Borderline Personality Disorder and Substance Abuse
The term personality is one that is freely used in both lay circles and professional and clinical circles.
Personality is often considered to be something that is consistent and enduring that defines an individual; however, there is a good body of research to suggest that many traits that have been defined as a component of personality are not expressed by individuals who are alleged to have them in every situation.
The definition of personality also varies from theorist to theorist; however, the personality theorist and psychologist Gordon Allport proposed a definition of personality that is still used and built upon by modern personality theorists: “Personality is the dynamic organization within the individual of those psychophysical systems that determine his unique adjustment is environment.”
Allport’s definition regards personality is a mechanism that is developing and changing but also performs a function and uniquely guides the individual’s adjustment to changes in the environment, motivates the person to action, and guides the person’s interactions with others.
According to the book Cognitive Therapy for Personality Disorders: A Guide for Clinicians, a personality disorder represents a persistent pattern of behavior and inner experience expressed by the person that significantly deviates from expectations of that person’s culture, has been expressed by that person since early adolescence or early adulthood, remains stable and resistant to change, and results in stress or impaired functioning in an individual. Individuals who have personality disorders demonstrate rather stable, rigid, and inflexible tendencies that significantly deviate from cultural and societal expectations, and result in the individual experiencing negative effects. In addition, individuals with personality disorders typically do not view themselves as being the source of their problems, but instead place the blame regarding their issues with functioning in society on other people.
This profile makes personality disorders often very complicated to treat. The individuals who are diagnosed with them are often very unstable and open to the development of a number of other comorbid (co-occurring) psychological conditions.
A Quick History of the Diagnosis of Personality Disorders
Personality theorists believe that so-called personality traits can be quite fluid, the clinical perception of a personality disorder has not accepted this idea.
For quite some time, the American Psychiatric Association has used an approach to diagnosing personality disorders that is based on defining them as separate disorders that are discrete, mutually exclusive, and standalone psychiatric/psychological conditions. However, despite this approach, the actual diagnostic criteria of many of the defined personality disorders share quite a bit of overlap, and individuals are often diagnosed with more than one personality disorder at the same time based on the same presentation.
This situation raised quite a bit of controversy with personality theorists for many years, and the American Psychiatric Association had promised to revamp its diagnostic scheme for personality disorders in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), which was released in 2013. Unfortunately, there was no revision of personality disorders from the previous editions of the DSM,and personality disorders are diagnosed according to the same criteria that were used over 20 years ago despite hope that the diagnostic scheme would be upgraded. The situation continues to result in a number of diagnostic quandaries for individuals diagnosed with personality disorders, such that they may be diagnosed with more than one personality disorder, symptoms may be applicable to a number of other conditions, and the current diagnostic scheme does not provide a measurement or definition of the actual severity of the personality disorder in question.
Nonetheless, the current diagnostic scheme will probably continue to be used for at least several more years.
Personality disorders are diagnosed according to a set of specified diagnostic criteria that are applied to each one. Individuals who are diagnosed with these disorders do not have to meet all of the criteria listed in the manual but typically have to meet a specific number of them (e.g., four out of seven, four out of eight, etc.). Currently, there are 10 recognized personality disorders that are generally clustered into three different groups based on their general presentation. One of the most severe and difficult of these disorders to treat is borderline personality disorder.
Borderline Personality Disorder
Borderline personality (BPD) disorder is a severe disorder personality that has been described in the literature for many years. The term borderline was originally used to signify that individuals who express this personality disorder straddled the border between psychotic behavior and more normal behavior. Individuals diagnosed with this personality disorder often have extreme variations in their presentation that are fueled by emotional extremes.
BPD is placed in cluster B of the three clusters of personality disorders in the DSM-5. Cluster B personality disorders are characterized by eccentric emotional type responses. In order to diagnose borderline personality disorder, the individual must express five of nine potential symptoms. The nine diagnostic criteria for BPD are:
- Intense and uncontrollable efforts by the person to avoid being abandoned (real abandonment or imagined abandonment)
- A persistent and extremely unstable self-image
- Marked impulsivity that occurs within at least two areas and is potentially hazardous or damaging to the person, such as substance abuse, unprotected sex, gambling, etc.
- A persistent pattern of intense and unstable personal relationships that is portrayed by an alternation between the extremes of the devaluing and idealization of others
- Emotional instability that is characterized by a very reactive mood and/or irritability and/or anxiety that lasts for short periods (from a few hours to a few days)
- Recurrent suicidal attempts, threats, gestures, or recurrent acts of self-mutilation (e.g., arm cutting, leg cutting, etc.)
- Intense and inappropriate outbursts of anger or difficulty controlling their anger, such as having frequent temper tantrums, physical fights, consistently being angry at others, etc.
- Chronic feelings of boredom and emptiness
- Intermittent expressions of paranoia or dissociative symptoms, such as feeling detached from one’s body, detached from reality, or severe amnesia of people or events
In order for a formal diagnosis of BPD to be made, the person would have to formally satisfy five or more of the nine diagnostic criteria. The person’s presentation could not be better explained by another mental health disorder, by the effects of drugs or medications, or as a result of some other medical condition.
The psychiatrist and personality disorder expert the late Otto Kernberg believed that the main drive in individuals with borderline personality disorder related to longstanding feelings of emptiness and loneliness that led the individual to extreme desires to be wanted or to feel needed by another person. These extreme desires to avoid feeling lonely or abandoned and wanting to be needed resulted in the presentation of BPD. Many of the conceptualizations of BPD have continued to follow Kernberg’s deep understanding and analysis of individuals with this disorder.
Unfortunately, the diagnostic criteria for BPD are set up in such a manner that it is possible to have over 100 different individuals with different presentations being diagnosed with BPD. This has resulted in a number of personality theorists trying to identify different subtypes of BPD, such as impulsive BPD, discouraged BPD, self-destructive BPD, etc.; however, no specific subtype of BPD is formally diagnosed, according to the American Psychiatric Association.
BPD and Substance Abuse
BPD is diagnosed at a female-to-male ratio of 3:1. Estimates of its prevalence rate range from a little over 1 percent of the population to nearly 6 percent of the population, and this prevalence is obviously higher in psychiatric inpatient groups (with estimates ranging to nearly 20 percent). There is no known cause associated with BPD, although individuals who have suffered some form of traumatic abuse, especially in childhood, appear to be at significantly increased risk for the development of BPD. The risk to be diagnosed with BPD is also significantly increased if one has a first-degree relative diagnosed with the disorder.
The term comorbidity or comorbid is used to indicate the situation where two or more disorders can be diagnosed in the same person at the same time. BPD has a number of common comorbid psychological/psychiatric conditions, outlined below.
- Major depressive disorder is one of the most common comorbid diagnoses with BPD. Individuals with BPD suffer from a number of emotionally traumatic experiences as a result of their style of interaction with others, and this often results in a diagnosis of major depression along with BPD.
- Individuals with BPD are also often diagnosed with bipolar disorder due to the extreme instability of their mood states, which may range from mania to depression.
- BPD is often also diagnosed with another comorbid personality disorder.
- Because a number of individuals who are later diagnosed with BPD suffer severe traumatic stress in childhood, they are also often given the diagnosis of post-traumatic stress disorder or some other trauma- and stressor-related disorder.
- Individuals with BPD are prone to developing eating disorders.
- Because of severe issues with adjustment, emotional extremes, and chronic feelings of emptiness and loneliness, individuals with BPD often turn to self-destructive behaviors. It is very common for an individual diagnosed with BPD to have a co-occurring substance use disorder. Substances of abuse often include alcohol; stimulant medications and illicit stimulant drugs such as cocaine; cannabis products; and central nervous system depressant drugs, such as benzodiazepines or narcotic pain medications. A number of different research studies have indicated that 50 percent or more of individuals diagnosed with BPD may have a co-occurring substance use disorder.
The common clinical observation that individuals with BPD often have co-occurring substance use disorders is often explained as being a result of these individuals attempting to use drugs and alcohol as a substitution for a personal relationship and/or as a method for them to attempt to achieve control over their own inner feelings, extreme emotions, and poor self-image. However, turning to substance abuse to attempt to manage these issues is always a failed endeavor.
When a person with BPD also has a co-occurring substance use disorder, this can be an extremely complicated situation to treat. BPD is notoriously difficult to treat, and individuals who have substance use disorders can also be difficult to treat. As a result, a specialized treatment plan is required.
There are no specific medications that are designed to treat BPD. Certain medications can be used to address some of the symptoms of BPD. These include antidepressants, medications for anxiety, and antipsychotic medications for individuals who have severe issues with emotional regulation.
BPD is commonly treated with a combination of Cognitive Behavioral Therapy and medications if needed. Individuals with co-occurring substance use disorders also need to be treated with the necessary protocol associated with their substance use disorder. This may include a program of residential withdrawal management to assist the individual in withdrawing from drugs like opioids or alcohol, substance use disorder therapy, participation in support groups, family therapy, and other forms of treatment and support as needed.
A specific type of Cognitive Behavioral Therapy known as Dialectical Behavior Therapy has been identified as the first line treatment for individuals who suffer from BPD. Dialectic Behavior Therapy concentrates on assisting the individual in paying attention to their feelings, recognizing them, identifying alternative and more productive ways of expressing themselves, and reducing self-destructive behaviors.
Individuals who are diagnosed with BPD and a co-occurring substance use disorder require both of these conditions to be treated simultaneously. Trying to address the substance use disorder without addressing the BPD or trying to address the BPD without addressing the substance use disorder will not result in a productive outcome. Individuals with BPD and substance use disorders often express difficulties with compliance for treatment, issues with personal relationships that can complicate the treatment process, a manipulative style that results in them trying to play different therapists against each other, and self-destructive behavior including suicidal ideations that are often very difficult to address unless one is experienced in handling these issues. Nonetheless, individuals with BPD, and those with BPD and co-occurring substance use disorders, can be successfully treated if they are handled with empathy, concern, genuine care, and a professional approach that utilizes empirically validated treatment methods.