Borderline Personality Disorder and Substance Use

Borderline personality disorder (BPD) has historically been difficult to understand and cope with for young people and their families. The symptoms are a painful mix of emotional turmoil, and unstable sense of self, volatile relationships and self-destructive behavior, including suicide attempts.

People who develop BPD are by temperament highly emotionally sensitive and reactive. When their very intense feelings are chronically dismissed as an overreaction, they have difficulty managing their emotions, and are often overwhelmed by intense anger and feelings of abandonment, emptiness, shame and self-loathing.

While in the past BPD was not diagnosed before the age of 18, it is now recognized that onset is often in adolescence. The earlier treatment begins, the better the outcome.

Symptoms of Borderline Personality Disorder

These are the criteria used to diagnose borderline personality disorder:

  • Frantic efforts to avoid abandonment, real or imagined
  • A pattern of unstable and intense relationships
  • An unstable self-image or sense of self
  • Dangerous impulsivity such as unsafe sexual encounters, substance use
  • Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
  • Emotional instability due to high reactivity
  • Chronic feelings of emptiness
  • Inappropriate, intense anger or difficulty controlling anger
  • Transient, stress-related paranoia or severe dissociative symptoms

A young person with BPD might be overly sensitive to how their friends or fellow students think or act, and quick to interpret things negatively. Minor slights are taken as evidence of abandonment, and the reaction can be swift and intense. She or he might go from “I love you” to “I hate you” in a heartbeat.

Young people with BPD often find unhealthy ways to manage their emotions, including substance use, risky sex, reckless thrill-seeking and self-injury like cutting, scratching and opening wounds.

Borderline Personality Disorder Treatment

The gold-standard treatment for borderline personality disorder is dialectical behavioral therapy (DBT). DBT teaches patients skills to regulate their overwhelming emotions and stop self-destructive behaviors. While in the past BPD was considered largely treatment resistant, long-term studies show that those treated with DBT have a good prognosis: In one study 74% of participants had no active symptoms after 6 years.

Medications cannot treat BPD itself but may be used to reduce specific symptoms including aggression and anxiety. Young people with BPD are often misdiagnosed with bipolar disorder, depression or ADHD, and may be given medications that are ineffective or harmful. As with bipolar disorder, early identification by a clinical professional is very important.

Hospitalization may be required for young people who are at risk of self-injury.

Borderline Personality Disorder & Interaction With Substance Use

Substance use is very common in teenagers and young adults with BPD. Alcohol, nicotine and marijuana are the most commonly used substances, and studies show that as many as half of all BPD patients meet criteria for a substance use disorder.

Young people with BPD tend to use drugs or alcohol not to get “high” but to feel less empty or to numb painful feelings, including self-loathing.

Alcohol and other substances worsen the symptoms of BPD, increasing paranoia and impulsivity. Young people with BPD who use are more likely to have risky sexual encounters, contract sexually transmitted diseases and make more serious suicide attempts. Substance use also interferes with treatment for BPD.