Thursday, June 1, 2023

Substance Use in Borderline Personality Disorder


Ruwan M Jayatunge M.D.

 A personality disorder is an enduring pattern of inner experience, of seeing the world and relating to others in a manner that markedly deviates from cultural expectations, and includes, and results in, problematic and habitual behaviors that are pervasive and inflexible (APA). The first clinical conceptualization of Borderline Personality Disorder (BPD) was provided in 1975 by Gunderson and Singer.  By 1980, the construct of BPD was considered developed and validated to the extent that the disorder was included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association 1980) (Ogrodniczuk &Sierra Hernandez, 2010).

According to Stern (1938) the term ‘borderline’ originally referred to a group of mental illnesses characterized by psychopathology with features of both psychosis and neurosis, but which did not clearly meet historical criteria for either group of conditions. Borderline Personality Disorder is a severe Axis II personality disorder characterized by intense and significant instability across a number of domains (Rizvi et al., 2011). BPD is the most frequent personality disorder (Oumaya et al., 2008). It is diagnosed predominantly in women, with an estimated gender ratio of 3:1. The disorder may be missed in men, who may instead receive diagnoses of antisocial or narcissistic personality disorder (APA). Borderline symptoms are thought to emerge from the interaction of temperamental factors and environmental stressors. Both parental invalidation and attachment disorganization have been hypothesized to play an etiological role (Lyons-Ruth et al., 2014). 

Borderline Personality Disorder is characterized by severe functional impairments, a high risk of suicide, a negative effect on the course of depressive disorders, and extensive use of treatment (Leichsenring et al., 2011). There is a high rate of stigma associated with BPD (Aviram et al., 2006). Persistent feelings of emptiness are often expressed by individuals with BPD. They are usually unable to express their aspirations and desires (Ogrodniczuk &Sierra Hernandez, 2010).   In addition, BPD is marked by impulsivity, instability of mood (Paris, 2005), and deficits in the capacity to work and maintain meaningful relationships (Levy et al., 2006).  It is a complex disorder associated with substantial morbidity, mortality, and public health costs (Stanley & Silver, 2010).

BPD has shown a strong association with substance use disorders (Gunderson & Links, 2008). BPD patients have a particularly high vulnerability to the development of Substance Use Disorders over the course of time (Walter et al., 2009). Many of the core features of BPD are also independent risk factors for the development of SUD (Lubman et al., 2011). Persons with a borderline personality disorder often abuse substances in an impulsive fashion that contributes to lowering the threshold for other self-destructive behavior such as body mutilation, sexual promiscuity, or provocative behavior that incites assault (including homicidal assault) (APA).  

According to Few and colleagues (2014), both genetic and individual-specific environmental factors contribute to comorbidity between borderline personality features and substance use disorders i.e. that both are impulse spectrum disorders.  Cheetham and colleagues (2010) believe that impulsivity and affective dysregulation play a key role in the development and maintenance of addictive disorders. In addition, childhood attachment problems, past trauma, poor sense of self, and profound state of unease and dissatisfaction help to maintain addictive behaviors. BPD patients often use dependence-producing substances in an attempt to mitigate emotions perceived as overwhelmingly negative or to replace these with a pleasant state, such as feeling intoxicated (self-medication hypothesis). Apart from that, the use of addictive substances can also be triggered by factors related to the social environment, such as peer pressure (Kienast et al., 2014).  Substance Use Disorders significantly reduce the likelihood of clinical remission of BPD (Zanarini et al., 2004; Lubman et al., 2011).


Challenges Faced by the Health Care Workers

With patients with borderline personality disorder, there is a risk of boundary crossings and violations (APA). Moreover, substance use disorder often complicates the Negative counter-transference or the unconscious development of negative feelings toward the patient on the part of the clinician (Lubman et al., 2011). Negative counter-transference is one of the hindering factors found by therapists while working with clients diagnosed with BPD (Beatson et al., 2010). Self-destructive behaviors, anger, mood instability, and pervasive fear of abandonment all interfere with a clinician’s ability to establish a therapeutic alliance and sustain a successful treatment (Goodman, & Siever, 2012). BPD patients have been described as highly vigilant for social stimuli, especially for social cues that signal social threat or rejection (Linehan, 1995; Domes et al., 2009). Also, they have a disturbed sense of identity Jørgensen, 2006). 

According to Holmes (2003) BPD sufferers lack of meaning in their lives because they are unable to play 'language games' with their potential intimates, resorting to actions rather than words to express feelings.  Therefore therapeutic communication could become substandard. On the other hand BPD sufferers frequently jeopardize their relationships with the health care providers creating a deep void in the treatment procedures. As indicated by Lubman and collogues (2011) management of co-occurring substance use disorder and borderline personality disorder within primary care is further compounded by negative attitudes and practices in responding to people with these conditions, which can lead to a fractured patient-doctor relationship.    

BPD patients often present with quickly fluctuating complaints and symptoms. Many of the clinical characteristics of patients with borderline personality disorder may be seen as consequences of disordered self-organization and a limited rudimentary capacity to think about behavior in mental state terms (Fonagy, Target & Gergely 2000). Sometimes they blame their therapists for not addressing fluctuating complaints and symptoms.   

BPD patients are psychologically fragile. Psychological trauma is deeply embedded in PBD. As indicated by Arntz (1994). It is assumed that chronic traumatic abuse or neglect in childhood has led to the development of almost unshakeable fundamental assumptions about others (dangerous and malignant), about one’s own capabilities (powerless and vulnerable) and upon one’s value as a person (bad and unacceptable).

Suicidal behavior often accompanies borderline personality disorder (Zeng et al., 2015).  Although recurrent suicidal threats, gestures or behaviour or self-mutilation are common in patients suffering from borderline personality disorder they often lack systematic suicidal intentions.  (Oumaya et al., 2008).  However BPD complicated by substance use disorders could lead to complete suicides.



The management of patients with borderline personality disorder may be difficult, because these patients often make disproportionate demands on the physician's time and they tend to experience complicated and/or incomplete recovery from organic or functional illness (Sansone & Sansone, 1991).  Nonetheless management of the patient-therapist relationship is paramount and may be in itself the most effective and safe treatment for both crisis situations and longer therapy (Dawson, 1988).

Patients with borderline personality disorder and comorbid addiction should be treated as early as possible for both conditions in a thematically hierarchical manner ( Kienast et al., 2014). Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder (Stoffers et al., 2012). Drug counseling is a useful component in the treatment process.

Lieb et al (2010),  have suggested that mood stabilisers and second-generation antipsychotics may be effective for treating specific symptoms of BPD and associated pathology  A positive therapeutic relationship plays a central role in the management of both BPD and SUD (Lubman et al., 2011).

Brown and Shapiro (2006) provide preliminary evidence for use of EMDR in the treatment of Borderline Personality Disorder. van der Hart and collogues (2010) highlight the significance    of  EMDR in  trauma-related borderline personality disorder. Wesselmann and team (2012) point out that EMDR is a treatment mode to improve attachment status in adults and children.

Wetzelaer and colleagues (2014) indicate the efficacy of Schema therapy in BPD.  According to Rizvi, and colleagues (2011) Dialectical behavior therapy (DBT) has received strong empirical support and is practiced widely as a treatment for borderline personality disorder (BPD) and BPD with comorbid substance use disorders (BPD-SUD). Furthermore ongoing communication between all treatment providers is essential for a coordinated treatment approach and a designated case coordinator, who is responsible for managing communication between professionals, is recommended to ensure splitting does not occur (Lubman et al., 2011). In adding together other interventions such as Psycho-education, Family therapy also plays an important role in managing BPD.



Individuals with borderline personality disorder (BPD) often experience severe functional impairments, Interpersonal difficulties   higher levels of depressive symptoms, Identity diffusion, feelings of emptiness, parasuicidal behaviors and many other psychosocial difficulties. In BPD often the Comorbidity is associated with substance use disorders and it leads to a complex mental disorder. Although BPD is difficult to treat, patient - therapist relationship is paramount to provide services.



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