Borderline Personality Disorder & Substance Abuse

By Team RehabAid

Last Updated March 21, 2024

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The term “Borderline Personality Disorder” can appear confusing at first. After all, how can one’s personality be considered “borderline?” The reason this term came to be is that when the condition was first recognized, the symptoms seemed to “border” between psychosis and neurosis.

Today, Borderline Personality Disorder (BPD) is defined as a mental health condition characterized by erratic mood swings, impulsive behavior, recklessness, paranoia, and anxiety and depression. The prevalence of BPD in the U.S. is about 1.6% (roughly 5.2 million people) in a given year, while the proportion of people who have had it in their lifetime is roughly 5.9%.

Due to the extremes in mood and behavior associated with BPD, many individuals turn to substance abuse in order to cope. However, substance abuse is also bi-directional, as long-term use can also cause BPD and its symptoms, making these co-occurring conditions very complex.

However, despite the complicated nature of BPD and addiction, there is ample hope for recovery. In this article, we outline what borderline personality disorder is, how it overlaps with substance abuse, and what types of treatments are available.

What Is Borderline Personality Disorder (BPD)?

Borderline personality disorder (BPD) is a serious psychiatric illness that is marked by an inability to effectively regulate one’s emotions. People with BPD often have an ongoing pattern of varying moods, self-image, and behavior, as well as intense episodes of anger, depression, and anxiety. As a result of these unstable mood patterns, two hallmark features of BPD are impulsive actions and relationship problems.

Starting in adolescence or early adulthood, BPD often co-occurs with other mental illnesses, such as substance abuse, anxiety, depression, eating disorders, and other personality disorders. While some people with BPD can be high functioning, their private lives and relationships can often be in turmoil.

Diagnosis

Recognized as a psychiatric condition in 1980, BPD is a relatively new condition and is two decades behind other major mental illnesses in terms of research, education, and therapies. This means BPD is often misdiagnosed or missed entirely during psychiatric assessments. For example, bipolar disorder is often confused with BPD; however, the difference is that for bipolar individuals, mood changes can last for weeks or months. For someone with BPD, on the other hand, those mood changes are much shorter and can even occur in one day.

While BPD has often been met with stigma and misunderstanding, new evidence-based research is bringing hope and paving the way towards improved treatment for these individuals and their families.

Co-Occurring Conditions With BPD

Many other psychiatric conditions co-occur with bipolar disorder. Below are some of the primary ones:

BPD and Bipolar Disorder

As mentioned above, BPD is often mistaken for bipolar disorder. To further confuse the matter, BPD can also co-occur with bipolar disorder, making diagnosis tricky. When these two conditions are present together, the symptoms and mood changes are more severe and unpredictable. Therefore, people with these conditions are best treated by therapists who are trained in dual diagnosis approaches and who can address each comprehensively and concurrently.

BPD and Major Depressive Disorder (MDD)

Major Depressive Disorder (MDD) is also another common co-occurring condition with BPD. In fact, one study revealed that the lifetime prevalence of MDD during BPD was as high as 83%. However, diagnosing both conditions is tricky, since many patients with BPD also have depressive symptoms. Therefore, accurate diagnosis is important so that BPD and MDD can be treated accordingly.

BPD and Suicide

Tragically, suicide rates are high amongst people with BPD. According to the American Psychiatric Association, the BPD suicide rate is between 8% and 10% — which means that roughly 1 in 10 people with this condition will commit suicide. The co-occurrence of borderline personality disorder and suicide is especially common among people in their teens or early adult years.

BPD and Trauma

Trauma is one of the most common contributing causes of mental illness. When it comes to borderline personality disorder, researchers have linked childhood trauma with the development of BPD, especially when it comes to issues of abandonment. Therefore, it can be helpful for people with BPD to also seek out trauma treatment.

BPD and PTSD

As trauma is a supporting factor in the development of borderline personality disorder, it is no surprise that post-traumatic stress disorder (PTSD) often co-occurs with this condition. The conditions are also bi-directional, in that people with BPD are likely to have PTSD and people with PTSD are also more likely to develop BPD. Therefore, treatments that target the unique characteristics of each condition should be given.

Signs of Borderline Personality Disorder

Signs of borderline personality disorder can vary depending on each person, but there are general signs to look out for. These include:

• Intense emotional mood swings, lasting for a few hours or days.
• Extreme episodes of depression or anxiety
• Impulsive and often dangerous behavior.
• Efforts to avoid real or imagined abandonment (e.g., rapidly ending relationships or cutting off communication in anticipation of being abandoned).
• Extreme changes in perceptions of others.
• Paranoid thoughts or feelings.
• A pattern of intense and unstable relationships (e.g., swinging from extreme closeness to extreme dislike).
• Episodes of extreme anger or aggression.
• Distorted and unstable sense of self.
• Intense fear of abandonment or being alone.
• Presence of eating disorders.
• Feelings of dissociation.
• Feelings of emptiness.
• Manipulative behavior.
• Self-harming behavior, such as cutting.
• Recurring thoughts of suicide or suicide attempts.
• Chronic feelings of emptiness.
• Inappropriate, intense anger, or problems controlling anger.
• Difficulty with trust, sometimes accompanied by irrational fears about others’ intentions.

Underlying Risk Factors

While there is no exact cause of borderline personality disorder, there are several key risk factors. These include:

Trauma

As mentioned above, people who have seen or experienced trauma have a higher likelihood of developing BPD.

Neurobiology

Three key areas of the brain are shown to be smaller or more active in people with BPD — the amygdala, hippocampus, and orbitofrontal cortex. These areas control impulses and emotional regulation. However, it is not clear whether these changes are due to BPD or are caused by it.

Brain chemistry

Like many other mood disorders, altered functioning of neurotransmitters such as dopamine, serotonin, and noradrenaline may lead to the development of BPD. These chemicals are responsible for emotional regulation and urges.

Genetics

Scientists believe that genetics play a role, as BPD often runs in families. They also suggest that some inherited traits like aggression may increase the risk of BPD, especially when combined with environmental factors.

Environmental Factors

Individuals with BPD often report experiencing traumatic life events, abuse, violence, or unstable families. These factors can contribute to BPD and mental health disorders like substance abuse.

BPD & Substance Abuse Stats

According to the National Education Alliance for Borderline Personality Disorder, BPD affects 14 million Americans at some point in their life. Other studies reveal that people with BPD are 1.7 times more likely to have a substance abuse problem in their lifetime.

Other stats include:

• BPD affects 50% more people than Alzheimer’s disease, and nearly as many as schizophrenia and bipolar combined (2.25%).
• The National Education Alliance for Borderline Personality Disorder also reports that BPD affects 20% of patients admitted to psychiatric hospitals.
• It is estimated that approximately half of those with BPD also have a substance use disorder, including with stimulants like amphetamines.
• About 78% of individuals with BPD also develop a substance abuse problem or addiction at some point in their lives.
• About 50 percent of people with BPD self-report a history of prescription drug abuse.
• Many individuals with BPD experience a decrease in their impulsive behavior in their 40’s.

How Do BPD and Substance Abuse Overlap?

Substance abuse rates among those with borderline personality disorder are very high, and the two conditions overlap in several ways:

• BPD and substance abuse are marked by impulsive, self-destructive behaviors.
• BPD and substance abuse can be characterized by mood swings, alternating with periods of depression and mania.
• BPD and substance abuse involve a pattern of instability in terms of relationships, finances, and employment.
• BPD and substance abuse are marked by behaviors that are often manipulative or deceitful.
• BPD and substance abuse often involve a lack of care for one’s health, well-being, and safety in the pursuit of dangerous behavior — despite the risks.

Why Do People With BPD Engage in Substance Abuse?

Borderline personality disorder and substance abuse are complicated, because they have the potential to cause each other. In fact, research has shown that people with BPD also tend to have addictive personalities. The exact cause of this is not clear; however, other factors can lead people with BPD to engage in substance abuse.

To Self-Medicate

People who struggle with mental health conditions such as BPD will often self-medicate, using substances to cope. Whether it’s alcohol, prescription medications, or street drugs, individuals with BPD who want to escape or ease their symptoms (particularly depression) will often turn to substances to feel better. The problem with using substances to achieve relief is that it not only leads to addiction, but it can also exacerbate BPD symptoms, particularly when the drugs wear off.

Biochemical Imbalances

Neurological factors also play a role in substance abuse and mood disorders. The reason is that neurotransmitters such as dopamine, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) are thought to be connected to depression, addiction, and impulse control. As mentioned above, an imbalance in these neurochemicals is thought to be a contributing factor to the development of DPD. Conversely, if an individual has a pre-existing imbalance in these neurotransmitters, they could be more prone to addiction and substance abuse.

Following Substance Use & Withdrawal

Due to the way that drugs alter the biochemistry of the brain, long-term substance use can initiate uncomfortable symptoms like depression and anxiety. Alcohol, for example, can enhance depressive symptoms, even though it initially helps numb those feelings. Stimulants, on the other hand, can cause increased agitation, restlessness, irritability, and irrational fears during the withdrawal period. These symptoms can therefore cause individuals with BPD to relapse or take more substances to cope.

How Does Substance Abuse Affect Borderline Personality Disorder?

Another factor when it comes to BPD and substance abuse is how they affect each other. In this section, we’ll explore some of the substances that are most commonly abused by individuals with BPD, and explain and what their effects are.

Alcohol & BPD

People with BPD are known to abuse alcohol more than any other substance. While drinking on occasion isn’t a bad thing, using it as a crutch can lead to long-term health problems. If you find yourself in a cycle of drinking to cope with BPD (or other co-occurring conditions, like depression), you could end up with extended, and often more extreme symptoms.

Some of the primary traits of people with BPD are paranoia, an intense fear of abandonment, and high levels of suspicion. When alcohol is introduced into the equation, these traits can become pronounced, leading them to act more impulsively and experience augmented feelings of shame and rejection.

Stimulants & BPD

Stimulants can be an attractive drug choice for people with BPD because the feelings of euphoria and confidence can ease their symptoms of powerlessness and desolation. However, it is believed that in some cases, stimulants can also cause BPD and its symptoms. This is due to the way that stimulants increase the production of dopamine and serotonin in the brain.

As these neurotransmitters become destabilized with long-term drug use, it can lead to decreased impulse control, memory problems, and reduced motor functions. Therefore, drugs that influence the brain chemicals responsible for emotional regulation and impulses can greatly aggravate BPD symptoms like impulsivity, paranoia, and emotional instability.

Cannabis & BPD

Cannabis (marijuana) is a more complicated substance, because it can act as both a depressant and a stimulant. While cannabis can be effective at easing symptoms, it can also increase negative symptoms once the drug wears off. This is especially the case if the individual has been using cannabis in high doses or for extended periods. When it comes to BPD, high levels of THC are also linked to an increase in symptoms such as paranoia, anxiety, and irritability, so this substance is best avoided.

Borderline Personality Disorder & Substance Abuse Treatment Options

Treating borderline personality disorder is trickier than other mental health conditions. Depending on the severity, people with BPD may make unrealistic demands of their therapists, and in some cases, become hostile or paranoid about their treatment team.

However, despite the complexity of co-occurring conditions like BPD and substance abuse, treatment is available. These conditions are best managed simultaneously using multiple levels of care that begin with detox and continue through to inpatient/residential, outpatient, and aftercare programs.

If you need to seek help, many of these programs are found in rehab facilities or drug treatment centers across the country.

Dual Diagnosis

Centers that offer dual diagnosis treatment are recommended as they are set up to diagnose and treat concurrent mental health conditions and substance abuse. This kind of treatment is especially useful for people who have underlying issues such as BPD, bipolar disorder, anxiety, and depression. Dual diagnosis programs allow clinicians to safely address these conditions while an individual withdraws from alcohol or drugs. Dual diagnosis can be found in both inpatient and outpatient clinics.

Key Therapies

Other key treatments to be aware of when it comes to anxiety and substance abuse are:

Dialectical-Behavior Therapy (DBT)

The gold-standard treatment for BPD is dialectical-behavior therapy (DBT), a type of cognitive-behavioral therapy that focuses on mindfulness, how to live in the moment, cope with stress, and improve relationships. DBT also helps clients better regulate their moods, impulsiveness, and how to develop healthy coping skills. This kind of therapy is useful for people who have co-occurring conditions, especially those who have BPD, depression, or bipolar symptoms. DBT is also effective for PTSD and for people who exhibit self-destructive behaviors.

Cognitive-Behavioral Therapy (CBT)

Another similar therapy for BPD and substance abuse is cognitive-behavioral therapy (CBT). CBT helps individuals change negative cycles of thought and behavior into more positive ones. When it comes to BPD, especially, CBT can help identify where a person’s impulsive behavior and fears of abandonment stem from. Clients receiving CBT for addiction often learn how to recognize “automatic thoughts” and dysfunctional thinking patterns, how to understand the behavior and motivation of others, and how to develop a greater sense of self-understanding and confidence.

CBT also teaches clients how to find solutions to triggers that might encourage drug use. CBT is known to be effective and long-lasting, as clients can continue utilizing these strategies once their therapy sessions have ended.

Eye Movement Desensitization and Reprocessing (EMDR)

Since a history of trauma and abuse can cause or exacerbate BPD, treatments such as EMDR that focus on trauma are also effective. Consisting of 8 phases, EMDR is led by a therapist who guides an individual through a series of rapid eye movements to help redirect negative or traumatic memories. This redirection helps the person form new connections or associations, so that the memory is less emotionally distressing over time. This therapy is therefore useful for individuals with mood disorders, as it helps them overcome the emotional suffering associated with traumatic events.

Motivational Interviewing (MI)

Motivational Interviewing (MI) is a type of collaborative therapy between a therapist and the client. During these sessions, the client and therapist work together to define sources of motivation and achieve self-defined goals. MI is known for its positive, client-centered approach, and has shown to be effective in treating addiction and mood disorders.

Medications

Medications are not a primary treatment modality for borderline personality disorder and substance abuse. However, the following are sometimes used to ease symptoms.

Anti-Depressants

One of the most prescribed medications for BPD are anti-depressants, such as selective serotonin reuptake inhibitors (SSRIs), tricyclic and tetracyclic antidepressants, and monoamine oxidase inhibitors (MAOIs). These drugs are also useful for substance abuse, particularly during the withdrawal period. Common anti-depressants for BPD include Nardil, Prozac, Zoloft, Effexor, and Wellbutrin.

Antipsychotics

Antipsychotics are useful for BPD, as they can reduce anxiety, paranoid thinking, and impulsivity — traits that are also augmented through substance abuse. Some of the common antipsychotics include Abilify, Geodon, Risperdal, Seroquel, and Zyprexa.

Mood Stabilizers/Anticonvulsants

Mood stabilizers and some anticonvulsant medications have also proven useful for BPD in terms of treating addiction, impulsive behavior, and rapid changes in emotion. Common mood stabilizers include Lithobid, Depakote, Lamictal, and Tegretol.

Anxiolytics (Anti-Anxiety Drugs)

Many individuals with substance abuse disorder and BPD also have intense anxiety; therefore, anti-anxiety (anxiolytics) medications such as benzodiazepines are also sometimes prescribed. Common anxiolytics include Ativan, Klonopin, Xanax, and Valium.

Alternative or Holistic Therapies

Holistic therapies are also effective at treating addiction and mood disorders. The purpose of holistic therapies is to treat the whole person and not just the symptoms. These can be incredibly beneficial for providing calmness, spiritual support, emotional expression, improving physical health, and teaching valuable skills. Some of the popular holistic therapies include:

• Relaxation techniques
• Nutritional therapy
• Animal-assisted therapy (e.g., emotional support dogs)
• Massage
• Adventure therapy (e.g., hiking or rock climbing)
• Mindfulness and meditation
• Art therapy, Music therapy
• Yoga, Tai-Chi
• Equine-assisted (horse) therapy

Long-Term Recovery

Alongside these treatments, there are other ways to enhance your recovery by making personal lifestyle adjustments like the ones below:

Exercise

can stimulate endorphins which can help with anxiety, depression, and low mood. Examples include low- and high-intensity exercises such as walking, running, swimming, cycling, or yoga.

Meditation

can help calm anxious or racing thoughts and reduce impulsive behavior which is useful when recovering from BPD and addiction.

Eating Well

the right diet can help repair damage incurred following sustained drug use and lead to improved immunity, cognitive function, and energy.

Avoiding Triggers

learning to avoid triggers like certain people, situations, or circumstances can help prevent BPD symptoms and a desire to take drugs.

New Hobbies

while cravings can be difficult to manage, hobbies such as sports, art, music, or crafts can be useful distractions.

Resources

If you or a loved one are struggling with borderline personality disorder and substance abuse or addiction, you are not alone. Treatment and support are readily available. Contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment.

You can also find a list of treatment centers near you on our website to help get you on the path to recovery.

Key Sources

Editorial Staff. (2021). Borderline Personality Disorder and Addiction. Dual Diagnosis.org. https://dualdiagnosis.org/borderline-personality-disorder-and-addiction.

Editorial Staff. (2021). Borderline Personality Disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml#part_145390.

Editorial Staff. (2021). Overview of BPD. National Education Alliance for Borderline Personality Disorder. https://www.borderlinepersonalitydisorder.org/what-is-bpd/bpd-overview.

Grant, B., Tulshi, S., Ruan, J., Goldstein, R.B., Chou, P., Jung, J., Zhang, H., Smith, S., Pickering, R., Huang, B., and Hasin, D. (2016). Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Borderline Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA. 73(1), 39–47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676679/.

Kienast, T., Stoffers, J., Bermpohl, F., Lieb, K. (2014). Borderline Personality Disorder and Comorbid Addiction. Dtsch Arztebl Int. 111(16), 280–286. https://10.3238/arztebl.2014.0280.

Trull, T.J., Freeman, L.K., Vebares, T.J., Choate, A.M., Helle, A.C., and Wycoff, A.M. (2018). Borderline personality disorder and substance use disorders: an updated review. Borderline Personal Disord Emot Dysregul. 5(15). https://10.1186/s40479-018-0093-9.

Zanarini, M.C, Frankenburg F.R, Dubo E.D, et al. (1998). Axis I comorbidity of borderline personality disorder. Am J Psychiatry. 155, 1733-1739. https://10.1176/ajp.155.12.1733

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