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A shocking rate of people with borderline personality disorder will also develop an alcohol or drug problem. Why, and what treatment options are available?

People with borderline personality disorder develop substance abuse problems at alarming rates. Treatment is tricky, but not impossible. What do you need to know?

What is Borderline Personality Disorder?

Borderline personality disorder — BPD for short — is a serious and debilitating mental illness chracterized by instability and impulsivity. Turmoil defines the moods, social relationships, and self-image of people who suffer from the disorder, who often but not always have a history of severe childhood trauma.

The diagnostic criteria, as seen in the fifth edition of the diagnostic and statistical manual of mental disorders, give some insights into the kinds of things a person with borderline personality disorder may experience:

  • Frenzied, panicked, efforts to prevent abandonment on the part of people in their lives. The thread of abandoment may be, the DSM-5 specifies, real or only imagined — but these kinds of "clingy" behaviors can lead social relationships to come to an end even where the other person wasn't about to pull away before. 
  • A pattern of turbulent social relationships which the DSM-5 describes as "alternat­ing between extremes of idealization and devaluation", but which the loved ones of people with the disorder often see as a "push-pull" relationship in which they can do nothing wrong one moment, and are the root of all evil the next. 
  • A fluctuating, uncertain, or non-existent sense of self. 
  • An impulsive, unstable kind of self-harm — behaviors that can cause great harm to the person themselves, like risky sex, substance abuse, gambling, out-of-control shopping, and binge eating. 
  • Repeated suicidal threats or attempts, or physical self-harm. 
  • Extreme mood swings, including episodes of severe distress. 
  • Pervasive feelings of emptiness. 
  • Intense episodes of anger and irritation. 
  • Episodes of burning distrust, to the point of paranoia, and dissociation. 

Borderline personality is a difficult condition to diagnose. Because many of its symptoms overlap with those of other mental conditions, including post traumatic stress disorder and bipolar disorder, it's not uncommon for people with BPD to be misdiagnosed with another mental illness, and vice versa. 

Borderline personality disorder is also difficult to treat, in part because the very symptoms make it hard for a person to trust clinicians. With greater understanding of the nature of BPD, however, it's become clear that it is possible for someone with borderline personality disorder to reach remission from the symptoms. 

How common are substance use disorders in people with borderline personality disorder?

A variety of studies have looked into the prevalence of substance use disorders in people with borderline personality disorder. They've estimated that about 14 percent of those with borderline personality disorder will have a substance addiction at any given time, while lifetime rates exceed 70 percent. More common in men than women with BPD, the substances people in this group become addicted to span the whole range of possibilities, from alcohol to cannabis and prescription medications. 
As with many mental disorders, self-medication — an attempt to find relief from the symptoms of the condition — is among the main causes of addiction in people who suffer from BPD. People with borderline personality disorder often live difficult and traumatic lives, and the symptoms of the disorder make it hard for them to maintain a strong social support network. These, too, are risk factors for addiction. 

How does a substance use disorder impact the prognosis for boderline personality disorder patients?

People who suffer from borderline personality disorder while also facing an addiction:

  • Are more likely to start abusing substances early in life. 
  • Are less likely to function well in daily life. 
  • Display more impulsive behaviors than people with "only" one of these disorders. 
  • Have lower odds of getting clean and sober, while being more likely to relapse. 
  • Are less likely to be able to complete treatment programs for addiction, either because they quit the program or are removed from it as a result of their behaviors.
  • Are more likely to feel suicidal, attempt suicide, and commit suicide. 
  • Have less favorable outcomes overall. 

What are the treatment options for people with borderline personality disorder and substance addictions?

Borderline personality disorder and substance addiction are both mental illnesses — and as with all dual mental diagnoses, this means that planning a treatment program becomes a challenge as clinicians decide whether to priortize one or tackle both together. 

Dialectical behavior therapy, a form of talk therapy actually specifically designed to help people with borderline personality disorder, has been adapated to serve those who suffer from addiction as well as BPD, too. This therapy offers hope. It aims to bring balance to a person's life by teaching coping skills, attachment strategies that can help improve interpersonal relationships, and works towards remission from addiction in an intense but step-by-step program that focuses on the individual's needs. 

Two other forms of psychotherapy called dynamic deconstructive psychotherapy and schema therapy have also shown success.

Medication can help, too. Medications that have been used with success to assist people with substance addictions on their path to remission include buprenorphine and naloxone (for opioid use disorders) and acamprosate and naltrexone (for alcohol use disorders). SSRI antidepressants can dampen some of the impulsive behaviors and mood disturbances associated with borderline personality disorder, meanwhile. 

Whatever approach is ultimately taken, it is important for someone with borderline personality disorder to be guided and assisted on their way to achieving what they should also be ready for themselves — healing and remission. People with borderline personality disorder will often have encountered misunderstanding and negative stereotyping from clinicians already, and it takes a lot to establish trust. Maintaining personal dignity is essential. 

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