An At-Risk Population: Borderline Personality Disorder and Substance Use | Center on Addiction

An At-Risk Population: Borderline Personality Disorder and Substance Use

An At-Risk Population: Borderline Personality Disorder and Substance Use


For those diagnosed with both borderline personality disorder (BPD) and a substance use disorder, finding the right kind of treatment can be difficult. As a counselor at a rehabilitation center, a jail and a halfway house for the mentally ill, I experienced first-hand the gaps that exist in providing sufficient care to people with these two commonly co-occurring problems.

BPD is a serious psychiatric disorder marked by unstable moods, behaviors and relationships. Those with BPD often have deep fears of abandonment, impulsive behaviors, and highly unstable views and actions toward others. For example, someone with BPD may express excessive admiration or idealization toward someone in one moment and then angry condemnation the next. BPD usually emerges during adolescence and no later than early adulthood. An estimated 1.6 percent of the population has BPD, and 5.6 percent is diagnosed with the disorder at some point in their life.

Adolescence is also a time when people are most at risk for using substances. Research suggests that among individuals with BPD, substance problems are significantly more common than in the general population. One study noted that half of people who were at some point in their lifetime diagnosed with BPD were also diagnosed with a substance use disorder in the last year.

What can complicate the process of accurate diagnosis and effective treatment is that the symptoms for BPD can sometimes be related to, exacerbated by, or even overlap with a substance problem. Many individuals with BPD struggle on a daily basis with unpleasant emotions and interpersonal conflicts, which research has shown to be among the strongest predictors of relapse to substance use. In addition, the unstable moods and strained relationships common in BPD can be made worse by substance use.

A Hands-on Experience

During my time spent working in a halfway house, I treated a young woman suffering from both BPD and substance problems who frequently complained of excruciating back pain. She visited doctor after doctor seeking powerful pain medications, which she would then hide or tell staff she wasn’t using. Though we understood that her back pain could be extreme, her history of addiction made her use of painkillers worrisome. In the past, she had nearly overdosed on opioid medication and alcohol on more than one occasion.

As a novice counselor, I asked more experienced staff members for advice on how to address the issue of substance use with this young woman. Our collective training for these co-occurring disorders was limited. The other counselors’ responses were similar to what I would imagine many in the field who did not have sufficient training in treating both disorders would say. Most told me to take a hardline: if the patient didn’t stop using opioids, we would have no other choice but to impose a consequence. The suggestions ranged from intentionally ignoring her, to taking away television privileges, to potentially alerting her family about her opioid use – in turn jeopardizing her stay at the halfway house, as well as the counseling she was receiving outside of it.

How Can Those with BPD and a Substance Problem Get Help?

This story illustrates a common problem seen when treating addiction and another serious psychiatric disorder. There aren’t always clear guidelines for the best treatment approach. Dialectical behavioral therapy (DBT), a cognitive behavioral treatment that was originally developed to treat chronically suicidal individuals, has been shown to successfully treat patients with BPD for many years. Yet DBT has not been shown to be strongly effective for treating substance problems.

With many people struggling with a substance problem and another mental illness, more research is needed on effective treatment models that focus on both disorders simultaneously, with a combination of medication and psychotherapy delivered by a well-trained professional. Otherwise, the most complicated patients struggling with addiction will continue to receive insufficient care.

  Max Dorfman, MA

  Max is a Science Writer at Center on Addiction



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