People often speak of personality as if it is some type of measurable and quantifiable aspect of functioning. Psychological theories of personality have been prevalent for many years; however, their actual usefulness in the understanding of behavior is quite limited.
Numerous theories regarding the basic traits or characteristics that comprise personality have been developed; however, the different theories often have contrasting general traits, or too few or too many traits for practical reasons. As it turns out, there are probably only a handful of general traits or dispositions that can be empirically validated to comprise what most people think of as a person’s personality. Each of these general dispositions is composed of numerous substrates that a person may or may not express.
Research studies consistently find that the theoretical dispositions that are believed to make up personality have limited predictive value when attempting to determine how a person will respond in any given situation, but they have fair predictive value when attempting to predict how a person will behave in general. Thus, the concept of personality and personality types may describe how a person will generally respond over numerous different situations, but very often, it has limited value in describing how a person will respond in any single situation.
What Is a Personality Disorder?
Like the general concept of personality, the concept of a personality disorder has been referred to in clinical psychology and psychiatry for many decades, but it is also poorly defined. In general, the notion of a personality disorder is defined as an enduring pattern of behaving, thinking, and feeling that is in significant disagreement with cultural expectations of proper behavior, and it has been occurring in an individual since their early development (e.g., early childhood or early adolescence).
The American Psychiatric Association (APA) has long been the organization in the United States that develops the diagnostic protocols used in formally identifying individuals with different types of mental illness. APA has continually presented the diagnostic criteria for the different personality disorders in each edition of its diagnostic manual, The Diagnostic and Statistical Manual of Mental Disorders. The diagnostic criteria for the personality disorders as presented by APA have received significant criticism because the disorders in the manual are loosely defined, share numerous characteristics with one another that make them hard to distinguish, and violate the methodological standards that APA claims it follows. Even though the APA had announced its intent to restructure the diagnostic classification of personality disorders in the current diagnostic manual (DSM-5), because of longstanding methodological and conceptual issues with this classification, the diagnostic criteria for these disorders have not changed for over 25 years. While many researchers and clinicians agree that the notion of a personality disorder is a valid notion, the current diagnostic scheme for these disorders remains controversial among many healthcare professionals and researchers.
Borderline Personality Disorder (BPD)
APA continues to recognize 10 major personality disorders that are divided into three different groups (referred to as clusters) that are based on the general features of the particular disorder. The notion of borderline personality disorder (BPD) remains one of the oldest identified personality disorders.
The use of the designation of a borderline personality was initially meant to describe a longstanding and pervasive pattern of behavior and inner experience (thoughts, emotions, etc.) that often borders on psychosis (loss of the ability to cope with reality). The psychiatrist and personality disorder specialist Otto Kernberg developed some of the best conceptualizations of BPD and other personality disorders based on a basic understanding of the general features that are present in people with these disorders. According to Kernberg, the major feature of BPD is an established perception of loneliness and emptiness in the person that drives many of the other patterns of behavior these individuals express.
While the formal diagnosis of BPD remains fraught with inconsistencies and overlapping diagnostic symptoms, the concept of a borderline personality has been one that has endured for many years. The formal diagnostic criteria for borderline personality disorder as presented by APA consists of nine potential symptoms (diagnostic criteria). A person diagnosed with BPD would have to satisfy at least five of the nine criteria. Although the formal diagnosis can only be made by a licensed mental health clinician and will not be formally presented here, the diagnostic criteria to make this diagnosis cover numerous issues that the person expresses, including:
- A very unstable concept of oneself
- Chronic issues with feeling empty or with boredom
- Significant tendencies toward impulsive behaviors that can include issues with substance abuse and other problems
- A significant feeling of loneliness or fear of being abandoned
- Displaying very reactive states of mood, such as being very irritable, anxious, angry, happy, content, etc., and having significant alternating periods of mood states
- Recurrent outbursts of anger/aggression that are often inappropriate
- Alternating between totally idolizing others and then totally devaluing them (formerly referred to as splitting)
- Repeated issues with suicidality, including threats or actual suicide attempts
- Other repeated issues with self-harm, such as self-mutilation
- Issues with potential psychotic-like behaviors or dissociative experiences that can include delusions, hallucinations, idiosyncratic interpretations of the behavior of others, feeling detached from oneself or from reality, etc.
The formal diagnosis would include understanding the person’s pattern of behavior from childhood or adolescence, ruling out any possible medical conditions that could result in the behaviors being expressed, and also ruling out other types of mental health conditions that may better explain the behavior. BPD, like other personality disorders, represents enduring patterns of reacting, feeling, and thinking that are apparent early in the person’s development, and the formal diagnosis would have to confirm this. If the behavior is something that is out of character for the person and has only occurred for a short period of time, it is less likely that a personality disorder is present.
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BPD, Vulnerabilities, and Substance Abuse
APA and other sources indicate that borderline personality disorder is more commonly diagnosed in females than in males. APA reports that the female-to-male ratio of BPD diagnoses is 3:1.
Its overall prevalence rate is considered to be quite low; estimates range from 1 percent to 6 percent in the general population. However, the prevalence rate that occurs in hospitalized psychiatric patients is relatively high; estimates by APA suggest that nearly 20 percent of psychiatric inpatients have a BPD diagnosis, indicating that a fair number of individuals with BPD have severe manifestations of their disorder that may include issues with suicidality, potential psychosis, and substance abuse. Thus, individuals with BPD are particularly vulnerable to numerous other complications.
Like the vast majority of identified mental health disorders, there is no identified cause of borderline personality disorder. Instead, there are numerous identified risk factors that may contribute to an increased probability that a person will have a diagnosis of BPD. A risk factor is not an actual cause, but represents some condition that is associated with an elevated probability that a person will have some type of diagnosis. The actual relationship between a risk factor and the associated diagnosis can be quite varied and subject to numerous other influences. Having one or more risk factors does not guarantee that one will develop the disorder, and having no risk factors also does not guarantee that one will not develop a particular disorder.
- A family history of BPD, particularly in first-degree relatives
- A family history of some other psychiatric/psychological disorder
- Potential neurological alternations that result in problems with emotional regulation and impulse control
- A history of trauma or abuse
- A history of unstable relationships with one’s parents
According to APA, risk factors associated with a diagnosis of borderline personality disorder include:
Individuals diagnosed with BPD are extremely vulnerable to other types of comorbid (co-occurring) mental health disorders.
- BPD is commonly associated with having a diagnosis of depression (major depressive disorder).
- BPD is commonly associated with a diagnosis of bipolar disorder.
- BPD is very often associated with a diagnosis of any of the other personality disorders.
- Trauma and stressful experiences are risk factors for BPD. This results in a diagnosis of a trauma- and stressor-related disorder, such as PTSD, being commonly diagnosed with BPD.
- Individuals with BPD are commonly diagnosed with some type of eating disorder.
- Individuals with BPD commonly have a formal diagnosis of a substance use disorder.
Substance abuse is a common co-occurring condition among individuals who are diagnosed with borderline personality disorder. The most commonly occurring substance use disorder that occurs in individuals with BPD is an alcohol use disorder; however, any co-occurring substance abuse should not be ruled out. Individuals with BPD are prone to using and abusing prescription drugs like opiates and benzodiazepines, stimulant drugs such as cocaine and methamphetamine, cannabis products, and other types of substances.
The need for an individual with borderline personality disorder to attempt to control their unstable emotional reactions, volatile feelings, and chronic feelings of boredom and emptiness, along with their tendency to be extremely impulsive, results in a very large number of these individuals having some issue with substance abuse. Some studies have suggested that more than half of individuals diagnosed with BPD have some form of a substance abuse issue. Thus, whenever an individual is considered for a diagnosis of BPD, they should also be fully examined for a potential issue with substance abuse. People who have a diagnosis of BPD and depression or some other personality disorder are at an increased risk for substance abuse.
Individuals diagnosed with BPD also have an increased risk to engage in other types of impulsive and/or compulsive behaviors. These behaviors can include excessive gambling, having multiple sexual partners, eating disorders (as mentioned above), engaging in self-harm (e.g., cutting or other types of self-mutilation), shoplifting, and other issues associated with difficulties controlling impulses. Many of these individuals have numerous co-occurring diagnoses that further complicate their presentation.
How Co-Occurring BPD and Substance Abuse Are Treated
Because personality disorders represent chronic and deeply ingrained patterns of behavior, it is unrealistic to believe that any individual who is diagnosed with a severe personality disorder such as BPD can be treated and “cured” of their disorder. Instead, the treatment for personality disorders often involves helping individuals reconceptualize themselves, others, and how to act in various situations. Individuals with personality disorders will retain many of their inherent tendencies, but they can often learn to understand the motivations for their actions and adapt to behaviors that are more functional.
There are no medications that are formally approved for the treatment of BPD. Instead, medications can be used to manage some of the specific symptoms of BPD, but the use of medications alone is not sufficient for treating any personality disorder. Instead, an individual with a personality disorder will often be treated with a combination of medications, therapy, and other interventions.
Likewise, even though there are medications that can assist in the treatment of substance use disorders, there are no medications that can be used to fully address substance abuse issues. Instead, the treatment of a substance use disorder involves the use of medications for specific issues and symptoms (e.g., withdrawal symptoms, cravings, etc.), therapy and counseling, and other interventions. An individual with a diagnosis of BPD and a substance use disorder would be treated with medications, therapies, and other interventions designed to specifically address their issues.
The overall treatment plan for the specific case should be designed to meet the needs of the person. This may include inpatient or residential treatment for withdrawal symptoms (medical detox or withdrawal management), inpatient treatment for suicidal issues or psychosis, medications, therapy, complementary interventions, and eventually a transition to long-term outpatient treatment for these issues. Treatment can include family therapy, group therapy, peer support groups (e.g., 12-Step groups), specialized interventions like art or music therapy, exercise, nutrition, etc.
The person should be treated for their BPD and substance use disorder at the same time. Attempts to address one of the disorders while not treating the other will not be successful. Instead, the treatment plan will need to address all of the major issues that contribute to the individual’s impairment, including significant physical issues, family problems, occupational issues, etc., in conjunction with their mental health diagnoses.
The preferred form of therapy for treating BPD and for treating issues with substance abuse is some form of Cognitive Behavioral Therapy (CBT). This covers numerous forms of therapy based on the principles of cognitive psychology and behavioral psychology. The goal is to help an individual recognize their dysfunctional beliefs and expectations, restructure their thoughts and beliefs, and actively participate in altering their behavior in a manner that is proactive for them but at the same time does not result in significant distress or impairment.
A specialized form of CBT, Dialectic Behavior Therapy (DBT), is specifically designed to address the issues that commonly occur in people who are diagnosed with BPD. DBT is the preferred form of psychotherapy for borderline personality disorder, although other forms of psychotherapy have also been shown to be effective, such as psychodynamic therapy (the type of therapy that was originally developed by Freud and has been refined over the years).
Treatment compliance is often a concern for individuals diagnosed with BPD or with any type of substance use disorder, and when an individual has a co-occurring BPD and substance use disorder diagnosis, treatment compliance becomes an even bigger issue. The goal of therapy should be to get the individual involved in their treatment and have them continue in treatment, even if it means using forms of coercion to keep them involved in treatment-related activities. Over the long run, individuals who remain in treatment can demonstrate significant progress. The single most important factor in helping a person to recover from substance abuse and to make adjustments as a result of having a personality disorder is the length of time they remain in treatment-related activities.
In addition, ensuring that the individual has significant support from peers in recovery and family members can go a long way in helping the person to progress. This is why the use of peer support groups and family therapy are commonly recommended for individuals who have co-occurring disorders.
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