Personality Disorders & Drug Addiction

Substance Abuse & Personality Disorder

Personality disorders are a type of mental health condition in which people have problematic or maladaptive patterns of thought and behavior which are characteristically inflexible, inappropriate, and disrupt the lives of those affected. People with personality disorders have difficulty controlling their emotions and tend to behave or react to others in socially unacceptable ways. This often causes distress and turmoil in their personal, professional, and social lives. People with personality disorders often do not realize or accept that their thought patterns or behaviors are the cause of their problems; instead, they tend to shift blame onto others.¹

There are 3 main types, or clusters, of personality disorders, which are grouped based on some similarities in their characteristic features and presentation.^1,19

• Cluster A—Disorders characterized by odd or eccentric thoughts and behaviors. This includes paranoid or schizoid personality disorders.
• Cluster B—Disorders characterized by dramatic or disordered emotional reactions and unpredictable or inappropriate behaviors. Borderline personality disorder (BPD), antisocial personality disorder (APD), and narcissistic personality disorder are in this group.
• Cluster C—Disorders characterized by anxious or fearful thoughts and behaviors, including avoidant and dependent personality disorders and obsessive-compulsive personality disorder.

People with BPD often have unstable and intense emotional reactions, impulsive and harmful behaviors, and chaotic relationships with others.⁴ People with APD, sometimes called sociopathy, have little regard for social rules, are manipulative, and treat others coldly or harshly, without guilt or remorse for any harmful consequences of their actions.⁵

Substance use is commonly seen in people with personality disorders. Certain ones—such as BPD and APD—are very strongly associated with substance abuse.²¹ Though we often see alcohol or drugs in the context of mental disorders, such problematic substance use can worsen or complicate the course of these mental health disorders in the long run.²

The use of substances by people with mental health issues can increase the likelihood of developing a co-occurring substance use disorder (SUD), which is often characterized as problematic alcohol or drug use that continues despite giving rise to health issues or causing problems at work, school, or home. A person with an SUD often come to “need” the substance to face daily life and may continue seeking and using the substance, even if it results in a situation where they are in financial distress, desperate and alone, after cutting ties with family and friends who disapproved of their substance abuse.³

Substance abuse and substance use disorders (SUDs) can be common with mental illnesses, including personality disorders. If someone is dealing with both a mental illness and a substance use disorder then that is identified as a co-occurring disorder.

Standards in the Diagnostic and Statistical Manual used by mental health professionals indicate that, for those who have both a substance use disorder and a personality disorder, the primary disorder is the personality disorder provided that the personality disorder does not occur due to the effects of the alcohol or drugs.²⁰  The personality disorder is primary if the disorder’s symptoms were apparent before the addiction began and continue when drug and alcohol use has stopped.²⁰ Being diagnosed with a personality disorder and an SUD allows care providers to then work to determine if the personality is primary or substance-induced so that then they can determine the most effective treatment.²⁰

What Is Borderline Personality Disorder?

BPD usually starts in adolescence or early adulthood.⁶ A person with BPD may have trouble regulating their emotions and can experience dramatic mood swings. They may have intense feelings of anger, sadness, or anxiety that can last for hours or days and quickly shift from one intense emotion to the next. This turbulent emotional state can trigger intense, uncomfortable feelings and impulsive behaviors and result in a chronic pattern of dysfunctional and chaotic relationships with others.⁷

People with BPD may also have a distorted, negative, and unstable self-image and feel that others regularly misunderstand or mistreat them. They may react to perceived mistreatment or abandonment with anger and aggression or by engaging in self-harm or other impulsive, risky behaviors.⁸

Other signs and symptoms of BPD include: ^6,9

• Intense fear of abandonment and being alone. People with BPD may go to extreme measures to avoid this; they may also cut off communication with someone abruptly in anticipation of being abandoned.
• Chronic patterns of intense and unstable relationships, which swing from idealization to intense dislike or anger.
• Impulsive and risky behaviors, such as unsafe sex, reckless driving, binge eating, and substance abuse.
• Self-harming behaviors, such as cutting or suicidal behaviors or attempts.

Borderline individuals may find it difficult to maintain employment and relationships or to complete educational or other goals. Bouts of intense, inappropriate anger may cause ongoing conflict in relationships and can result in legal issues and even jail time. People with BPD may be more likely to be in abusive relationships. The impulsivity common to borderline personalities can result in unplanned pregnancies, sexually transmitted diseases, accidents, and physical altercations.⁶

The exact causes of BPD are not fully understood, but it is thought to result from a combination of factors including the following:¹⁰

• Genetics – People with close family members who struggle with BPD may be also be at higher risk themselves.
• Brain structure and function – Certain neurological differences may make it more difficult for people with BPD to control emotions and could result in impaired judgment and communication abilities.
• Environment – exposure to prior traumatic life events may increase an individual’s risk of developing BPD.

Borderline Personality Disorder & Addiction

Some estimates have been made that as many as 2.7% of adults are affected by BPD and of these, nearly 80% will have a co-occurring substance use disorder or alcohol use disorder (AUD) at some point in their lives.¹² The high rate of co-occurrence of substance use disorders in people with BPD may be due in part to their characteristic impulsive behavior.¹³

People prone to acting impulsively may be more likely to drink or use drugs, even when they know that it could be damaging to their future goals or present life circumstances. Difficulty regulating emotions, especially negative emotions like anger and depression, is also a key characteristic of BPD, and using substances to dull the effect of negative emotions is reported to be one of the primary motivators leading to substance abuse.¹⁴

People with co-occurring BPD and SUD tend to be even more impulsive and unstable than those with only BPD. They also have higher rates of suicidal behaviors, drop out of treatment more often, and have shorter periods of abstinence or sobriety than those without BPD.¹²

BPD itself is difficult to treat due to the characteristic impulsivity and unstable self-image; a co-occurring SUD could make these issues worse, which in turn makes treatment more challenging. For these reasons, it could be beneficial to address both disorders at the same time. People with BPD who don’t receive adequate treatment are less likely to make healthy life choices and more likely to develop other chronic mental or medical illnesses.⁹

What Is Antisocial Personality Disorder?

People with APD have rigid and dysfunctional thought processes and a history of impulsive and aggressive behavior, with no remorse for the consequences or violating the rights of others.^15,16 The characteristic behaviors seen in APD cause problems in relationships and in maintaining employment.¹⁷ APD affects approximately 4.3% of the population, with the highest rates seen in young, unmarried men with lower levels of education. APD is prevalent among those who are/have been incarcerated.¹⁵

Other signs and symptoms of APD include:¹⁸

• Persistent lying or use of deceit to exploit others.
• Being callous, cynical, and disrespectful to others.
• Manipulating others for personal gain or personal pleasure.
• Having a history of legal problems, including criminal behaviors.
• Using intimidation and dishonesty to violate the rights of others.
• Engaging in impulsive and dangerous behaviors.
• Having no concern for the safety of oneself or others.
• Lacking empathy or remorse for having harmed others.
• Having a history of abusing others in relationships.
• Being unable or unwilling to consider negative consequences or learn from past mistakes.
• Repeatedly failing to fulfill work or financial obligations.

The characteristic behaviors associated with APD, which include violence, irresponsibility, recklessness, and dishonesty, can result in substantial psychological, legal, and financial burdens for affected individuals, their families, and spouses. APD is also associated with increased mortality from unnatural causes, especially at a younger age, and increased rates of suicide, medical illness, and injury.¹⁵

While the cause of APD is not yet known, the following factors are associated with an increased risk for developing APD:⁵

• Having been diagnosed with a conduct disorder in childhood.
• Having a family history of APD or other personality or mental health disorder.
• Having experienced abuse or neglect in childhood.
• Having a violent or chaotic family life in childhood.

Antisocial Personality Disorder (APD) & Addiction

Substance use disorders are very common in those with antisocial personality disorder. Prevalence estimates indicate that more than 80% of people with APD will have a co-occurring SUD at some point in their lifetime.¹⁵

People with APD also exhibit impulsive behaviors, which might increase the likelihood of greater substance use and being unable or unwilling to cut down or stop using a substance, even when use has become a problem in many aspects of their life.¹⁸ People with APD are also prone to engaging in risky behaviors, without regard for self-harm, which could lead to or escalate problematic substance use.

When it comes to treatment for this comorbidity, a long-term, highly structured integrated approach that addresses both the substance use and personality issues may be the optimal strategy.²¹ Such a strategy may involve some combination of evidence treatment approaches such as contingency management and cognitive behavioral therapy (CBT) to support changes in maladaptive thoughts and encourage healthy changes in behavior.

Other treatment approaches that support motivation may also prove useful in integrated treatment, as people with both BPD and APD tend to have chronic issues with negative self-image, and establishing external sources of motivation to boost their self-image could additionally support functional recovery.²

Sources

1. Mayo Clinic. 2020. Personality disorders.
2. National Institute on Drug Abuse. 2020. Common comorbidities with substance use disorders.
3. 2020. Substance use disorder.
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6. Mayo Clinic. 2020. Borderline personality disorder: Symptoms & causes.
7. 2018. Borderline personality disorder.
8. S. Department of Health & Human Services: Office on Women’s Health. 2018. Borderline personality disorder.
9. National Institute of Mental Health. Brochures and fact sheets: Borderline personality disorder.
10. National Alliance on Mental Illness (NAMI). 2020. Mental health conditions: Borderline personality disorder.
11. National Institute of Mental Health. 2017. Borderline personality disorder.
12. Kienast, T., Stoffers, J., Bermpohl, F., & Lieb, K. (2014). Borderline personality disorder and comorbid addiction: epidemiology and treatment. Deutsches Arzteblatt International, 111(16), 280–286.
13. Lane, S. P., Carpenter, R. W., Sher, K. J., & Trull, T. J. (2016). Alcohol craving and consumption in borderline personality disorder: When, where, and with whom. Clinical Psychological Science: A Journal of the Association for Psychological Science, 4(5), 775–792.
14. Trull, T. J., Freeman, L. K., Vebares, T. J., Choate, A. M., Helle, A. C., & Wycoff, A. M. (2018). Borderline personality disorder and substance use disorders: an updated review. Borderline Personality Disorder and Emotion Dysregulation, 5, 15.
15. Goldstein, R. B., Chou, S. P., Saha, T. D., Smith, S. M., Jung, J., Zhang, H. … & Grant, B. F. (2017). The epidemiology of antisocial behavioral syndromes in adulthood: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. The Journal of Clinical Psychiatry, 78(1), 90–98.
16. Fisher, K.A., & Hany, M. 2020. Antisocial personality disorder. In: StatPearls [Internet]. StatPearls Publishing, Treasure Island, FL.
17. 2020. Antisocial personality disorder.
18. Mayo Clinic. 2020. Antisocial personality disorder.
19. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
20. Pettinati, H. M., O’Brien, C. P., Dundon, W. D. (2013). Current status of co-occurring mood and substance use disorders: a new therapeutic target. The American Journal of Psychiatry, 170(1), 23–30.