Borderline Personality Disorder (BPD) can be an extremely challenging condition to live with, affecting how individuals experience emotions, relationships, and self-image.
BPD produces intense feelings, fear of abandonment, unstable relationships, and impulsive behaviors that seem to confirm every negative thought a person has about themselves. BPD creates a level of suffering that is often hard to articulate and easy to misinterpret as manipulative or weak behavior. Many people with BPD will find themselves using drugs and alcohol as their primary means of coping. This is why BPD and addiction frequently co-occur, and why successful treatment requires specialized, specific methods.
What Is Borderline Personality Disorder?
Borderline personality disorder (BPD) is a complex mental illness characterized by an instability in mood, self-image, relationships, and behavior, resulting in extreme highs and lows.[1] BPD is classified in the DSM-5 as a personality disorder, which means that it is characterized by a deep-seated, chronic pattern of thoughts, emotions, and behaviors that are in direct conflict with cultural norms, cause significant impairment or distress, and are stable over time.[2]
BPD can result from both biological predisposition, such as increased emotional sensitivity and reactivity, and environmental conditions, particularly in childhood. Research has shown that many people with BPD have suffered trauma, abuse, neglect, or come from a chaotic household, and many with BPD also meet the criteria for post-traumatic stress disorder (PTSD).[3]
While BPD may have the reputation of being difficult to treat, studies show that with the appropriate level of care, many can significantly reduce their symptom severity. Evidence also supports the finding that people with BPD who undergo dialectical behavior therapy (DBT) — which was developed specifically for BPD — make meaningful and durable gains in their quality of life.[4]
How is BPD Diagnosed?
BPD is diagnosed after meeting at least five of the nine criteria used by the American Psychiatric Association to diagnose mental health disorders.[5]
The nine criteria include:
- Frantic efforts to avoid real or imagined abandonment — Intense fear that loved ones will leave, and often desperate or impulsive behaviors to prevent it
- Unstable and intense interpersonal relationships — A pattern of alternating between idealizing and devaluing people, sometimes within the same relationship or even the same day
- Unstable sense of self — A markedly and persistently unstable self-image or sense of self that leaves the person uncertain about who they are, what they value, and what they want
- Impulsive behaviors in at least two potentially self-damaging areas — Such as substance abuse, reckless spending, binge eating, unsafe sex, or reckless driving
- Recurrent suicidal behavior, gestures, threats, or self-harm — Self-harm behaviors in BPD are often attempts to regulate unbearable emotional pain rather than attempts to end life, though suicide risk is genuinely elevated
- Intense mood swings — Episodic dysphoria, irritability, or anxiety lasting hours to a few days, driven by hypersensitivity to interpersonal events
- Chronic feelings of emptiness — A persistent, painful sense of inner emptiness that is one of the most distinctive and distressing features of BPD
- Intense, inappropriate anger — Difficulty controlling anger, with frequent displays of temper disproportionate to the situation
- Stress-related paranoia or dissociation — Transient, stress-related paranoid ideation or severe dissociation that can emerge during emotional crises
The Correlation Between BPD and Substance Abuse
BPD often co-occurs with substance use disorder. It is estimated that 50 to 70% of people with BPD in treatment also struggle with substance use disorder, most commonly alcohol and opioids.[6]
There are multiple reasons why BPD and substance use co-occur. Emotional dysregulation is a hallmark of BPD and often leads people to self-medicate, using substances to cope with intense emotions. Alcohol numbs emotional pain, opioids diminish the intensity of emotions, and stimulants temporarily increase confidence and sense of control.
Impulsivity, which is also characteristic of BPD, also makes it more likely that a person will use substances to cope with severe distress during emotional crises. The chronic feelings of emptiness associated with BPD also create an ongoing desire for something to fill that void.
Though substances may provide temporary relief, using them will further worsen emotional dysregulation and negatively impact the emotional and neurological systems of people with BPD.[7] Over time, this increases impulsive behavior, destabilizes relationships, and makes the core work of BPD treatment, developing effective emotion regulation and a stable self-identity, significantly more challenging. Substance use also greatly increases the already elevated risk of suicide associated with BPD, creating an urgent need for integrated dual diagnosis treatment.[8]
BPD and Alcohol Use
Alcohol is one of the most frequently misused substances by people with BPD.[9] The disinhibiting and numbing effects of alcohol may offer some immediate, albeit short-lived, respite from the acute emotional and interpersonal pain that is so common with the condition. However, alcohol is a CNS depressant, so the longer a person uses alcohol, the worse their emotional regulation becomes, resulting in greater impulsivity and a much higher risk of self-harm and suicidal behaviors.[10] Treating BPD and alcohol use simultaneously is critical because alcohol use greatly increases the difficulty and danger associated with the emotional work required for successful BPD treatment.[11]
When to Seek Help for BPD and Addiction
A person should seek professional help for BPD when symptoms of the disorder interfere with their daily functioning, relationships, or well-being, regardless of whether they are using substances.
When BPD and substance use co-occur, integrated dual diagnosis treatment should be sought. If a person is treated only for their substance use disorder and the BPD remains untreated, the psychological reasons for substance use will remain. Conversely, if a person is treated for BPD but continues to use substances, the effectiveness of the treatment methods will be diminished due to the lack of stabilization.
A higher level of care (inpatient) may be required for BPD or substance use disorder if the person is at risk for self-harm or has active suicidal ideation, regardless of substance use status. Safety is always the primary clinical concern.
How to Treat Borderline Personality Disorder
Dialectical Behavior Therapy (DBT)
DBT is considered the gold-standard evidence-based treatment for BPD and has the strongest empirical evidence of any therapeutic approach in its treatment.[12] Developed by Marsha Linehan — who lived with BPD — DBT incorporates individual therapy, group skills training, phone coaching, and therapist consultation to teach four primary skill sets: mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.
DBT skills can be used directly to assist a person in recovering from addiction. Distress tolerance skills provide alternatives when in emotional distress rather than resorting to substance use, emotional regulation skills help reduce the frequency and intensity of the dysregulated emotions that cause people to self-medicate, and interpersonal effectiveness skills help develop stable relationships that facilitate recovery. DBT has been specifically adapted to meet the needs of people with both BPD and substance use disorders, with versions of the program that address both conditions.
Cognitive Behavioral Therapy (CBT)
CBT addresses the distorted thought patterns and core beliefs about self, others, and relationships, which are associated with BPD symptoms. When combined with DBT, CBT provides an integrated cognitive-behavioral approach that can result in lasting change.
Medication Management
The FDA has not approved any medication specifically for BPD, but healthcare professionals sometimes use atypical antipsychotics, mood stabilizers, and other medications to manage BPD, particularly mood instability, impulsivity, and psychosis-like symptoms.[13] Managing medication for people who also have a co-occurring substance use disorder requires careful psychiatric supervision.
Trauma-Informed Care
The majority of BPD clients have prior trauma histories. Trauma-informed care interventions such as EMDR and trauma-focused CBT are often a primary focus of comprehensive BPD treatment and are typically provided once stabilization has been achieved.
