Borderline Personality Disorder and Addiction

What is borderline personality disorder (BPD)?

Borderline personality disorder (BPD) is a personality disorder characterized by long-term instability in interpersonal relationships, emotions, and sense of self. This often results in intense and turbulent relationships, impulsivity, feelings of emptiness, black-and-white thinking, anger, fear of abandonment, sensitivity to rejection, and suicidal ideation. BPD is the most common personality disorder, a type of mental illness featuring enduring maladaptive patterns of thought, behavior, and inner experience that cause distress or impairment.^[1]

Under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), an individual must present with at least five of nine criteria to be diagnosed with BPD:^[1]

• Frantic efforts to avoid real or imagined abandonment by others.
• A pattern of unstable and intense relationships, switching between extremes of idealization and devaluation.
• Markedly and persistently unstable self-image.
• Impulsivity in at least two self-damaging areas, such as sex, spending, substance abuse, reckless driving, binge eating, and gambling)
• Recurrent suicidal behavior, gestures, threats, or self-harm.
• Unstable and highly reactive emotions (for example, intense periods of dysphoria, often lasting just hours or days).
• Chronic feeling of emptiness.
• Intense periods of inappropriate anger or difficulty controlling anger.
• Transient stress-related paranoid ideation or dissociative symptoms.

Related: Narcissistic personality disorder

The relationship between BPD and addiction

There is a strong connection between BPD and substance use disorders, and many people with BPD have a co-occurring substance use disorder. A literature review of 70 studies has found that rates of lifetime substance abuse among people with BPD range from 45% to 86%.^[2] Another study estimated that 47% of people with BPD experience alcohol dependence and 22% experience drug dependence.^[3] 

Among people who abuse alcohol, those with personality disorders such as BPD often display more severe symptoms of dependence, an earlier onset, and a lower level of functioning. They also have more frequent relapses, increased suicidal behavior, more frequent use of other drugs, and are more likely to drop out of treatment. Combined, the research indicates that people with BPD are at risk for more severe substance use disorders and are more likely to engage in high-risk patterns of use.

As with other mental health conditions, the relationship between BPD and alcohol and drug abuse is multi-faceted. Sometimes people with BPD turn to drugs and alcohol to numb the intense emotions they experience and other times they use drugs to feel less numb.

People who present with impulsive symptoms of BPD may abuse drugs and alcohol, disregarding the consequences and seeking thrill and risk. While this use may at first be episodic and associated with binges, it can develop into an addiction.

Read here to learn more about drug addiction and mental health.

Common causes of BPD and addiction

BPD and addiction also share underlying risk factors, with childhood trauma and abuse being the most common. Many clinicians believe that BPD is a byproduct of complex trauma and that BPD symptoms are really just old coping mechanisms and defenses they developed growing up in dysfunctional homes.^[7]

This may help explain why many of the symptoms of BPD overlap with those seen in people with addictions, including self-destructive and impulsive behavior, mood fluctuations, and suicidal ideation.^[1]

Risk factors for BPD and substance abuse

Like most mental health conditions, experts believe that BPD develops as a result of an interplay of neurological, developmental, environmental, and genetic factors. People who develop BPD may have a family history, but they often have also experienced trauma in childhood.^[7] Many of these risk factors—especially parental drug and alcohol use, childhood abuse, other mental illnesses, and trauma—also increase the risk of substance abuse in later life.^[4]

Risk factors for developing BPD include:

• A dysfunctional family environment during childhood, including physical, sexual, and emotional abuse; neglect and abandonment; parental drug and alcohol use and mental illness; an unstable family life; poor communication among family members; and violence in the family.
• Family history of BPD: Twin, sibling, and family studies have shown that heritability is between 37% and 69%. You’re more likely to have BPD if your parent or sibling does.
• Diagnosis of another mental illness, especially depression, bipolar disorder, or another personality disorder.

BPD and behavioral addiction

The brain’s reward systems can also be hijacked by other compulsive behaviors that activate the pleasure centers in the brain. This can cause people with BPD to develop behavioral addictions that mimic many of the signs and symptoms of substance use disorders. Recognizing this in 2011, the American Society of Addiction Medicine adjusted its definition of addiction to accommodate addictions beyond substance dependence.^[5]

Non-substance addictions are known as behavioral addictions or process addictions. Previously, they were categorized as impulse control disorders in the DSM 5. While the only formally recognized behavioral addiction in the DSM 5 is gambling disorder, researchers believe it is also possible to develop addictions to ^[1][5][6]

• Pornography or sex
• Shopping or spending
• Gambling
• Video games
• Internet and social media
• Physical exercise
• Work

For some people with borderline personality disorder, the impulsive behaviors they engage in, such as spending, sex, and gambling, may rise to the level of addiction and require treatment alongside BPD. Behavioral addictions are usually treated using the same modalities developed to treat substance abuse.^[6] These may include cognitive behavioral therapy (CBT), motivational therapy, and self-help groups.

Treating BPD and addiction

As with other co-occurring disorders, a person with both BPD and a substance use disorder must receive treatment for both conditions. Thankfully, the treatments used for BPD also work to help people overcome addictions. Extra care must also be taken because BPD is known to increase the likelihood that someone drops out of addiction treatment programs and increases the likelihood of relapse.

Treatment for co-occurring BPD and addiction may include:

• Dialectical Behavioral Therapy (DBT): The mainstay of treatment for BPD, DBTis a type of cognitive behavioral therapy that teaches people to tolerate distress, regulate their emotions, navigate interpersonal relationships, and cope with difficult feelings in non-destructive ways. It can be done individually or in groups.
• Schema-focused therapy: Schema-focused therapy helps patients identify needs that were unmet during childhood and have subsequently led to maladaptive behaviors, which may have been necessary for survival at one point but are causing harm in adulthood.
• Cognitive behavioral therapy (CBT): CBT is a type of talk therapy that teaches patients to identify and correct problematic behaviors, such as substance abuse, other impulsive behavior, suicidal gestures, and anger, and develop more effective coping strategies. CBT can also correct negative inner monologues and boost self-esteem. It’s a first-line treatment for substance abuse and is also shown to be beneficial for BPD, particularly in people who engage in risky and destructive behaviors.

Final thoughts

BPD is a chronic condition characterized by emotional instability, impulsivity, unstable relationships, and destructive tendencies. It’s very common for people with BPD to struggle with addictions to drugs, alcohol, or even to have behavioral addictions that they use to cope, numb, or enhance their experiences.

While BPD and addiction cannot be cured, they can be managed with treatments like DBT and the use of healthier coping skills.

If you believe you or a loved one may be suffering from a substance use disorder and BPD, then treatment is available. Visit our rehab directory today to find treatment facilities for co-occurring disorders.