Rage. Instability. Mood swings. Impulsivity. These characteristics make people with borderline personality disorder (BPD) prone to substance abuse as well as over-spending, promiscuity, eating disorders and other compulsive behaviors. In fact, studies suggest that 50 to 70 percent of those with BPD also have a co-occurring substance use disorder.
David Sack, M.D., is board certified in psychiatry, addiction psychiatry and addiction medicine, and writes a blog about addiction. He is CEO of Elements Behavioral Health, a network of mental health and addiction treatment centers that includes a teen drug rehab at The Right Step and Promises young adult rehab.
Editor: Nadeem Noor
Addicts with co-occurring borderline personality disorder are known as some of the most difficult patients to treat. Here are a few of the most common challenges, along with insights into the most effective research-based treatments:
Addicts with BPD have been described as both treatment demanding and treatment resistant. Research shows more positive outcomes the longer an addict with BPD stays in treatment, yet keeping them in treatment is no easy task. In a study of patients in a detox program, those with BPD were significantly more likely to have an unplanned discharge than those without BPD.
While a number of treatments have proven effective for BPD, therapies for BPD patients with co-occurring substance abuse are less established. Studies suggest that the most promising treatments include dialectical behavior therapy, cognitive-behavioral therapy and psychodynamic approaches. A combination of support and management from an experienced dual diagnosis treatment center can improve retention rates, along with ongoing involvement in self-help groups such as AA and NA.
Dropout rates among patients with BPD and substance use disorders are high largely because of the difficulties engaging this group in a therapeutic relationship. In one moment, the patient may view the therapist as a much needed source of support. At the first perceived sign of rejection, criticism or disapproval, the therapist becomes an enemy who cannot be trusted. The patient may become resistant, passive, or stop attending therapy sessions altogether, while the therapist may feel increasingly helpless and angry.
Without appropriate skills and knowledge, working with individuals with co-occurring BPD and substance abuse can take a toll on the treatment professional. Negative attitudes and stigma can compromise the effectiveness of treatment, and finding the balance between validation and behavioral change can be an ongoing challenge. Professionals who regularly work with this group need specialized training to understand the nature of the problem, maintain boundaries, provide consistent, nonjudgmental support, and prevent negative countertransference.
To work successfully with addicts with BPD, the therapist requires many levels of support. A team approach is typically best. Having a trusted group of colleagues to turn to with frustrations and questions about treatment planning can prevent burnout and damage to the therapeutic relationship. A team that works cohesively and maintains ongoing communication guards against splitting (playing one member of the treatment team against another) and provides seamless care.
High Relapse Rates
Patients with dual diagnosis are at high risk of relapse. Among addicts with BPD, underlying issues (such as trauma) may be driving addictive patterns. Integrated dual diagnosis treatment provided by a multidisciplinary team of medical and mental health care professionals is essential to address all issues simultaneously. Relapse prevention must focus not only on substance abuse but also self-harm, noncompliance with medications and other risky behaviors.
Even though they crave attention and affection, addicts with BPD typically have turbulent interpersonal relationships that result in the very rejection they fear most. Studies show that social deficits are associated with a range of problems, including substance abuse, unemployment, delinquent behavior and poor academic performance. Twelve-Step groups, online forums and group therapy can aid in building social skills and a sober social support network.
Family relationships also may be marked by conflict and communication problems, which may be both a contributing factor and consequence of BPD and addiction. In treatment, families must be educated about both illnesses and provided with support and skills training in order to improve the functioning of the family system. Many families find self-help support groups such as Al-Anon helpful.
Individuals with BPD are at increased risk of suicidal ideation, recurrent suicide attempts and self-mutilation (e.g., cutting, burning, or overdosing) in an attempt to cope with difficult emotions. When under the influence of drugs or alcohol, these risks are even greater. Randomized controlled trials have shown that dialectical behavior therapy can be particularly effective in addressing suicidality.
Studies of pharmacotherapy for BPD and addiction have produced mixed results. While certain medications, such as SSRIs, mood stabilizers, and antipsychotics, may be helpful in treating BPD, their efficacy isn’t well-established. Similarly, medications approved for chemical dependency, such as naltrexone, haven’t been adequately studied in patients with co-occurring BPD and addiction. The addictive potential of opioids and benzodiazepines could put patients at risk and should be prescribed with caution.
Other concerns that arise when medicating patients with BPD include noncompliance, overdose, demands for frequent changes in medication, and failure to accurately report when a medication is easing symptoms or worsening them. In addition, patients may be either resistant to the idea of medication or demand medication at the start of treatment.
Dual Diagnosis Treatment Rises to the Challenge
While the challenges are numerous, addicts with BPD can be effectively treated so long as specialized programming is set up to meet their unique needs. Effective dual diagnosis treatment begins with a comprehensive assessment that takes into account suicide risk and crisis management. It also includes a stable, supportive treatment environment; individualized care from a coordinated team of professionals familiar with the issues of borderline personality disorder and addiction; and long-term continuing care. Not every treatment program is equipped to manage co-occurring BPD and substance abuse, but those that are offer a great deal of hope to these patients and their families.