Antisocial Personality Disorder Associates with Greater Substance Use Disorder Risk Than Borderline Personality Disorder in Patients with Nicotine Dependence: A Retrospective Study

Abstract

Background: Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are both associated with substance use disorders (SUDs), yet their comparative risks across specific substances remain unclear, particularly among patients with nicotine dependence. Methods: We conducted a retrospective cohort study using the TriNetX database, including 48,916 patients with BPD and nicotine dependence and 12,150 patients with ASPD and nicotine dependence. Outcomes included alcohol use disorder, cocaine abuse, opioid abuse, and cannabis abuse. Risk ratios, odds ratios, and Kaplan-Meier survival analyses with Cox proportional hazards models were used to compare substance use incidence between cohorts. Results: The ASPD cohort exhibited significantly higher risk and odds for all four substance use outcomes compared with the BPD cohort. Risk ratios ranged from 0.405 to 0.668, and odds ratios ranged from 0.343 to 0.591, consistently favoring higher risk in ASPD. Kaplan-Meier analyses confirmed these differences, with hazard ratios (95% CI) of 0.367 (0.350–0.384) for cocaine abuse, 0.568 (0.550–0.587) for alcohol use disorder, 0.630 (0.606–0.655) for opioid abuse, and 0.569 (0.539–0.600) for cannabis abuse. Conclusions: Among patients with nicotine dependence, ASPD is associated with substantially higher risk of alcohol, cocaine, opioid, and cannabis use disorders compared with BPD. These findings underscore the need for targeted screening and interventions tailored to the ASPD population.