Borderline personality disorder (BPD) is a complex psychiatric condition that co-occurring substance abuse and other mental health disorders can intensify. The added challenges of addiction and other mental illness may worsen BPD symptoms or the symptoms of the co-occurring disorder.
Behavioral health conditions that commonly co-occur with borderline personality disorder include:
- Mood disorders (typically BPD and depression or BPD and bipolar disorder)
- Substance abuse
- Posttraumatic stress disorder (PTSD)
- Eating disorders (particularly bulimia)
- Attention deficit hyperactivity disorder
- Anxiety disorders
BPD and Major Depressive Disorder
Many people with BPD experience frequent mood swings. They shift between an upbeat mood to a dark, angry, irritable mood. Dysthymia or mild depression is a symptom of borderline personality disorder. However, some people with BPD meet the criteria for major depressive disorder (MDD). Symptoms of MDD include:
- Feeling sad or empty most of the time
- Low energy
- Difficulty concentrating or making decisions
- Thoughts of suicide
- Sleep and appetite disturbances
- Agitation or restlessness
- Feelings of hopelessness, guilt and worthlessness
People with BPD may already struggle with a sense of being inherently bad. Agitation and irritability are also very common. Major depressive disorder exacerbates these issues. Suicidal ideation is a frequent problem in people with BPD and major depression.
BPD and Substance Abuse
Drug and alcohol abuse is very common in people with borderline personality disorder. A review of 70 studies on addiction and BPD found that around half of people with BPD also have a substance use disorder. BPD and alcohol abuse is most common. Researchers believe several factors contribute to this vulnerability:
- A family history of substance abuse or addiction is common in the chaotic childhoods of many borderlines. This may indicate there’s a genetic predisposition and / or it’s a learned coping mechanism.
- The tendency of people with BPD to be impulsive and engage in reckless or self-destructive behaviors.
- A desire to self-medicate and numb the frequent pain and distress BPDs feel.
Alcohol and drugs can be especially dangerous in the hands of someone with BPD. They may cause any combination of the following:
- Intensify feelings of rage and other negative emotions.
- Increase the risk of self-mutilation and suicidal thoughts and behaviors.
- Increase impulsivity.
- Worsen judgment that is already impaired in stressful situations.
- Cause further damage to relationships that are already unstable.
- Intensify mood swings.
- Trigger or increase paranoid ideation and transient psychotic symptoms.
BPD and PTSD
BPD and PTSD (posttraumatic stress disorder) commonly co-occur together. Studies show borderline people often experienced childhood sexual abuse or physical abuse. PTSD is triggered by traumatic experiences and can develop at any stage of life. Since BPD typically begins to develop in childhood, the frequent comorbidity of these two disorders makes sense. Often maladaptive coping skills typical of BPD develop as a way of coping in an unpredictable, chaotic environment. People with both BPD and PTSD often experience trauma much earlier in life than those with only a PTSD diagnosis.
BPD and Eating Disorders
Eating disorders like anorexia and bulimia are common in people with BPD. Childhood trauma is a frequent underlying issue in people with eating disorders as well as people with BPD. The impulsive, self-destructive tendencies of borderlines may also make them particularly vulnerable to developing an eating disorder. Research shows that effectively treating co-occurring BPD and eating disorders can be challenging. BPDs tend to move between different types of eating disorders, which can hinder recovery.
BPD and ADHD
A recent National Epidemiologic Survey on Alcohol and Related Conditions found that more than 30% of people with BPD also have ADHD. Like BPD, people with ADHD often struggle with impulsivity. Co-occurring BPD and ADHD can be difficult to treat because some ADHD medications may make borderline symptoms worse.
Typical ADHD medications (e.g. Ritalin) are stimulants. This can intensify impulsive, aggressive behaviors and emotional reactivity in people with BPD. If ADHD symptoms are mild, behavioral therapy without medication may be enough. If medication is necessary for ADHD symptoms, some clinicians add a low dose of an antipsychotic medication. This can help offset the stimulant effects.
BPD and Anxiety
One study found as many as 70% of BPD patients had a co-occurring anxiety disorder. Sometimes this stems from early experiences of trauma, conflict and a chaotic environment. Under these conditions, children are prone to developing an anxiety disorder. BPD people may also use maladaptive coping skills to help manage underlying anxiety. This compounds the problem.
Since substance abuse is so common with borderline personality disorder, clinicians are usually cautious about using benzodiazepines to treat anxiety in these cases. Benzodiazepines (e.g. Xanax and Valium) are highly addictive medications. They have a strong sedative effect and people with BPD may abuse them as a way to self-medicate anxiety and emotional pain.
BPD and Other Personality Disorders
Many people with BPD also meet the criteria for a second personality disorder. Personality disorders that often co-occur with BPD include:
- Narcissistic personality disorder
- Schizotypal personality disorder
- Antisocial personality disorder
- Histrionic personality disorder
Narcissistic personality disorder, antisocial personality disorder, histrionic personality disorder and BPD are all part of the “Cluster B” group of personality disorders. Overlapping traits include manipulative behaviors and impulsivity. Histrionics and borderlines both tend to engage in attention-seeking behavior and emotional displays that can quickly shift.
People who have both BPD and narcissistic personality disorder are typically very destructive when it comes to relationships. Extreme fear of rejection, intense emotional displays, lack of empathy for others, and manipulative behavior make interpersonal situations very difficult.
Schizotypal personality disorder traits that overlap with BPD include ideas of reference and paranoid ideation. Odd or eccentric behaviors and beliefs, and excessive social anxiety are characteristic of schizotypal individuals.
BPD and Bipolar Disorder
A fair number of people with BPD are also diagnosed with bipolar disorder. One review of recent studies found around 10% of people with BPD had bipolar I disorder and 10% had bipolar II disorder. BPD and bipolar have both unique and overlapping symptoms. Both disorders involve mood swings and erratic behaviors, although the mood patterns are very different. While many people do meet the criteria for both BPD and bipolar disorder, sometimes bipolar disorder is misdiagnosed in people with BPD, and vice versa. Having both disorders is particularly challenging.