Borderline Personality Disorder

A person who suffers from this disorder has labile interpersonal relationships characterized by instability. This pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person’s affect, or feelings. Relationships and the person’s affect may often be characterized as being shallow. A person with this disorder may also exhibit impulsive behaviors and exhibit a majority of the following symptoms:

  • An unstable sense of self, identity or self-image
  • A pattern of unstable and intense relationships that alternate between wholly positive feelings and wholly negative feelings about the other person
  • Frantic efforts to avoid real or imagined abandonment
  • Emotional instability including periods of depression and anger
  • Chronic feelings of emptiness
  • Impulsivity that is potentially self-damaging
  • Recurring suicidal behavior, gestures, threats or self-injury
  • Stress-related paranoia
  • Dissociation
  • Transient, stress-related paranoid thoughts or severe dissociative symptoms

Triggers to Self-Medication

Persons with BPD are especially sensitive to the environment, relationships and the behavior (or perceived behavior) of others.  They are generally considered to have difficulty tolerating change of any type and will respond to even expected and usual changes in the environment and the behavior of others with frequent and changing symptoms such as those listed above.  Particularly sensitive in any relationship to increased intimacy as well as decreased intimacy, people with BPD have difficulty managing relationships with others in the course of everyday routines.   Problematic areas can include such settings as work, home, recreation, religion, neighborhood and social events.   Periods of conflict, emotional intensity, anxiety and impulsive behavior is often evident in friendships, family relationships and dating.  People with BPD are typically oversensitive to situations in which they feel rejected or abandoned even if the unavailability of others is temporary, imagined or done in the course of normal routines such as working.

Substance Use and Other Compulsive Behavior

There are a significant percentage of people with BPD who use substances and who develop a Substance Use Disorder over the course of this condition.  Some estimates suggest that over 60% of people with BPD misuse substances to self-medicate.  Due to the chronic nature of the condition many will self-medicate for a prolonged period and consequently will develop an addiction.

Alcohol and sedative-hypnotics are the primary substances misused by people with BPD for their sedating efforts; however other self-medicating attempts to achieve ‘calm’ or sedation can involve the use of over-the-counter sleep aids and pain relievers.  Other prescription drugs such as opiates and benzodiazepines are also used to self-medicate the emotional intensity felt in this disorder.

While alcohol is by far the most common substance used in the self-medication of BPD, other addictive processes are often used.  These include such mood-altering activities as gambling, compulsive eating and other food-related behaviors, sexual promiscuity, compulsive Internet use, compulsive shopping and overspending.  Some who engage in these types of behaviors will develop a co-occurring condition such as a Sexual Addiction, an Eating Disorder or a Gambling Addiction.

Self-Medication and Psychiatric Medication

Due to the variety of symptoms that can occur in BPD, their intensity and likelihood that functioning can be impaired by them, many people with BPD are prescribed psychiatric medications.  These can include anti-depressants, anti-anxiety medications, mood stabilizers and antipsychotics.  In efforts to self-medicate increased symptoms some will misuse these medications.  Misuse involves use other than as directed and can involve hoarding to acquire a quantity large enough for binges and even self-injury.  As a result of not taking medications as prescribed a cycle of instability can lead to even more attempts to self-medicate.

Self-Injury and Substance Use

Periods of intense emotional distress and mood instability can lead to self-injuring behavior with substances.  This might involve intentional overdoses of prescribed medications, over-the-counter medications, alcohol or illicitly obtained drugs.  Additionally, combinations of substances may occur in which the effects of the substances are potentiated and cause an unintentional overdose or other medical emergency.  The impulsivity typically found in persons with poorly controlled BPD increases the risk of self-injury by substance use during times of increased distress and crisis.

Treatment of BPD and Medications Prescribed

Due to the impulsivity and tendency to self-injury that some with BPD have, care providers may choose prescribed medications that will limit the potential for self-harm or suicide by misuse of medications.  A history of suicidal thinking, gestures or attempts may indicate a need for careful control of medications prescribed.  Care providers may limit the quantity of medication available at one time or avoid the prescription of certain medicines that have a serious overdose potential.  Additionally, prescribers may avoid giving combinations of medicines that can interact with toxicity or potentiated negative effects.

Co-occurring Treatment

For those with BPD who have self-medicated, the treatment of BPD will include goals and objectives that target self-medication.  Alternate methods of coping with symptoms and periods of increased symptoms will typically aim to reduce the need for substance use to sedate, calm or soothe.  Those who have developed a Substance Dependence will require assistance in planning and completing withdrawal and detoxification safely.

The distress of withdrawal and detox may temporarily increase BPD symptoms including impulsivity and self-injurious thoughts and behaviors.  For these reasons, persons with BPD and a co-occurring Substance Disorder require therapeutic support and medical supervision during withdrawal and early recovery from substance use.  Some may require an inpatient or residential setting for detox in which care providers are trained in the treatment of Dual Disorders or Co-Occurring Disorders.  Care providers who assist with substance withdrawal and detox should be able to prescribe psychiatric medications for BPD symptoms if these are indicated.

Self-help Groups for Co-occurring BPD and Substance Use

Some with BPD who have developed Substance Disorders may benefit from the use of community self-help groups such as Alcoholics anonymous or Narcotics anonymous.  Since these groups rely heavily upon the support of others in the group, however, some with BPD will require additional support and guidance in managing the relationships of these recovery efforts.  People with BPD who use 12 Step meetings for additional support often address such issues with their ongoing care providers to identify strategies for coping well in these groups.  12 Step participation can be successful and can reinforce the types of healthy interactions and interpersonal boundaries that many with BPD need to learn and practice.

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