Dual Diagnoses: BPD and Addiction

Addiction and Borderline Personality Disorder By: Nicole Armstrong

When it comes to treating addiction and Borderline Personality Disorder (BPD) simultaneously, the similarities between addiction and BPD can make a correct diagnosis tough. At Palm Partners, we are able to treat Addiction and Borderline Personality Disorder because we are a dual-diagnosis treatment facility. Borderline personality disorder is known by a few characteristics that are also frequently seen in someone with an addiction. The characteristics of borderline personality disorder are someone who is extremely manipulative, dramatic and needy. There is more to borderline personality disorder though.

This kind of behavior stems from a way to cope with overpowering fear and emotional pain. The emotional insecurity and pain along with impulsive behaviors put someone with BPD at a high risk for addiction or can be confused with addiction and in some situations where both are obvious, worsen the symptoms.

Addiction and Borderline Personality Disorder: Diagnosis

When addiction and borderline personality disorder correspond with each other it can be really tough to treat. The resemblances between addiction and borderline personality disorder can make a proper diagnosis practically impossible. When addiction and borderline personality disorder overlap, the symptoms are very much the same, both are characterized by: impulsive and self-destructive behaviors, mood swings, manipulative and deceitful actions, lack of concern for one’s own safety and health, insistence on chasing dangerous behavior, suicidal behavior, depression, paranoia, and instability in jobs, finances and relationships.

Since the characteristics between addiction and borderline personality disorder are so alike, it shows you that it is really important that an individual with drug addiction try to find a dual diagnosis program. In dual diagnosis programs they can successfully diagnose between mental illness and drug abuse.

Addiction and Borderline Personality Disorder: Treatment

Treating addiction and borderline personality disorder is very well-known amongst mental health professionals as being challenging. Clients with addiction and borderline personality disorder frequently will make impractical demands of their therapists and will most likely need continuous contact with their treatment team. An individual with an addiction and BPD might come off as reliant on others because they are often searching for caretakers who can satisfy their emotional needs. They can also be the exact opposite and rebel against their caretakers and become aggressive, angry and paranoid for no reason. This is specifically true of someone with a borderline personality disorder and the addiction just intensifies it.

Dialectical Behavioral Therapy (DBT) is one of the most effective ways to approach addiction and borderline personality disorder. DBT is centered on the belief that change can be balanced with self-acceptance. DBT assists individuals with severe psychiatric disorder in creating significant and established lives. This is particularly imperative in someone with an addiction and borderline personality disorder because when someone has an addiction it may appear that they have a mental illness when they really don’t; so using medication to treat mental health issues could be unsafe for someone who has an addiction. While waiting for an addict to recover from their addiction somewhat it is best to use some kind of therapy until an accurate diagnosis can be determined. This makes DBT perfect for someone with addiction and borderline personality disorder. DBT is presented at most drug and alcohol treatment centers including Palm Partners. Some of the benefits of a dual diagnosis program that offers DBT for addiction and borderline personality disorder are: it helps the client find motivation to make changes in their life, it teaches the client to manage moods and handle triggers, it eliminates environmental cues and social situations that promote alcohol or drug abuse, it reduces cravings, it helps the client achieve recovery goals and clients are able to identify and purse self-affirmative activities that help them connect with others.

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The following discussion (in the yellow section) is adapted, paraphrased or quoted from the text of "The Dual Disorders Recovery Book" by Hazelden, Center City, Minnesota.

"...People with dual disorders continued to suffer. Even if they stayed sober, they still wrestled with depression, anxiety, or other emotional turmoil. Often their symptoms were so serious that they began abusing substances again, hoping for relief, and the cycle would begin anew. As if things weren't bad enough, they also had to wrestle with the social stigma of mental illness. Through ignorance or insensitivity, other people looked on them as weak-willed or morally bankrupt, rather than as affected by not one but two devastating illnesses. They were seen as failures. The truth was, treatment had failed them.

....then came the introduction of the Twelve Step philosophy in the 1930's, with Alcoholics Anonymous actually forming in 1934. In 1952 the American Medical Association recognized alcoholism as a disease, a concept that the public has gradually come to accept.

People with addictions problems are more likely to develop other psychiatric conditions than the general population, and people with psychiatric problems are at much higher risk of becoming substance abusers.

*If you have diagnosis of:*	*Your risk of substance abuse is:*
Phobia	2.4 times as great
Obsessive-compulsive disorder	3.4 times as great
Major depression	4.1 times as great
Panics disorder	4.3 times as great
Schizophrenia	10.1 times as great
Manic-depressive disorder	14.5 times as great
Anti-social personality disorder	15.5 times as great

"Chemical dependency can either mask or mimic psychiatric illness".

"The key to successful recovery from dual disorders lives in first stopping all use of drugs or alcohol or any behavior (eating, gambling, sex) that is being used to great excess, and that is harming oneself and/or others.

...Dependent Personality Disorder is different from co-dependency (which describes a relationship, and not a psychiatrist diagnosis), and needs to be mentioned here. People with DPD have trouble making everyday decisions. They need constant reassurance, prompting, and advice from others. Fearing rejection, they will go to extreme -even unhealthy- lengths to please others. They may find them themselves in a co-dependent relationship with someone who is chemically dependent or who has a psychiatric illness.

...People with dual disorders are encouraged to attend meetings of the twelve Step group most suited to their needs, (AA, NA or Overeaters Anonymous). Whereas the Twelve-Steps can address a compulsion to drink, drug or eat, they can't treat co-existing emotional disorders. It doesn't matter which came first (the addiction or the emotional condition) -- what is important is that both receive the appropriate attention.

Human beings differ from animals in many ways. While animals grown primarily in body and in physical functioning, people grow in character development as well. Character includes not only intelligence but also the ways in which we think, feel, and behave. These are influenced by abilities that are unique to humans and that make up the human spirit.

Human beings have the unique ability to learn from the past; to think about the purpose of existence; to think about and implement self-improvement; to reflect on the long-term consequences of our actions; to delay gratification; and to distinguish right from wrong and act accordingly. When we exercise these abilities, we implement our spirit; we are then spiritual, and our spirituality influences the way we think, feel, and behave. Spirit has been defined as the vital principle or animating force within living beings. Recovery is a spiritual journey. A spiritual journey can be the process of unleashing the vitality of life that lies within each of us. This vitality is the richness of an authentic and honest existence directed by our Higher Power.

To gain control over our out-of-control addictions and the destruction they cause, abstinence is critical. As long a we use addictive substances, which affect the way we think and feel, we can't see this clearly. We may thing things are ok when they are not. Mood-altering chemicals change our perception of reality, and we lose our normal clarity or "sanity". A dual disorder distorts reality two ways: through the addiction and through the emotional illness.

The Twelve-Step program doesn't ask that we will ourselves into believing something we don't. If you look carefully at Step Three, you'll see that all that is required is that we turn our will and our lives over to a Higher Power, as we understand that Higher Power...and "it" doesn't have to be God. You can define your own Higher Power. This program offers us hope by providing a path out of the chaos of lives ruled by our dual disorders.

Personal determination will not prevent depression, stop a manic episode, or allow us to say "no" to cocaine. As in a tornado (another force that we cannot control), we are sent running to basements. A single shot of whiskey becomes a whole bottle that sends us back into a depression. Daily activities are impossible as our actions are driven by our dual disorder.

Our needs are complex, because we are not dealing with mental illness or addiction alone, but with the complicated consequences of the interaction between these two. Our recoveries depends on a Twelve-Step group and a mental health support group (that addresses the disorder from which an individual is suffering.

...Mental illness and chemical dependence are not separate entities and sobriety begets stability, and stability begets sobriety. But, we need to remember: The Stigma of Mental Illness" is greater than the stigma attached to addiction. Even when people are enlightened about chemical dependency--someone who has a treatable mental illness may frighten them....

...Those of us who are afflicted with a dual disorder need to rise above the stigma that may interfere with our recovery. Maybe when our full potential is reached, we can help educate the ignorant by being open about our mental illness. This could pave the way for others to recover. We shouldn't give stigma credibility, and it will disappear as we move on with our new lives; stronger for having come to terms with a dual disorder and achieving serenity despite all the obstacles in our path."

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Dual Diagnosis Recovery by Cliffside Malibu website

Dual diagnosis recovery can be challenging and difficult. It’s hard enough to recover from an addiction or a mental disorder. When you’re fighting the combination of the two, recovery is even harder to achieve. Dual diagnosis recovery has to work on both of these problems to be truly successful. That idea might seem overwhelming. After all, going into treatment can be a frightening experience if it’s just for one thing. The idea of tackling two is twice as scary.

Your dual diagnosis recovery is something that you’ve probably needed for a long time. Perhaps good addiction treatment earlier could have helped you avoid a mental disorder. Or perhaps it was the mental disorder that pushed you into using alcohol or drugs to feel better, and made you an alcoholic or drug addict. While knowing this can help with your dual diagnosis recovery, the important thing is that you resist both things together. They are attached, and if one is left untreated it will only aggravate the other problem.

Proper dual diagnosis facilities treat you for your addiction and your mental disorder at the same time. Why is this important? If you’re treated for an addiction by one facility or therapist and treated for mental illness by another, the treatments aren’t working together. There could be things that even conflict during treatment. Having one facility monitor your entire treatment is the preferred way of treating these problems. Dual diagnosis facilities are designed to do this so your treatment works to help you over both addiction and mental illness. Without this integrated approach to treatment, staying in recovery is an even bigger challenge than normal.

Dual diagnosis facilities are designed to make sure that your addiction and your mental disorder no long fuel each other, keeping you in a state of despair. When a mental illness goes untreated, it’s easy to think that drugs or alcohol will make you feel better. You self-medicate to ease the symptoms. Then the substance abuse causes more symptoms from the mental disorder. A dual diagnoses treatment center will treat you like a whole person. Your addiction and your mood disorder will be treated together, at the same time. This gives you the best chance of recovery.

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Dual Diagnosis Treatment: Treating The Addicted Borderline Personality Disorder by Sharon C. Ekleberry

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.

For more information, see section on Addiction Recovery.

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The Prevalence of Alcoholism in BPD from About.com website

There is a remarkable overlap between substance abuse disorders and borderline personality disorder. One study found that about 60% of patients in psychiatric hospitals who have been diagnosed with BPD also have a co-occurring substance use disorder (the symptoms and course of BPD and the substance use disorder overlap). The most common substance use disorder among people with BPD is alcoholism. It has been estimated that about 50% of people with BPD in inpatient treatment settings are also alcoholics.

Effects of Co-Occurring Alcoholism and BPD

Unfortunately, there is also evidence that people with both BPD and alcoholism have more difficulties in their lives and are less responsive to treatment than people who have only one of the disorders. For example, people with alcoholism and BPD are less likely to stay in substance abuse treatment, have more distress and suicidal thoughts, and are more likely to engage in other addictive behaviors (such as binge eating or gambling) than those with alcoholism who do not also have BPD.

Why Do Alcoholism and BPD Co-Occur So Frequently?

Why do people with BPD also often develop alcoholism? Most likely, several factors that account for the high rate of co-occurrence. First, BPD and alcoholism may share common genetic pathways. That is, some of the genes that put people at higher risk for BPD may also create higher risk for alcoholism. Also, there may be common environmental causes for alcoholism for BPD. For example, experiences of maltreatment in childhood (such as physical or sexual abuse, or emotional abuse or neglect), have been linked to both BPD and alcoholism.

But, there may also be other reasons for the link between alcoholism and BPD. Individuals with BPD may use alcohol to decrease the intense emotional experiences that are a hallmark of BPD. Because people with BPD have strong emotions frequently, casual use of alcohol may lead to abuse or dependence.

Getting Help for Alcoholism and BPD

If you or someone you care about is struggling with alcoholism and BPD, they need to get help. These two conditions are not easily tackled alone.

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