Clinical Challenges in Co-occurring Borderline Personality and Substance Use Disorders

Borderline personality disorder (BPD) is a serious illness involving multiple symptoms and mal adaptive behaviors. According to DSM-IV, "the essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects" (p. 650). This pervasive pattern of instability also applies to behaviors that are impulsive and potentially damaging, including excessive spending, sexual promiscuity, reckless driving, binge eating, and substance misuse.^1,2

Substance misuse associated with BPD is often frequent and severe enough to warrant a separate diagnosis. As the Figure illustrates, about 50% to 70% of psychiatric in patients with BPD also have a substance use disorder (SUD), especially alcohol abuse or dependence but often in combination with other drugs.^1,2

Depending on the sample, structured diagnostic interviews have found a variable prevalence of BPD among patients being treated for drug or alcohol dependence. The reported prevalence of BPD has ranged from 18% to 34% in patients receiving treatment for cocaine dependence.^3-5 In large samples of patients treated for opiate dependence, rates of co-occurring BPD have varied from 5% to 45%.^6-9 Among persons in treatment for alcohol use disorders, the prevalence of BPD appears similar to that for those in treatment for drug dependence, ranging from 16% to 22%.^10,11

Co-occurrence worsens course
There is evidence that co-occurring BPD worsens the outcome of alcohol and drug rehabilitation. In the study by Marlowe and colleagues⁴ of persons dependent on cocaine, BPD was the only Axis II disorder diagnosis that was consistently associated with a negative outcome, including measures of both treatment compliance and abstinence, and this relationship was in dependent of measures of anxiety, depression, or initial severity of drug dependence. Cacciola and colleagues6 examined 7-month outcomes of 197 men admitted to a methadone clinic. In that study, BPD had no significant effect on drug use, but it was associated with negative outcomes on other measures, including alcohol use, medical and psychiatric symptoms, and social relationships.

There is also evidence that BPD worsens the severity or course of alcohol use disorders. In a retrospective study by Martinez-Raga and colleagues,¹² patients at a detoxification program who had BPD or antisocial personality disorder were significantly more likely to have an unplanned discharge from the facility than those who did not have those personality disorder diagnoses. In the previously cited study by Morgenstern and colleagues,¹¹ co-occurring BPD predicted lifetime severity of alcohol dependence, psychological problems re lated to drinking, earlier age at onset of drinking, worse adaptive coping, and suicidal ideation, even after controlling for the effects of gender and concurrent Axis I disorders.

Likewise, studies examining patient populations in treatment for BPD have demonstrated that co-occurring SUD adversely affects outcome on measures of psychopathology. According to Miller and colleagues,¹³ BPD complicated by an alcohol use disorder is associated with unemployment, poor school performance, and promiscuity, com pared with BPD without a co-occurring alcohol use disorder. In their 2001 study, van den Bosch and coauthors¹⁴ compared 29 patients who had BPD with 35 patients who had co-occurring BPD and SUD. The latter group was found to have greater levels of anxiety, antisocial behavior, and suicide attempts.In a large psychological autopsy study of substance-related suicides, female victims were noted to have had high rates of BPD.¹⁵ Ryle and Golyn kina¹⁶ reported that cognitive analytic therapy for BPD was less effective for those patients with co-occurring alcohol abuse. However, a post hoc analysis of a randomized trial of dialectical behavior therapy (DBT) indicated that the presence of a co-occurring SUD was not a significant determinant of improvement in psychopathology.¹⁷

In a large prospective study of 290 subjects with diagnosed BPD who had been hospitalized at McLean Hospital in Belmont, Mass, Zanarini and associates2 reported that co-occurring SUD strongly and negatively correlated with remission from BPD at 6-year follow-up. The presence of SUD had a greater effect on outcome than did the presence of any other co-occurring Axis I disorder, including posttraumatic stress disorder, bipolar disorder, eating dis orders, or major depressive disorder. In their discussion, the authors stressed the need for the development of treatments that specifically target persons who have co-occurring BPD and SUD.

Possible mechanisms
It is not clear why so many patients with BPD also have SUD and why this combination is so detrimental. Do patients with BPD misuse substances simply because they are impulsive? Indeed, research studies have demonstrated a correlation between substance use and measures of impulsivity and affective lability in this population.¹⁸ However, patients sometimes describe their substance use as a mal adaptive coping mechanism. In the words of one patient, "You feel like a big shot when you're on cocaine, like you're important and in control and nothing else matters." Other patients note a calming effect from substances: "I feel like drinking after our sessions because we touch on a lot of things I've been trying to cover up, or hide, or not feel. So when I leave here, I have all kinds of feelings going on that I'm now going through. The drinking calms me down or lets me focus on something else."

Some intriguing neurobiologic research suggests that substance use in some persons can serve as a substitute for unmet attachment needs. In large prospective studies in Denmark, early weaning from breast-feeding has been associated with the development of alcoholism in adulthood.^19,20 These findings are similar to findings in animal studies. Barr and colleagues²¹ found that macaque monkeys separated from their mothers developed higher levels of ethanol preference. In addition, Moles and coinvestigators²² reported that mice that were lacking the µ-opioid receptor gene displayed both reduced reward dependence to nonopioid drugs of abuse and reduced attachment be haviors to ward their mothers. Satisfaction of unmet attachment needs may make substances particularly attractive to patients with BPD, who may otherwise exhibit pathologic interpersonal dependency.

Treatments for BPD/SUD Pharmacotherapy
Almost every major class of psychotropic medication has been tried in controlled treatment trials of BPD. Although a variety of medications, including SSRIs, mood stabilizers, and antipsychotic agents, may be helpful in some patients, a recent Cochrane review suggests that their efficacy compared with placebo has generally been very modest,²³ and thus medications are not considered the primary treatment for BPD.²⁴ There is evidence from one controlled study that although patients often prefer benzodiazepines to other classes of medications, benzodiazepines may actually worsen the course of the disorder, possibly through disinhibition.²⁵

Unfortunately, many pharmacotherapy protocols have excluded the large number of patients with co-occurring BPD/SUD from their trials. It is unclear whether medications are helpful at all in this subgroup, and benzodiazepines may be even more problematic in persons with active SUD because of their addictive potential.

Another important class of medications consists of those specifically de veloped and approved for use in sub stance dependence, such as nal trexone or acamprosate. Unfortunately, these also have not been examined in the large and refractory group of patients with co-occurring BPD and SUD.

Psychotherapy
Various psychotherapy modalities have been developed for the treatment of BPD that can be effective for both symptom management and core features of the disorder. Of these, DBT, a form of cognitive-behavioral therapy, has been the most studied in randomized controlled trials, and it appears to be especially effective for parasuicidal behavior.26 DBT is a complex and sophisticated treatment that integrates aspects of cognitive-behavioral and meditative practices.

A modified form of DBT has been developed for patients with co-occurring BPD/SUD; it has been used in combination with drug replacement therapy and tested for efficacy in 2 small trials.^28,29 The results of both studies indicated improvement in recreational drug use with combined treatment. However, there was little improvement in parasuicidal behavior, and dropout rates were 36% to 45%. The high dropout rates in these 2 studies highlight the difficulties in engaging this co-occurring subgroup in a meaningful therapeutic relationship.

Schema therapy is another form of cognitive-behavioral therapy that has shown promise in a recent randomized controlled trial.²⁹ This treatment identifies maladaptive schemas and modes of interaction and provides a combination of psychoeducation, coping strategies, and limited reparenting. This treatment has also been modified for persons who have co-occurring personality disorders and SUD.³⁰

Another treatment modality shown to be effective for BPD has been psy chodynamic psychotherapy. Bateman and Fonagy³¹ compared the effects of a psychodynamically oriented partial hospital program to usual care in the community. Compared with patients receiving usual care, those who had received psychodynamic treatment continued to improve on measures of self-injurious behavior, depression, anxiety, interpersonal functioning, and inpatient utilization for 2 years following discharge from the partial hospital program.³² Although the results were very positive, the study protocol excluded subjects with co-occurring SUD.

A manual-based form of psychodynamic psychotherapy, labeled transference-focused psychotherapy (TFP) is also being evaluated.³³ In a 3-year randomized trial comparing TFP with schema therapy for patients with BPD, both treatments were effective in reducing core symptoms of BPD, but overall better results were obtained in the latter group.²⁹ In this study, some of the patients had co-occurring SUD.

A study that more directly addresses the efficacy of psychodynamic psycho therapy for the co-occurring subgroup is presently in progress. A manual-based form of psychodynamic therapy labeled dynamic deconstructive therapy (DDT), specifically for those pa tients with BPD who are most difficult to engage in a therapeutic process, in cluding those who have a co-occurring SUD, has been developed.^34,35 DDT posits that persons with co-occurring BPD and substance dependence feel very vulnerable in relationships and have a fear of close attachments. The treatment recognizes the patient's need for autonomy and encourages the therapist to maintain a nonjudgmental and nondirective stance toward maladaptive behaviors. Results of a study by Karno and Longa baugh³⁶ indicate that the outcome of alcoholic patients with moderate or high reactance is strongly and negatively related to the degree of therapist directiveness.

An ongoing 30-month study is as sessing the effectiveness of DDT com pared with high-intensity community care for patients with co-occurring BPD and alcohol use disorders. Initial findings suggest that DDT is effective in reducing parasuicidal behavior, alcohol misuse, and institutional care and is associated with far better treatment retention than community care.³⁷

SUMMARY
Persons with co-occurring BPD and SUD represent a large subgroup of both the BPD and substance using pa tient populations. This subgroup ap pears to be especially impaired and dif ficult to engage in treatment. Although there is evidence that a variety of treatments may be effective for BPD, treatments for the co-occurring subgroup are much less well established. Initial studies of modified forms of cognitive-behavioral and psychodynamic therapies hold promise for the development of effective treatments in this very challenging population, but further research is necessary.

Dr Gregory is associate professor of psychiatry in the department of psychiatry at the State University of New York Upstate Medical Uni versity in Syracuse. He reports that he has no conflicts of interest concerning the subject matter of this article.

References:

References1. Dulit RA, Fyer MR, Haas GL, et al. Substance use in borderline personality disorder. Am J Psychiatry. 1990;147:1002-1007.
2. Zanarini MC, Frankenburg FR, Hennen J, et al. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. Am J Psychiatry. 2004;161:2108-2114.
3. Kleinman PH, Miller AB, Millman RB, et al. Psychopathology among cocaine abusers entering treatment. J Nerv Ment Dis. 1990;178:442-447.
4. Marlowe DB, Kirby KC, Festinger DS, et al. Impact of comorbid personality disorders and personality disorder symptoms on outcomes of behavioral treatment for cocaine dependence. J Nerv Ment Dis. 1997;185:483-490.
5. Kranzler HR, Satel S, Apter A. Personality disorders and associated features in cocaine-dependent inpatients. Compr Psychiatry. 1994;35:335-340.
6. Cacciola JS, Rutherford MJ, Alterman AI, et al. Personality disorders and treatment outcome in methadone maintenance patients. J Nerv Ment Dis. 1996;184:234-239.
7. Cacciola JS, Alterman AI, Rutherford MJ, et al. The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients. Drug Alcohol Depend. 2001;61:271-280.
8. Brooner RK, King VL, Kidorf M, et al. Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry. 1997;54:71-80.
9. Darke S, Ross J, Williamson A, Teesson M. The impact of borderline personality disorder on 12-month outcomes for the treatment of heroin dependence. Addiction. 2005;100:1121-1130.
10. Nurnberg HG, Rifkin A, Doddi S. A systematic assessment of the comorbidity of DSM-III-R personality disorders in alcoholic outpatients. Compr Psychiatry. 1993;34:447-454.
11. Morgenstern J, Langenbucher J, Labouvie E, Miller KJ. The comorbidity of alcoholism and personality disorders in a clinical population: prevalence rates and relation to alcohol typology variables. J Abnorm Psychol. 1997;106:74-84.
12. Martinez-Raga J, Marshall EJ, Keaney F, et al. Un planned versus planned discharges from in-patient alcohol detoxification: retrospective analysis of 470 first-episode admissions. Alcohol Alcohol. 2002;37:277-281.
13. Miller FT, Abrams T, Dulit R, Fyer M. Substance abuse in borderline personality disorder. Am J Drug Alcohol Abuse. 1993;19:491-497.
14. van den Bosch LM, Verheul R, van den Brink W. Substance abuse in borderline personality disorder: clinical and etiological correlates. J Personal Disord. 2001;15:416-424.
15. Pirkola SP, Isometsa ET, Heikkinen ME, et al. Female psychoactive substance-dependent suicide victims differ from male-results from a nationwide psychological autopsy study. Compr Psychiatry. 1999;40:101-107.
16. Ryle A, Golynkina K. Effectiveness of time-limited cognitive analytictherapy of borderline personality disorder: factors associated with outcome. Br J Med Psychol. 2000;73:197-210.
17. van den Bosch LM, Verheul R, Schippers GM, van den Brink W. Dialectical behavior therapy of borderline patients with and without substance use problems: implementation and long-term effects. Addict Behav. 2002;27:911-923.
18. Trull TJ, Sher KJ, Minks-Brown C, et al. Borderline personality disorder and substance use disorders: a review and integration. Clin Psychol Rev. 2000;20:235-253.
19. Goodwin DW, Gabrielli WF Jr, Penick EC, et al. Breast-feeding and alcoholism: the Trotter hypothesis. Am J Psychiatry. 1999;156:650-652.
20. Sorensen HJ, Mortensen EL, Reinisch JM, Mednick SA. Early weaning and hospitalization with alcohol-related diagnoses in adult life. Am J Psychiatry. 2006;163:704-709.
21. Barr CS, Newman TK, Lindell S, et al. Interaction between serotonin transporter gene variation and rearing condition in alcohol preference and consumption in female primates. Arch Gen Psychiatry. 2004;61:1146-1152.
22. Moles A, Kieffer BL, D'Amato FR. Deficit in attachment behavior in mice lacking the mu-opioid receptor gene. Science. 2004;304:1983-1986.
23. Binks CA, Fenton M, McCarthy L, et al. Phar ma cological interventions for people with borderline personality disorder. Cochrane Database Syst Rev. 2006;(1):CD005653.
24. American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158(suppl 10):1-52.
25. Cowdry RW, Gardner DL. Pharmacotherapy of borderline personality disorder. Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. Arch Gen Psychiatry. 1988;45:111-119.
26. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48:1060-1064.
27. Linehan MM, Schmidt H 3rd, Dimeff LA, et al. Dia lectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict. 1999;8:279-292.
28. Linehan MM, Dimeff LA, Reynolds SK, et al. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend. 2002;67:13-26.
29. Giesen-Bloo J, van Dyck R, Spinhoven P, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry. 2006;63:649-658.
30. Ball SA. Manualized treatment for substance abusers with personality disorders: dual focus schema therapy. Addict Behav. 1998;23:883-891.
31. Bateman A, Fonagy P. Effectiveness of partial hos pitalization in the treatment of borderline personality dis order: a randomized controlled trial. Am J Psychiatry. 1999;156:1563-1569.
32. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry. 2001;158:36-42.
33. Clarkin JF, Foelsch PA, Levy KN, et al. The develop ment of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Personal Disord. 2001;15:487-495.
34. Gregory RJ. Thematic stages of recovery in the treatment of borderline personality disorder. Am J Psychother. 2004;58:335-348.
35. Gregory RJ. The deconstructive experience. Am J Psychother. 2005;59:295-305.
36. Karno MP, Longabaugh R. Less directiveness by therapists improves drinking outcomes of reactant clients in alcoholism treatment. J Consult Clin Psychol. 2005;73:262-267.
37. Gregory RJ. Psychodynamic therapy for co-occuring borderline personality disorder and alcohol use disorder: a newly designed ongoing study. Presented at: 159th Annual Meeting of the American Psychiatric Association; May 20-25, 2006; Toronto.