Considered to be the third most predominant personality disorder in the United States, borderline personality disorder, or BPD, likely co-occurs with substance abuse disorders (SUDs) more than any other personality disorder aside from antisocial personality disorder, the journal Innovations in Clinical Neuroscience publishes. The National Alliance on Mental Illness (NAMI) reports that between 1.6 and 5.9 percent of the American adult population may suffer from BPD, a serious mental illness that may make it difficult for an individual to complete daily tasks and form normal relationships with others.
Three-fourths of those diagnosed with borderline personality disorder are women, although NAMI postulates that men may suffer equally from BPD and may often be misdiagnosed. Men who suffer from BPD, more often than women, will also commonly struggle with substance abuse disorders and addiction, the National Institute on Mental Health (NIMH) reports. Between 50 and 70 percent of those suffering from BPD also battle a SUD, Psych Central estimates.
Characterized by impulse control issues, difficulties with interpersonal relationships, and unstable mood patterns, borderline personality disorder is often recognized in early adulthood. The exact cause of BPD is not entirely clear, although NIMH reports that the disorder is likely heritable and points to both genetic and environmental aspects as potential risk factors. Emotional trauma and high levels of stress may trigger BPD symptoms, and individuals in unstable environments may be at a higher risk for developing the disorder than others.
In order to be diagnosed with BPD, the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as published by the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) In Brief, states that at least five of the following symptoms must be present:
- Inflexible, unchangeable, and pervasive behavior patterns
- Inability to recognize that behavior patterns are out of the ordinary or problematic
- Behaviors start at least by early adulthood
- Behavior patterns that are fixed, rigid, and way outside the realm of culturally acceptable
- Significant distress interfering with aspects of daily life
- Symptoms have no other identifiable cause (e.g., head trauma, drug or alcohol use, or other mental illness)
Someone who suffers from borderline personality disorder may experience extreme mood swings that may seem out of proportion to the situation and triggered by seemingly inane circumstances. Impulsivity, reckless behaviors, and those that are deemed self-destructive may also be common. Binge eating, risky financial decisions, unsafe sexual encounters, and drug and alcohol use may be typical examples of potentially dangerous behaviors. Boredom, feelings of emptiness, paranoia, and low self-worth may also be the norm with BPD. It may be difficult for someone struggling with BPD to maintain healthy relationships due to the unpredictable and volatile nature of the mood swings and behavior patterns. A person may swing from idolizing a particular person to feeling rejected by them, prompting violence and rage.
Suicidal and self-harming behaviors are also relatively common, as almost 80 percent of individuals diagnosed with BPD attempt suicide. These individuals die by suicide at rates more than 50 times that of the general population. Other self-harming behaviors that are not meant to be fatal, but rather intended as a method to feel something, to punish themselves, to regulate emotions, or as a release, are called non-suicidal self-injury, or NSSI, and include cutting, burning, head banging, hair pulling, hitting, or skin-picking. In Brief publishes that more than three-quarters of those battling BPD engage in deliberate NSSI behaviors.
The Relationship between Substance Abuse and BPD
There are several reasons that a person may battle both addiction and a mental illness concurrently, known as co-occurring disorders. Genetics and brain structure may play a role, for example, as regions of the brain that are related to emotional regulation, impulse control, and reward processing may be involved in both substance use disorders and borderline personality disorder, the National Institute on Drug Abuse (NIDA) postulates.
Environmental factors like stress and early trauma can also impact brain structure and may be related to patterns of substance abuse and also to the onset of BPD. Someone who suffers from BPD may be more inclined to use drugs or alcohol as a method of self-medication, or in an effort to manage symptoms of the disorder. Drugs and alcohol may improve moods and self-image, making them desirable and temporarily effective coping mechanisms. Psychiatric Times reports that alcohol, cocaine, and opioid drugs are common substances of abuse for individuals battling BPD. Cocaine may provide a kind of invincible feeling of not being able to do any wrong and of being in better control, while alcohol and opioid drugs may calm turbulent emotions and seem to smooth emotions.
Substance abuse can have the opposite of its desired effect, however, actually heightening already volatile emotions and potentially leading to a higher incidence of risk-taking behaviors, violent outbursts, and crime. NIMH reports that adults who suffer from BPD are more likely than their peers to be the victim of rape, violence, or other crimes. The risk for suicidal and self-harming behaviors goes up as well with the introduction of drugs and/or alcohol.
Chronic drug or alcohol use makes changes to the brain’s chemical structure, thus further impacting a person’s ability to feel pleasure, regulate emotions, or control impulses. Addiction is the product of being unable to manage how much, or how often, substances are abused, and numerous negative behavioral, social, emotional, physical, and interpersonal consequences may result. BPD symptoms may get worse, and treatment may be complicated due to addiction.
When a person suffers from co-occurring borderline personality disorder and addiction, they may be less likely to stay in treatment for the necessary amount of time, medications may be less effective, and substance abuse relapse rates may be higher, Psych Central publishes. Co-occurring BPD and addiction are treatable, however; as Psychology Today points out, an individualized and comprehensive integrated treatment model using both medical and psychiatric methods can be highly beneficial and even potentially lifesaving.
Treatment for BPD and Addiction
The National Survey on Drug Use and Health (NSDUH) reports that in 2014, over 20 million Americans over the age of 11 battled a substance use disorder. Drug tolerance, dependence, and withdrawal symptoms are all potential signs and side effects of an SUD. In the presence of an SUD, detox is often required to allow drugs or alcohol to leave the body and help to regulate the disrupted brain chemistry. When co-occurring mental illness is also present, as in the case of a BPD diagnosis, medical detox is the safest and most secure method of withdrawal.
During medical detox, potentially dangerous and even life-threatening withdrawal symptoms can be managed, often with the help of medications, and vital signs are continuously monitored. Mental health professionals can ensure both the individual’s safety and the safety of those around them, from possible violent or self-destructive outbursts. Detox usually lasts 5-7 days depending on the individual circumstances; however, in some instances, it may last longer. After detox, a person can move right into a complete treatment program.
Medications, like mood stabilizers, are often beneficial in treating BPD. These medications need to be carefully monitored and potentially modified in the case of co-occurring substance abuse in order to ensure that there are no additional complications or adverse reactions. Therapeutic methods such as Dialectical Behavior Therapy (DBT) and Cognitive Behavioral Therapy (CBT) are both commonly employed in the treatment of BPD. DBT is considered one of the standard methods of treatment for BPD, focusing on acceptance of difficult emotions and improvement of a person’s self-image, NAMI publishes. Behavioral therapies teach individuals how to recognize potential triggers as well as coping mechanisms for managing them as they arise. Group skills training sessions as well as individual and more focused sessions and even phone access to the therapist are all part of a DBT plan.
Relationships are difficult with borderline personality disorder, and this can extend to the relationship between the therapist and client as well. As a result, it’s best to choose a therapist who has extensive experience in treating individuals with BPD. It is important that a strong and healthy therapeutic alliance be formed in order to further treatment goals. When addiction co-occurs, this may be even more complicated.
For this reason, an integrated approach that includes a team of medical, substance abuse, and mental health professionals who all understand and are trained in treating co-occurring addiction and BPD is highly beneficial. Experienced professionals can work together to design and carry out a treatment plan that will be suit the individual and be able to grow with them as their needs evolve. Borderline personality disorder and addiction are treatable with specialized care and attention.