Comorbid Borderline Personality Disorder and Substance Use Disorder

It’s common for individuals diagnosed with a substance use disorder to have a co-occurring or comorbid emotional disorder. One of the most common comorbid disorders is borderline personality disorder, or BPD for short. Borderline personality disorder is 1 of 10 personality disorders listed in the DSM-5 – the diagnostic manual used by mental health professionals. Research shows that as many as 73% of adults diagnosed with BPD will battle substance abuse or addiction at some point in their lives.

What is a Personality Disorder?

Personality disorders are characterized by pervasive, deeply ingrained, and dysfunctional patterns of behavior that cause problems in the lives of people that have them. These patterns of behavior generally develop as coping mechanisms early in life. Because these unhealthy behavioral patterns are so deeply entrenched and pervasive, personality disorders are generally considered to be life-long, rather than episodic or occurring for a finite period like many psychiatric disorders. Even with treatment, the prognosis is generally poor in most cases involving individuals with a personality disorder.

Borderline personality disorder is one of the exceptions, however. There are a handful of effective therapeutic approaches that can help individuals with BPD learn healthier interpersonal and intrapersonal coping skills. When used in dual diagnosis treatment (treatment that addresses both the substance use disorder and other psychiatric disorder(s) simultaneously), these therapies can be very beneficial for individuals with comorbid substance use disorder and BPD.

Symptoms of Borderline Personality Disorder

Mental health professionals coined the term “borderline” in the 1930s. It originated from clinicians’ observation that patients exhibiting a unique pattern of symptoms seemed to be on the “border” of neurosis and psychosis but did not actually fit into either category. Even though more clinically appropriate names for this personality disorder have been considered, it has stuck over the years. It’s important to note that BPD is not a psychotic disorder.

One of the hallmark characteristics of BPD is emotional dysregulation, or the inability to manage intense emotions. This symptom manifests in the volatile mood swings typically seen in individuals with this disorder. Their mood can switch from upbeat and euphoric to despondent, depressed, and dysphoric very quickly. This trait is one of the reasons clinicians misdiagnose people with BPD: the symptoms closely resemble bipolar disorder.

Other symptoms of BPD include:

  • Frantic attempts to avoid perceived or actual abandonment. The intense fear of abandonment often plays a role in the volatile emotional ups and downs of individuals with BPD. This is one of the ways to distinguish the disorder from the mood fluctuations in bipolar disorder.
  • Frequent and often chronic suicidal thoughts, threats, gestures, and /or attempts (often triggered by the intense fear of abandonment)
  • Bouts of intense anger, rage, or aggression
  • Impulsivity
  • A fragile sense of self
  • Frequent feelings of emptiness
  • Paranoid thoughts
  • Fleeting dissociative or psychotic episodes, especially during significant stress
  • Self-destructive behavior, such as cutting, substance abuse, and or reckless behavior
  • Intense and often rocky relationships with others, in which there is a back and forth pattern of idealizing and devaluing those closest to them  

BPD Statistics

According to a study published in the April 2008 Journal of Clinical Psychiatry, nearly 6% of the population will meet the criteria for borderline personality disorder at some point in their lifetime. This study, the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, involved face-to-face interviews with 34,653 adult men and women. The researchers did not find any significant difference between the rates of BPD with regards to gender.

According to this study:

  • 3% of individuals with BPD will have any alcohol use disorder at some point in their lifetime, with 41.6% having an alcohol dependence problem
  • 2% of individuals with BPD will have any drug use disorder at some point in their lifetime, with 17.7% having a drug dependence problem
  • 6% of individuals with BPD will develop nicotine dependence at some point in their lifetime

[Please note: the clinical terminology used in these statistics reflects that of the DSM-IV, which differs somewhat from the terminology in the more recent version, the DSM-V.]

It’s apparent that substance abuse and addiction are frequent issues in individuals with borderline personality disorder. Alcohol is one of the most commonly abused substances among individuals in this population, followed by marijuana and nicotine. Stimulants such as methamphetamine, cocaine, and prescription drugs like Adderall are also abused at times.

Similarities between Addiction and BPD

The challenges of treating individuals with BPD are well known to mental health professionals.  Interestingly, there are many close similarities between these challenges and those faced in the treatment of individuals with a substance use disorder. The symptoms of both disorders have significant overlap, including:

  • Impulsive tendencies
  • Frequent lying and manipulation
  • Self-destructive patterns of behavior
  • A history of dysfunctional, volatile relationships
  • Frequent job loss and financial instability
  • Severe fluctuations in mood, including bouts of extremely high energy and/or euphoria and episodes of acute depression and despair

Suicidal thoughts and gestures, which are very common in individuals with BPD, are exacerbated by the disinhibiting and depressive effects of alcohol and other substances. Any substance use disorder, but particularly alcohol abuse or dependence, in this population can be especially problematic because it increases an already elevated risk of a serious suicide gesture or successful suicide attempt.

Each of these similarities can make treating individuals with BPD and a co-occurring substance use disorder especially challenging. Therefore, it’s crucial to find a dual-diagnosis treatment program well-versed in the complexities of borderline personality disorder with staff well-trained in appropriate methods of treatment for this population.

The Connection between BPD, Substance Abuse, and Addiction

When you consider the symptoms of borderline personality disorder, it’s not difficult to understand the connection to substance abuse and addiction. Consider, also, that individuals with BPD often struggle with symptoms of anxiety and depression. They may have other comorbid disorders, including anxiety disorders, PTSD, and major depressive disorder, as well. Substances are especially appealing to individuals with BPD as they, at least temporarily, can:

  • Provide an escape from intense negative emotions
  • Reduce self-loathing
  • Calm feelings of rage
  • Boost mood during bouts of depression
  • Lower social inhibitions for those with anxiety, helping them feel more outgoing
  • Make the constant ups and downs seem more tolerable
  • Numb the pain of abandonment
  • Provide excitement and relieve boredom
  • Alleviate feelings of emptiness

Sadly, these “positive” effects of substances quickly subside, and the individual with BPD must face their demons once again. The temporary reward reinforces the desire to drink or use again, creating a vicious cycle that often leads to addiction and disordered use. Treatment attempts will usually be futile unless clinicians address the substance use disorder and personality disorder simultaneously.

Treatment for Comorbid BPD and Substance Use Disorder

For individuals who have both BPD and substance use disorder, a dual diagnosis treatment approach is necessary. As mentioned above, dual diagnosis treatment involves treating both disorders simultaneously, rather than focusing on one disorder at a time. If someone with BPD engages in a treatment program that focuses solely on the substance use disorder, the odds of successful recovery are slim to none. This is because the substance use is likely fueled and almost certainly exacerbated by the BPD symptoms.

Personality disorders, as a rule, are notoriously difficult to treat. However, evidence shows some therapeutic approaches are effective in treating individuals with BPD. These therapies are often a component of dual diagnosis treatment. They include:

  • Dialectical Behavior Therapy (DBT and DBT-S)
  • Cognitive Behavioral Therapy (CBT)
  • Family Therapy
  • Pharmacologic Therapy

We’ll briefly discuss each of these approaches below.

Dialectical Behavior Therapy

Dialectical behavior therapy is a form of cognitive behavioral therapy, developed by Dr. Marsha Linehan and her colleagues back in the 1970s to treat borderline personality disorder. Over the years it has been found to be one of the most effective therapies for treating BPD. It’s also an effective treatment for a variety of other psychiatric disorders, including substance use disorders.

Dialectical behavior therapy helps individuals develop mindfulness skills, manage and regulate intense emotions, learn to handle stress, and develop effective interpersonal skills. It also focuses on strengthening and supporting their motivation to change while reducing the occurrence of unhealthy and self-destructive behaviors.

A specific type of dialectical behavior therapy (DBT-S) can also treat individuals with comorbid BPD and substance use disorder. It utilizes a group setting in which individuals learn traditional DBT skills as well as additional skills geared to help ensure successful recovery by reducing the likeliness of relapse.

Cognitive Behavioral Therapy

Cognitive behavioral therapy focuses on helping individuals identify and change underlying irrational thought patterns and distorted beliefs that fuel negative feelings and reinforce unhealthy, self-destructive behaviors. Traditional CBT, while still beneficial, is generally not as effective as DBT for individuals with borderline personality disorder.

Family Therapy

Borderline personality disorder and substance use disorder significantly impact the entire family. Family therapy can be very beneficial in conjunction with other forms of treatment to help family members learn to communicate more effectively, manage conflict and stress in healthy ways, and support the individual in treatment without enabling them.

Pharmacotherapy

The FDA has not approved any medications to treat BPD specifically. However, some medications can treat symptoms of the disorder, as well as co-occurring disorders like anxiety and depression. These include antidepressants, mood stabilizers, and antipsychotic medications.

There are some FDA-approved medications specific to substance use treatment. These include naltrexone, acamprosate, and disulfiram (Antabuse) for alcohol use disorder and naltrexone, buprenorphine, and methadone for opioid use disorder.  

Any medications must be prescribed and carefully monitored by a psychiatrist well-versed in dual diagnosis treatment involving individuals with BPD.

Other therapies used in a comprehensive dual diagnosis treatment program for BPD include:

  • EMDR (Eye Movement Desensitization and Reprocessing)
  • Mentalization-based therapy
  • Interpersonal group therapy
  • Dynamic deconstructive psychotherapy
  • Transference-focused therapy
  • Schema-focused therapy

Treatment Goals for Comorbid BPD and SUD

The primary treatment goal of dual diagnosis treatment, in a nutshell, is to help individuals effectively manage both their mental health disorder and substance use disorder while maintaining sobriety. Treatment does this by teaching healthy coping skills, working to reduce or eliminate social and environmental cues and influences as much as possible, and reducing cravings for alcohol and/or substances.

Borderline personality disorder can be a particularly challenging disorder to treat effectively, especially when there is a co-occurring substance use disorder. However, treatment can be very effective – and successful recovery a reality – when working with caring professionals, like those at Pinnacle Treatment Centers, who have the proper training, experience, dedication, and compassion.