Substance Abuse and Borderline Personality Disorder

A high rate of comorbidity between Borderline Personality Disorder (BPD) and substance abuse has been estimated (Also see section on Comorbities in the Associated Features page). Indeed, substance abuse is represented within the DSM-IV-TR criteria set for BPD as a form of self-damaging, impulsive behaviour (APA, 2000; See page on Diagnosis for BPD). Over 50% of patients with BPD are likely to have a co-occurring substance use problem, and over 50% of individuals seeking substance abuse treatment are likely to also suffer from BPD (Trull, Sher, Minks-Brown, et al., 2000). For many individuals with BPD, drug or alcohol abuse likely reflects an effort to regulate emotional experiences that are felt to be intolerable or difficult to handle. An expectation of total abstinence from substance use may not be realistic, without due attention to core BPD features (See page on the Key Features of BPD). On the other hand, severe substance abuse could conceivably be so incapacitating as to preclude participation in meaningful psychotherapy for BPD. Deciding how to address this complex, intertwined comorbidity is a challenging task for clinicians working in substance use and mental health care settings.

Very few studies exist which specifically address the issue of treating comorbid BPD and substance use disorders. Limited support is available for modified versions of both cognitive behaviour therapy (Linehan, Schmidt, Dimeff, et al., 1999; Linehan, Dimeff, Reynolds, et al., 2002; See page on Dialectical Behaviour Therapy [DBT]) and psychodynamic therapy (dynamic deconstructive psychotherapy; Gregory, DeLucia-Deranja, & Mogle, 2010; See page on Other Dynamic Treatments for BPD). The most positive findings – across a range of outcome domains – were obtained with dynamic deconstructive psychotherapy (DDP). Alcohol use was the substance use disorder being addressed alongside BPD in this study, though many participants had polysubstance use disorders.

The two trials of DBT involved patients with opiate and stimulant abuse. In one of these studies (Linehan et al., 2002), patients in the comparison treatment, a form of systematic validation, achieved similar outcomes as those receiving DBT yet with a 100% retention rate. By contrast, patients with BPD and substance use disorders in the DBT condition – as well as patients in other Randomized Controlled Trials (RCTs)– had comparatively high rates of treatment dropout. Thus, the provision of systematic validation may be particularly useful in improving engagement among patients with BPD and substance use comorbidity. Such patients may feel especially isolated and misunderstood as a consequence of suffering from both disorders.

The available studies on combined treatment for BPD and substance use suffer from methodological flaws that limit the inferences that can be drawn from them (Pennay, Cameron, & Reichert, 2011). Nonetheless, these studies demonstrate that the question of choosing which disorder to prioritize in treatment is far from a black-and-white issue. Tackling both problems together may be both feasible and productive using a modified, structured approach. It should be noted that the integration of other treatment modes – e.g. pharmacotherapy for withdrawal management or opiate replacement (DBT); 12 step meetings (DBT and DDP) – were features of these trials.

In summary, the research to date indicates that addressing co-occurring substance abuse and BPD requires a specialized treatment effort – perhaps drawing upon expertise and support from both substance use and mental health resources. Careful clinical judgement is required to discern which patients will need and may benefit from such an approach, and which patients would be more suitable for primary treatment of either BPD or substance use disorder. This involves consideration of the respective severity and intensity of each issue, as well as the patient’s level of engagement and the program’s ability to promote patient retention in treatment. Matching to the appropriate intervention can reduce treatment dropout or failure – experiences that can be demoralizing for patients who are facing two very challenging health conditions.