional misconduct: arguments with staff, fights with inmates, time in isolation, receiving disciplinary infractions. Skew and kurtosis values for in-prison aggression, victimization, injury, and assault subscales reflect the transformed variable; these variables were square root or log transformed.
Table 2.
Sample descriptives split by BPD diganosis (n = 183)
| BPD Diagnosis (n = 69) |
No BPD Diagnosis (n = 114) |
||||
|---|---|---|---|---|---|
| N (%) | M (SD) | N (%) | M (SD) | p | |
| Age | ---- | 37.4 (10.3) | 40.5 (10.3) | .851 | |
| Sex (Female) | 28 (40.6%) | ---- | 38 (33.3%) | ---- | .322 |
| Race (Caucasian) | 45 (65.2%) | ----- | 71 (62.3%) | ---- | .689 |
| Hispanic (1) | 17 (24.6%) | ---- | 17 (15.0%) | ---- | .107 |
| State (Massachusetts) | 38 (55.1%) | ---- | 72 (63.7%) | ---- | .247 |
| ASPD Diagnosis (1) | 61 (88.4%) | ---- | 71 (62.3%) | ---- | <.001 |
3.1. Institutional misconduct
Results from regressions predicting disciplinary incidents/infractions and isolation from BPD diagnosis are presented in Table 3. Controlling for age, results showed a trend suggesting that prisoners diagnosed with BPD were more likely to report disciplinary incidents/infractions (OR 1.76; 95% CI = .93 – 3.32). Further examination of individual questionnaire items used to create the institutional misconduct variable (chi square analyses) showed that prisoners with BPD were no more likely to get into fights (x2 = .40, p = .525) or be put in isolation (x2 = .81, p = .367), but there were trends suggesting they were more likely to get into arguments with prison staff (x2 = 3.39, p = .066), and receive disciplinary infractions (x2 = 3.38, p = .066) compared to prisoners without BPD. The presence of a BPD diagnosis was not associated with having spent more time in isolation, among those who spent time in isolation (see Table 3).
Table 3.
The relationship of BPD diagnosis with aggression, victimization, CTS-2 subscales, and institutional misconduct during incarceration
| Disciplinary Incidents/ Infractions a |
Time Spent in Isolation b |
Aggression During Incarceration c |
Victimization During Incarceration c |
|
|---|---|---|---|---|
|
| ||||
| OR[95% CI] | B (SE) | B (SE) | B (SE) | |
| Age | .003** [.00, .06] | −.10 (.09) | −.14+ (.08) | −.09 (.08) |
| BPD Diagnosis | 1.76+ [.93, 3.32] | −.02 (.12) | .08 (.08) | .06 (.08) |
Note. Dichotomous outcome, analyzed as the sole outcome in a logistic regression model.
Continuous outcome, analyzed as the sole outcome in a linear regression model.
In-prison aggression and victimization are correlated in one path model. These outcomes are square root transformed due to positive skew. Model fit indices are not reported because all models are just identified. MLR scaling correction factor for the aggression and victimization model = 1.91.
p < .10,
p < .05,
p < .01
3.2. Aggression and victimization
Results from the path model predicting aggression and victimization from BPD diagnosis are presented in Table 3. Aggression (skew = 2.67, kurtosis = 11.67) and victimization (skew = 2.33, kurtosis = 10.25) scales were skewed and square root transformed (see Table 1). Aggression and victimization scales were highly correlated in the path model (r = .91, p < .001). Prisoners diagnosed with BPD were no more likely to have engaged in aggression toward others or report having been victimized by others during the past 3 months compared to prisoners not diagnosed with BPD (see Table 3).
3.3. Aggression and victimization subscales
Results from the path models predicting aggression and victimization subscales from BPD diagnosis are presented in Table 4. The injury (skew = 7.86, kurtosis = 66.69; skew = 7.62, kurtosis = 65.20) and physical assault (skew = 6.10, kurtosis = 42.40; skew = 6.56, kurtosis = 47.96) subscales on the aggression and victimization scales respectively were skewed and log transformed (see Table 1). Two path models were run: one containing the relationship between BPD diagnosis and all aggression subscales (correlated) and a second containing the relationship between BPD diagnosis and all victimization subscales (correlated). All aggression and victimization subscale outcomes were significantly correlated with each other in the path models at p < .001 (magnitudes ranging from r = .17 to .77) except for the negotiation with physical assault scale (victimization: r = .04, p = .617) and negotiation with injury scale (aggression: r = .15, p = .129, victimization: r = .04, p = .534). Having a BPD diagnosis was significantly positively associated with both perpetration and victimization of psychological aggression, and negatively associated with the victimization subscale capturing poor negotiation skills (see Table 4).
Table 4.
The relationship of BPD diagnosis with CTS-2 aggression and victimization subscales during incarceration
| Aggression Subscales |
Negotiation | Psychological Aggression |
Physical Assaulta | Injury a |
|---|---|---|---|---|
|
| ||||
| B (SE) | B (SE) | B (SE) | B (SE) | |
| Age | −.12 (.07) | −.14* (.07) | −.06 (.08) | .11 (.06) |
| BPD Diagnosis | −.10 (.07) | .22** (.07) | −.03 (.08) | .01 (.09) |
| Victimization Subscales | Negotiation | Psychological Aggression | Physical Assaulta | Injury a |
|
| ||||
| B (SE) | B (SE) | B (SE) | B (SE) | |
|
| ||||
| Age | −.16* (.07) | −.03 (.07) | −.04 (.09) | .09 (.08) |
| BPD Diagnosis | −.14* (.07) | .24** (.07) | .02 (.08) | .03 (.08) |
Note. All aggression outcomes are correlated in one path model; all victimization outcomes are correlated in a separate path model.
Log transformed due to positive skew. Model fit indices are not reported because all models are just identified. MLR scaling correction factor for aggression subscale model = 1.91. MLR scaling correction factor for victimization subscale model = 1.74.
p < .10,
p < .05,
p < .01
3.4. BPD and ASPD comorbidity
We ran a logistic regression predicting the presence of disciplinary incidents/infractions from a four level predictor: no BPD or ASPD diagnosis, BPD diagnosis only, ASPD diagnosis only, and both BPD and ASPD diagnosis, controlling for age. Contrasts indicated that prisoners with ASPD alone (OR = 2.78, 95% CI = 1.16; 6.66, p = .021) and comorbid BPD and ASPD (OR = 4.08, 95% CI = 1.68; 9.94, p = .002) were more likely than those with no BPD/ASPD diagnosis to report disciplinary incidents/infractions. However, there were no significant differences in prisoners with comorbid BPD and ASPD compared to those with ASPD alone (OR = .68, 95% CI = .33; 1.42, p = .306). Of note, all prisoners in this study also had MDD, so MDD diagnosis is present in all diagnostic groups being compared in this analysis.
Results from one-way ANCOVAs comparing continuous outcomes within the four comorbidity categories (controlling for age) are reported in Table 5. Results indicated no differences between any comorbidity categories on time spent in isolation (F(4) = .93, p = .453) or overall aggression (F(4) = 1.64, p = .167) or victimization (F(4) = .93, p = .453). The only CTS-2 subscales with any differences were psychological aggression perpetration (F(4) = 4.93, p = .001) and victimization (F(4) = 3.20, p = .015). Prisoners with comorbid BPD and ASPD (M = 12.47, SE = 1.05) reported significantly higher levels of psychological aggression perpetration (i.e., they engaged in more psychological aggression toward others) compared to those with no BPD/ASPD diagnosis (M = 7.14, SE = 1.24, p = .008) and those with only an ASPD diagnosis (M = 8.46, SE = 1.05; p = .036). Similarly, prisoners with comorbid BPD and ASPD (M = 10.84, SE = .92) reported significantly higher levels of psychological aggression victimization (i.e., they were victimized by more psychological aggression) compared to those with no BPD/ASPD diagnosis (M = 6.82, SE = 1.10, p = .035) and those with only an ASPD diagnosis (M = 6.88, SE = .87, p = .013).
Table 5.
ANCOVA examining BPD and ASPD comorbidity with continuous outcomes
| Diagnosis Groups
| |||||
|---|---|---|---|---|---|
| Outcomes | No BPD/ASPD Diagnosis (n = 43) M (SE) |
BPD Only (n = 8) M (SE) |
ASPD Only (n = 71) M (SE) |
Both BPD and ASPD (n = 61) M (SE) |
p |
| Time Spent in Isolation a | 4.09 (1.82)a | −.36 (4.60)a | 6.38 (1.18)a | 5.89 (1.16)a | .453 |
| Aggression Overall | 25.91 (2.90)a | 22.27 (6.73)a | 24.68 (2.26)a | 29.16 (2.44)a | .470 |
| Negotiation | 16.63 (1.19)a | 15.58 (2.67)a | 14.96 (.91)a | 13.69 (.97)a | .236 |
| Psycholog. Aggression | 7.14 (1.24)a | 6.44 (2.89)b,d | 8.46 (.98)a,c | 12.47 (1.05)d | .001 |
| Physical Assault | 1.73 (.95)a | .11 (2.18)a | 1.15 (.73)a | 2.07 (.79)a | .800 |
| Injury | .44 (.44)a | .13 (1.02)a | .19 (.34)a | .92 (.37)a | .290 |
| Victimization Overall | 25.92 (2.54)a | 22.47 (5.91)a | 20.98 (1.99)a | 25.60 (2.14)a | .443 |
| Negotiation | 15.38 (1.15)a | 12.72 (2.61)a | 13.58 (.88)a | 12.01 (10.14)a | .078 |
| Psycholog. Aggression | 6.82 (1.10)a | 9.44 (2.52)a | 6.88 (.87)b | 10.84 (.92)c | .015 |
| Physical Assault | 1.73 (.79)a | .17 (1.81)a | .39 (.61)a | 1.90 (.66)a | .279 |
| Injury | .76 (.45)a | .15 (1.03)a | .11 (.35)a | .93 (.38)a | .174 |
Note. N = 184. BPD = Borderline Personality Disorder; ASPD = Antisocial Personality Disorder Means/percentages without a common superscript letter are significantly different from one another (p < 0.05).
Sample size is reduced to those who spent time in isolation in the following order: no BPD/ASPD diagnoses = 12, BPD only = 2, ASPD only = 28, both BPD and ASPD = 29.
4. Discussion
The purpose of this study was to examine associations between BPD diagnosis, aggression towards others, victimization experiences, and institutional misconduct during incarceration in a sample of male and female prisoners. We hypothesized that, compared to prisoners without BPD, prisoners diagnosed with BPD would (a) exhibit increased aggression towards others, (b) experience higher levels of victimization, and (c) be more likely to report disciplinary incidents/infractions during incarceration. We also hypothesized these relationships may be stronger for prisoners with comorbid BPD and ASPD. Findings supported some of these hypotheses.
A sizeable portion of this sample of prisoners diagnosed with MDD (37.7%) had a BPD diagnosis, the majority of the sample (72%) had an ASPD diagnosis, and almost all prisoners with BPD had co-occurring ASPD (88%). This rate is not uncommon, especially among forensic psychiatric samples [28, 41]. Prisoners diagnosed with BPD were trend-significantly and about twice as likely as those without a BPD diagnosis to self-report disciplinary incidents/infractions during incarceration, defined as getting into fights in prison, getting into arguments with prison staff, having disciplinary action taken against them by the prison, or having been put in isolation. When examining individual indicators of institutional misconduct within this variable, we found that this association was driven by prisoners with BPD being more likely to report getting into arguments with prison staff, and to have disciplinary actions taken against them by the prison. Prisoners with comorbid BPD and ASPD diagnoses were over 4 times as likely to report disciplinary incidents/infractions compared to prisoners without a BPD or ASPD diagnosis, however, the risk of disciplinary incidents/infractions for the comorbid group did not significantly differ from those only diagnosed with ASPD. Our findings are consistent with previous studies showing BPD (as assessed on self-report personality inventories) may not necessarily predict institutional misconduct above and beyond ASPD [13]. Our study is one of the first to investigate the risk of engaging in institutional misconduct among prisoners diagnosed with BPD, considering comorbidity with ASPD diagnosis, using diagnostic interviews.
Contrary to our hypotheses, among prisoners with MDD, having a diagnosis of BPD was not associated with self-reported aggression toward others or victimization over the past 3 months of incarceration. Consistent with this finding, when examining individual indicators of misconduct within the institutional misconduct variable, we found no differences in rates of “getting into fights” among prisoners with and without a BPD diagnosis. This is somewhat surprising, given that people with BPD in community and clinical samples report more aggression [22, 42] and victimization [43] compared to people without BPD. Notably, only 7.1% of the sample reported getting into fights, which may have reduced power to detect an effect. Prisoners with a BPD diagnosis did, however, report engaging in and being victimized by more psychological aggression during incarceration. In addition, prisoners with comorbid BPD and ASPD reported significantly more perpetration and victimization by psychological aggression compared to prisoners with an ASPD diagnosis alone. This finding is consistent with research showing heightened use of psychological aggression among people with BPD in particular [44, 45], as well as the presence of a more severe constellation of dysregulated behaviors among people with comorbid BPD and ASPD [28]. People with BPD are removed from existing dysfunctional interpersonal relationships upon incarceration and placed in an environment involving direct supervision, which may reduce the likelihood of violent interpersonal conflict but not necessarily psychological/verbal forms of aggression. Of interest, prisoners with a BPD diagnosis were less likely to report that others used poor negotiation skills with them, which suggests that they perceived others attempted to compromise or resolve conflicts with them effectively during the past 3 months of incarceration. They were not more likely to report their own use of appropriate negotiation skills, suggesting that skills deficits or other BPD symptoms may have interfered with their ability to reciprocate positive problem-solving attempts.
Of note, the overall aggression and victimization scales were highly correlated in our sample (r = .90), suggesting that prisoners who self-reported aggressive behavior toward others also perceived being victims of those behaviors from other inmates or staff. Research has shown that individuals with BPD have difficulty differentiating between victimization and perpetration [46]. For instance, people with BPD are particularly prone to reactive aggression, that which occurs in response to a provocation [47]. It is also possible that certain types of prisoners with BPD do experience higher levels of overall aggression and victimization than other prisoners. For instance, there is reason to believe the relationship between BPD and aggression in particular differs among men and women [48]. This study was underpowered to examine gender differences, but this is an important direction for future research.
More research is needed to understand interpersonal difficulties or other symptoms as causes of institutional misconduct among prisoners with a BPD diagnosis, and particularly those with comorbid BPD and ASPD diagnoses. Overall aggression and victimization scores were only moderately correlated with disciplinary incidents/infractions in this sample (r = .24, r = .20 respectively), suggesting that other factors likely contributed to institutional misconduct. Our findings suggested that arguments and issues with prison staff (which could possibly be due to higher psychological aggression) drove the differences in institutional misconduct among prisoners with and without a BPD diagnosis. Other features of BPD such as high levels of impulsivity or emotion dysregulation may cause disruptive behavior that prompts disciplinary violations. For instance, extreme displays of emotion and behaviors that result from poor distress tolerance (e.g., self-injury, suicidal gestures) may prompt individuals with BPD to disobey correctional staff orders. Such behaviors may be important in explaining why people with BPD (and people with serious mental disorders in general; [49]) have high rates of institutional misconduct compared to other prisoners. Understanding which diagnostic criteria and/or correlates of BPD are responsible for this increased risk will help tailor prison mental health services to those prisoners likely to have difficulty adjusting to incarceration.
4.1. Limitations
The results of the current study should be interpreted in light of several limitations. First, we examined the relationship between BPD and behavioral outcomes among prisoners who also met diagnostic criteria for major depressive disorder (MDD). Notably, around 20% of people with BPD in the general population have co-occurring MDD [50] and, relative to other personality and psychiatric disorders, BPD is among the strongest predictor of MDD persistence [51], suggesting high comorbidity between these disorders. However, our results may not be generalizable to non-incarcerated individuals with BPD and comorbid depression, or to incarcerated individuals only diagnosed with BPD (i.e., no comorbid MDD). Relatedly, our sample of prisoners diagnosed with BPD (n = 69) was small and limited our power to investigate gender differences (i.e., 41 men diagnosed with BPD, 28 women diagnosed with BPD, 76 men without BPD, 38 women without BPD). Second, this research is cross-sectional, and as such we cannot determine causal relationships between a BPD diagnosis and outcome variables, or investigate mechanisms of this relationship. Third, two of our findings (relationship between BPD and individual institutional misconduct variables capturing getting into arguments with staff and receiving more disciplinary infractions) were suggestive rather than definitive because they were only trend-significant. We decided to interpret trend-significant findings due to our small sample size, however, larger studies should replicate these findings. Fourth, our institutional misconduct variables were self-reported and could have been underreported. Despite the limitations, this study provides an initial step toward understanding how prisoners with BPD behave during incarceration in comparison to other prisoners.
4.2. Conclusions
This research has important clinical implications for prisoners with BPD. Prisoners with BPD have greater psychiatric comorbidity, poorer quality of life, and overall worse functioning compared to prisoners without BPD [11]. Findings from this study suggest that, among prisoners with MDD, those with a BPD diagnosis (and particularly those with comorbid BPD and ASPD) may have greater risk for some kinds of disruptive behaviors and institutional misconduct, such as arguments with prison staff and other manifestations of psychological aggression. There is a need for future studies to identify other factors that underlie institutional misconduct among prisoners with BPD, as well as gender differences in these relationships. Interventions that address the emotional and behavioral dysregulation in BPD may not only improve prison adjustment for these individuals, but may also serve to reduce the time and resources correctional staff use to manage these prisoners. Interventions targeting the potential causes of institutional misconduct (e.g., emotion dysregulation, impulsivity) may reduce the chances that individuals with BPD experience institutional misconduct during incarceration.
Highlights.
Examined institutional misconduct, aggression, & victimization in inmates with BPD.
Compared outcomes in inmates with co-occurring BPD and ASPD to those with either disorder alone.
Inmates with BPD had higher risk of disciplinary infractions & psychological aggression.
Co-occurring BPD and ASPD associated with more psychological aggression than ASPD only.
Inmates with BPD at risk of verbal misconduct during incarceration.
Acknowledgments
This research was supported by funding from the National Institute of Mental Health (NIMH; R01 MH095230; Johnson, PI and NIDA T32DA019426-12 (KEM)). The work described in this article does not express the views of NIMH. The views expressed are those of the authors.
Footnotes
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Declarations of interest: none.
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