The Relationship between Borderline Personality Disorder and Addiction


Before discussing personality disorders and borderline personality disorder, it is important to understand that the descriptions of these disorders described in this article are offered for educational purposes and are not intended to be used for diagnosis. At Greenhouse Treatment Center, our Personalized and Therapeutic Healing (PATH) Program includes dedicated care for mental health and personality disorders by licensed practitioners who are passionate about your mental health and sobriety. Learn more here

What Is Personality?

Before discussing the definition of a personality disorder is important to define the term personality in a psychological sense. Personality comes from the Latin word persona, meaning “mask” and frequently refers to the set of characteristics that influence a person’s internal thinking and external behaviors.

Psychologists understand that the concept of a personality must function to express the person’s needs, define motivations, allow the person to build relationships and guide behavior.1 For example, if we say that someone is an extrovert (a well-documented personality trait), then most of the time, we should be able to correctly predict that the person is going to be outgoing in social situations.

What Is a Personality Disorder?

The American Pyschiatric Association utilizes the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) as the current clinical diagnostic manual for all psychological/psychiatric disorders. According to DSM-5, a personality disorder is:

“… an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”2

Using the clinical diagnostic criteria, this means that personality disorders are stable tendencies that have existed in the person at least since adolescence. They also go against the expectations of the person’s culture and cause the person to experience significant stress. Ultimately, personality disorders lead to issues with functioning in society in terms of relationships, jobs, or other areas.2

Three General Clusters

There are ten major personality disorders listed in DSM-5 that belong to one of three clusters:2

  • Cluster A: Odd or eccentric behavior is considered to be the central feature of the three personality disorders in this cluster. These disorders include schizotypal, schizoid, and paranoid personality disorders.
  • Cluster B: Dramatic and/or eccentric emotional type responses are common to this cluster. Personality disorders here include borderline, antisocial, narcissistic, and histrionic personality disorder.
  • Cluster C: Anxious or fearful behaviors characterize these personality disorders. They include avoidant, dependent, and obsessive-compulsive personality disorder.

Borderline personality disorder (BPD) is a disorder characterized by difficulties with emotional regulation (Cluster C). BPD is characterized by a longstanding or pervasive pattern of having unstable relationships with others, an unstable personal image, along with unstable emotions, as well as displaying significant impulsive behaviors. These behaviors are often first present during adolescence or early adulthood and occur in a variety of different situations.

According to DSM-5, nine diagnostic criteria can be used to formally diagnose BPD in a person:2

  • A pattern of volatile and intense relationships that alternate between poles of idolization and devaluation
  • Emotional volatility due to an observable mood reaction
  • Fleeting paranoid ideation related to stress or strong dissociative symptoms. These consist of feelings that one is removed or detached from the body, removed or detached from reality, or experiences of severe amnesia.
  • Frenzied attempts to avoid abandonment (whether actual or imagined)
  • Impulsivity and destructive behavior in two or more areas that are potentially self-harming (e.g., substance abuse, binge eating, and reckless driving)
  • Inappropriate, passionate anger or trouble managing anger (e.g., recurrent demonstrations of temper, perpetual anger, recurring physical violence, etc.)
  • Markedly and persistently unbalanced sense of self
  • Persistent feelings of desolation
  • Persistent suicidal behavior, suicidal threats, or self-harming behavior
  • To receive a formal diagnosis of BPD, a person has to display at least five of the nine symptoms.

Many researchers, such as the eminent psychiatrist Otto F. Kernberg, consider that pervasive feelings of loneliness which result in the need to feel wanted or to belong to someone/something are the driving forces behind this particular disorder.3 However, BPD is a disorder that can present in many different ways.

If you or someone you know needs help dealing with suicidal thoughts, help is available 24/7.

Call the National Suicide Prevention Hotline at 1-800-273-8255.
Veterans can also utilize the Veteran Crisis Line via text 838255 or via online chat with a crisis counselor.

Other Features of BPD

There are many different studies on the prevalence of BPD; however, the most up-to-date figures place the prevalence in the general population to be anywhere between 1.6 and 5.9 percent.2

In inpatient settings, it’s estimated the BPD affects up to twenty percent of all patients. Generally, the disorder is seen less frequently in older population groups, and the current male to female ratio of people diagnosed with BPD is 1:3.2

Being physically or sexually abused, neglected, coming from a home with domestic violence, or having lost a parent in childhood appear to be relatively common occurrences among people diagnosed with BPD. This disorder is about five times more common in first-degree biological relatives, indicating that a potential genetic component contributes to the probability of having the disorder.2 However, like all personality disorders, there is no distinct cause associated with the development of BPD in anyone, and it is believed that this disorder results from an interaction of genetic and environmental factors.

Types of BPD

Due to the manner in which BPD is diagnosed and the potential for many different presentations of the disorder, there have been several attempts to identify subtypes of BPD.3 Renowned psychologist Theodore Milton identified four distinct sub-groups of BPD. Some say that the work of the late personality psychologist Theodore Millon is the most recognized.4

Current research is still exploring the exact number of BPD subtypes. However, some distinct subgroups have emerged. Of those, these three seem to be the most often diagnosed:4

  • Impulsive: In this subtype of BPD, being impulsive is a major feature of their personality. This population group is at very high risk for attempted suicide or self-mutilation. The impulsive subtype of BPD is also often prone to becoming very bored and restless, getting involved in reckless and thrill-seeking activities, and demonstrating drastic mood changes.
  • Discouraged: This BPD subtype often presents as clingy, reliant on others, and very passive. Feelings of anger or abandonment are often focused inward, and this subtype is also at risk for suicide tempts or self-mutilating behavior. Their need for dependence on others, which never seems to be satisfied for long, leads to chronic feelings of emptiness or intolerance with relationships.
  • Petulant: This subtype of BPD often vacillates between feelings of unworthiness and explosive outbursts of anger. For this reason, it’s often referred to as the “angry” subtype. These individuals are fearful of being abandoned or rejected, and this leads to issues with jealousy, controlling, and manipulating other people, possessiveness, anxiety, and irritability.

Individuals with this subtype of BPD feel a need to control others to keep them close, and because of this need, they are often overprotective of people in their lives. At the same time, they do not experience satisfaction with relationships. This leads to the potential to develop issues with substance abuse. People with this subtype may harbor intense feelings of self-loathing, bitterness, and self-hatred. They may express a chronic need for attention from others and, if not satisfied, turn to self-destructive behaviors that can include substance abuse, eating disorders, risky sexual activities, or thrill-seeking behaviors.

Comorbidity of Other Disorders with BPD

Research findings indicate that numerous disorders co-occur with BPD. The most common co-occurring disorders include:5

  • Mood disorders. Mood disorders are the most commonly co-occurring group of disorders and include depression and bipolar disorder.
  • Anxiety disorders. These include panic disorders and phobias.
  • Post-traumatic stress disorder. This disorder was previously listed as an anxiety disorder but is now classified in a new category namedTrauma and Stressor-Related Disorders.
  • Substance use disorders or alcohol use disorder. Issues with substance abuse and addiction frequently occur in individuals diagnosed with BPD. Drugs and alcohol can represent a sort of substitution for a relationship that also allows individuals to achieve a perception, albeit a false perception, that by using, they can achieve control over their emotions, their relationships, and their self-image.3

When an individual is diagnosed with both BPD and another disorder, it means that creating a treatment plan can be more challenging.

Treatment Options for BPD

Personality disorders are notoriously complicated to treat. BPD has received notoriety as being even more difficult to treat than other personality disorders. However, recent research has indicated that BPD can respond to treatment and that individuals diagnosed with BPD can make gains.6

There are no specific medications that are designed or approved to treat BPD. Some research suggests that antidepressants, anti-anxiety medications, or even antipsychotic medications can be used to manage some specific symptoms of BPD. No one medication will work to treat the disorder, which often results in a person being placed on several medications, some of which might be more useful than others.

Individuals with BPD are typically treated with therapy or a combination of medication and therapy. The therapies typically used in the treatment of BPD are most often Cognitive Behavioral Therapies (CBT) that help individuals to identify and change their beliefs, expectations, and attitudes regarding relationships with others and their own personal feelings about themselves. CBT is particularly effective in helping to restructure a person’s self-image, reduce issues with mood and anxiety, reduce the tendency towards self-harm, and assist in recovery from substance use disorders.

Several specialized types of CBT appear to be especially effective for treating people who suffer from BPD.7

  • Dialectical Behavior Therapy concentrates on the concept of mindfulness, which refers to remaining aware and focusing one’s attention on the current situation. This type of therapy helps to teach the individual to control their intense feelings, improve their relationships, and reduce self-destructive types of behaviors.
  • Schema-Focused Therapy is useful in changing the self-image of people with BPD, how they react to their interactions with others, and how they cope with problems and stress.

Specialized forms of group or family therapy have also been useful in treating the symptoms and self-image of people with BPD.

Treating BPD and Substance Use Disorders Together

Issues with rage, mood swings, impulsivity, unstable relationships, and a dysfunctional self-image are features of BPD that increase the susceptibility to substance use disorders (addiction).11 Most often, people who have BPD struggle to comply with treatment. Because people with BPD have issues with relationships, and those with addictions find the relationship with their drug/activity of choice to be the most stable relationship that they have experienced, these individuals are more likely to have difficulties in developing a relationship with a therapist or engaging in group therapy.

Outside of therapy, individuals with BPD will typically have very unstable interpersonal relationships. It is important to help them to develop social skills to maintain relationships outside of therapy. Using 12-Step groups, group therapy, and other focused groups may help the individual to develop more functional personal relationships.

People diagnosed with BPD are at a higher risk of suicide and other forms of self-destructive behavior than other individuals. When these individuals are under the influence of drugs or alcohol, the risks for self-destructive behaviors increase. This issue often complicates therapy, and Dialectical Behavior Therapy appears to be particularly useful in addressing issues regarding feelings of suicide and self-destructive behavior.

Conclusions

BPD is a severe personality disorder that can present several different ways. Typically, it involves feelings of potential loneliness or abandonment, poor emotional regulation, issues with relationships, self-destructive behaviors, and other serious co-occurring disorders, including substance use disorders, which are quite common. Treatment can be complicated but effective in managing the disorder.

References

  1. Allport, G. (1937). Personality: a psychological interpretation. Holt.
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  3. Kernberg, O. (1985). Borderline Conditions and Pathological Narcissism. Aronson, Lanham, MD.
  4. Millon, T., Millon, C., Meagher, S., et. al. (2012). Personality Disorders in Modern Life. Wiley, Hoboken, NJ.
  5. Biskin, R., Paris, J. (Jan. 10, 2013). Comorbidities in Borderline Personality Disorder. Psychiatric Times, 30:1.
  6. Soler, J., Pascual, J., Campins, J., et. al. (June 1, 2005). Double-Blind, Placebo-Controlled Study of Dialectical Behavior Therapy Plus Olanzapine for Borderline Personality Disorder. J. Psych., 162:6.
  7. Gunderson, J., Links, P. (2014). Handbook of Good Psychiatric Management for Borderline Personality Disorder. American Psychiatric Publishing, Washington, DC.


About The Contributor

BRIAN WU, MD
BRIAN WU, MD

Psychiatrist

Brian Wu is an MD/PhD graduate and current psychiatrist. He is interested in transforming complex medical topics into material accessible for all. He is interested in systems based care and helping those through education and quality improvement... Read More


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