Expert Clinician Insights Into the Diagnosis and Treatment of Men With Antisocial and Borderline Personality Disorder: A Qualitative Study.

OBJECTIVES

Men with presentations consistent with borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are highly visible in community and forensic services. However, mis/underdiagnosis may be a consequence of their lower than expected engagement with mental health services, and when they do engage, systematised diagnostic biases may inaccurately differentiate these two subtypes. Given the substantial harms experienced by men who have personality disorder (PD), it is important to understand how personality disorder can be better identified and supported in clinical and forensic settings.

METHODS

Ten nationally and internationally recognised clinician participants who have expertise in the diagnosis and treatment of men with PD (80% male; 60% psychologists, 40% psychiatrists) participated in individual, semi-structured qualitative interviews. Participants shared their observations regarding PD presentations in men and recommendations for maximising treatment engagement in community and forensic settings. Transcripts from the 60-90-min interviews were analysed using inductive and deductive thematic analysis.

RESULTS

The analysis identified four themes: Getting men through the door, Unmasking Complexity, Holding Steady in the Face of Risk, and Addressing Shame through Connection. Men with BPD tend to under-report their symptoms and distrust mental health services. Clinicians may struggle to differentiate BPD from ASPD, as men's emotional dysregulation often manifests as anger. Participants emphasised appealing to the person's self-interest, building a trusting therapeutic alliance, and carefully addressing shame to facilitate treatment engagement.

CONCLUSIONS

Half of the expert clinicians were employed in forensic settings where men with BPD are disproportionately prevalent, rendering their perspectives especially valuable. Assessment of empathetic functioning can help counterbalance clinicians' overemphasis on aggressive behaviours when differentiating BPD from ASPD in men. Incorporation of gendered attributes and targeting associated defensive barriers may improve treatment engagement and effectiveness for men with personality disorder.