Dual Diagnosis Treatment: Treating The Addicted Borderline Personality Disorder

Cluster B: Incidence of Co-Occurring Substance Abuse Disorders

Cluster B has the highest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, O'Connell, ed., 1990, p. 184).

Stone (1993, p. 222) suggests that a complicated reciprocal relationship exists between BPD and illicit drugs. Abuse of alcohol and certain drugs, e.g., amphetamines, can intensify the symptomatology of BPD by making impulsivity worse. However, it is also possible that abuse of amphetamines, marijuana, or psychedelics sets in motion a deterioration of habits and self-control that leads to a clinical picture resembling BPD.

Millon (1996, p. 200) notes that individuals with BPD are characterized by drug-seeking behavior. Individuals with BPD will be particularly vulnerable to the escape offered by drugs and alcohol. Real world interaction triggers multiple interpersonal crises and overwhelming negative affect. Drugs can, ostensibly, offer relief from BPD turmoil and emptiness.

Khantzian, et. al. (1990, p. 3) view the treatment of any character disorder as the road to recovery from addiction. However, this approach demands a continued attention to and concern about maintaining abstinence and avoiding relapse. Addiction becomes a disorder in its own right and must be addressed directly. However, the treatment of personality disorders can lead to profound change in the personality disordered individual's experience of self and the world, which, in turn, can positively affect recovery from addiction.

Drugs of Choice for the Borderline Personality Disorder

Individuals with BPD experience extraordinary affective discomfort. They are frequently agitated, labile, and overwhelmed. They do not define themselves as able or effective in managing their own lives. Their defenses are regressive; under stress they become more childlike. Drugs and alcohol can offer these individuals a way of coping; drugs can block out sensations of pain, discomfort, or negative affect. The appeal of drugs and other compulsive behaviors in soothing, distracting, and escaping is apparent and powerful. Richards (1993, pp. 280-281) states that individuals with BPD, over any of the other personality disorders, are the "e;best candidates"e; for developing addictive disorders. These individuals will use almost any drug or route of administration to their own worst advantage, They often abuse prescribed medications and may hoard these medications for suicide attempts.

Individuals with BPD often use alcohol and other drugs in a chaotic and unpredictable pattern; they may engage in a polydrug pattern involving alcohol and other sedative-hypnotics for self-medication. Clients with BPD often abuse benzodiazepines that have been prescribed for anxiety -- which can lead to a relapse to their actual primary drug of choice (Ries, TIP #9, 1994, p. 55).

The issue of prescribed medication for individuals with BPD is complex and difficult. These individuals often demand medication for anxiety and become quite angry when denied. They are noncompliant with medication -- either using too much or too little. They are inclined to misreport the impact of the medication, saying they feel better when they do not or worse when they feel better. The intensity of their discomfort can make prescribing of addictive medication seem more reasonable than it should. Their propensity for crises often brings them into contact with an array of service providers and medical personnel. They are quite frequently successful in obtaining the medication they seek, usually benzodiazepines, from at least one doctor from whom they receive services. Then it becomes difficult to withdraw a drug to which they may have already developed physical adaptation and tolerance. Many individuals with BPD are informed enough to tell medical personnel that if they do not receive a prescription for Zanax, for example, they will probably have a seizure.

Another issue regarding drug of choice for individuals with BPD has to do with their intolerance for being alone and the intensity of their relationships. These individuals will often use drugs and alcohol as part of their contact with needed others. The drug of choice will then be incidental to that used by their social contacts. Recovery in these situations will be dependent upon linking addicted clients with BPD to a strong support network that fosters abstinence such as AA or NA.

Dual Diagnosis Treatment for the Borderline Personality Disorder

Richards (1993, p. 278) suggests that treatment failures for the dually diagnosed are often a result of failure to consider the function of the addiction, including the drug of choice, within the context of the psychopathology dominant in the individual. Salzman (Mule, ed., 1981, pp. 346-347) believes that the inner forces that initiate and sustain addiction are immaturity and inappropriate, magical coping techniques. Dual diagnosis treatment must involve recognition of these tendencies that foster addictive behavior, i.e., immaturity, escapism, and grandiosity. New ways must be learned for dealing with feelings of powerlessness and helplessness other than compulsivity.

When individuals with BPD cannot self-comfort, they flee into impulsive sex, food, drugs, shopping (or shoplifting). Impulsive and self-destructive behaviors will temporarily allow them to feel calmer (Oldham, 1990, p. 303). Conversely, panic is a frequent and significant reaction to confrontation of drug use or compulsive behaviors. The drug/behavior may have become so important to individuals with BPD that it is perceived as necessary for survival. This panic can be the cause of lying, avoidance, or treatment withdrawal. Life without the drug of choice appears impossible and incomprehensible.

When individuals with BPD, who have not previously reported other compulsive behaviors, are able to achieve abstinence from their drug of choice, service providers must address the possibility of or check for alternative addictive involvement, e.g., shopping, shoplifting, impulsive and unsafe sexual behavior, or gambling. Recovery programs must cover all addictive patterns.

Dual diagnosis treatment for addicted individuals with BPD must address the function of the addictive substance and/or compulsive behaviors while developing strong substitutes that can sustain recovery behaviors and abstinence, e.g., involvement in AA or NA, affect management (particularly anger), medication compliance, cognitive self-calming techniques, identified recovery behaviors, e.g., daily contact with sponsors, and therapy for issues related to a family history of physical or sexual abuse. The treatment modality of choice is rarely long-term individual therapy. Group more effectively addresses transference issues and is compatible with fostering affective management techniques, life management skills, and recovery community involvement

Twelve-step group participation may be a more successful process for individuals with BPD with pre-12-step practice sessions. These individuals should be helped to organize their thoughts and to practice saying "e;pass"e; when feeling unsafe. They should be encouraged to join same sex groups when possible and use same sex sponsors. If appropriate, sponsors can be brought into a treatment session to learn why individuals with BPD are taking medication and to discuss setting boundaries. Further, individuals with BPD need to learn the difference between powerlessness and helplessness (Ries, TIP #9, 1994, p. 60).

Relapse for individuals with BPD is defined as engaging in any unsafe behavior such as AOD use, self-harm, and noncompliance with medications. Relapse prevention must focus on both preventing AOD use and recurrence of psychiatric symptoms (Ries, TIP #9, 1994, p. 60).

Confrontation usual to substance abuse treatment may be useful with high-functioning individuals with BPD. It will overwhelm lower-functioning individuals. Service providers must be aware of the severity of pathology in each individual with BPD when deciding on the use of confrontation techniques. Abstinence can be a prerequisite to treatment only with very high-functioning individuals with BPD; otherwise, it needs to be a goal of treatment. Use should be confronted but not result in termination from treatment.