Personality disorders, violence and antisocial behaviour: updated systematic review and meta-regression analysis

Background Links between personality disorders and antisocial outcomes has not examined individual personality disorders, and the contribution of comorbidities remain uncertain. Previous systematic reviews are dated. Aims To synthesise evidence from observational studies on the risk of antisocial outcomes and recidivism associated with personality disorders. Method We searched six bibliographic databases (up to March 2024) for observational studies examining the risk of antisocial behaviour, interpersonal violence and recidivism in individuals diagnosed with personality disorders, compared to controls. We explored sources of heterogeneity using subgroup analyses and meta- regression. Results We identified 21 studies involving 83418 individuals with personality disorders from 10 countries examining antisocial and violent outcomes (Aim 1), and 39 studies of 14131 individuals from 13 countries with recidivism (or repeat offending) as the outcome (Aim 2). We found increased risks of violence among individuals with any personality disorder (odds ratio 4.5, 95% CI 3.0-6.7), particularly antisocial personality disorder (odds ratio 7.6, 95% CI 5.1-11.5) and borderline personality disorder (odds ratio 2.6, 95% CI 1.8-3.9). Individuals with any personality disorder (odds ratio 2.3,95% CI 2.0-2.6) and antisocial personality disorder (odds ratio 2.8, 95% CI 1.6-4.9) also demonstrated an elevated risk of recidivism. Personality disorder types and comorbid substance use disorder were associated with between-study heterogeneity. Conclusions The assessment and management of personality disorders should be considered as part of violence prevention strategies. Improving identification and treatment of comorbid substance misuse may reduce adverse outcomes in individuals with personality disorders.