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Presence of BPD complicates treatment

September 3, 2008
by Shannon Huggins, LCSW
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Dialectical Behavior Therapy offers a promising approach for this comorbid treatment population

As addiction professionals, we know that our confidence as clinicians grows in tandem with our ability to treat clients effectively. Yet there is a certain subset of clients that can humble even the most experienced clinician. With their powerful mood changes, intense anger, impulsive behaviors, chronic relational instability, and self-injurious or suicidal behavior, these individuals live in extreme emotional anguish and often evoke similar states of mind in those close to them. The relational disruption that inevitably results undermines intimacy in personal relationships and interferes with the development of a working alliance with treatment professionals. Indeed, the interpersonal chaos that ensues can wreak havoc on the functioning of families and entire treatment teams, leaving all involved feeling demoralized and helpless.

The scenario described above indicates the presence of a co-occurring disorder—in this case, a complex and frequently misunderstood personality disorder known as borderline personality disorder (BPD). According to the DSM-IV-TR, BPD is characterized by nine main problem areas, only five of which need to be present for someone to receive the diagnosis.1 These nine criteria encompass five categories of dysregulation: emotional (rage, anxiety, and depression); interpersonal (insecure, chaotic relationships and fears of abandonment); self (unstable identity or sense of self); behavioral (impulsivity and harm to self or others); and cognitive (mental disorganization and paranoia).

Research shows that, as though they were “primed” for addictive behaviors, fully two-thirds of people with BPD abuse alcohol, street drugs, and/or prescription drugs.2 BPD has a high rate of co-occurrence with other disorders as well, including mood disorders, bipolar disorder, anxiety disorders, eating disorders, and post-traumatic stress disorder (PTSD). Given this complicated symptom picture, “data indicate, on average, that five years elapse before BPD is accurately diagnosed in a patient.”3

This article aims to provide addiction professionals with useful information on BPD, research-based intervention strategies for BPD, how these strategies effectively partner with a 12-Step model of recovery, and what resources exist to support caregivers. My hope, while perhaps ambitious, is to reclaim the diagnosis and its sufferers from an unfair reputation as hopelessly untreatable. Indeed, “follow-up studies of individuals who receive a diagnosis of BPD suggest that the prognosis is not as grave as is often presumed.”4

Diagnostic issues

Research indicates that individuals diagnosed with BPD are disproportionately female (75%) and account for approximately 20% of psychiatric inpatients and 15% of outpatients.

5 Seventy-five percent of individuals with this diagnosis self-injure.

Like other mental disorders, BPD is the result of multiple risk factors, including a biogenetic predisposition toward emotional dysregulation. Preliminary studies indicate that certain neurological dysfunctions in the limbic or “emotional” region of the brain, consisting of the amygdala, hippocampus, thalamus, hypothalamus, and parts of the brain stem, affect the individual’s ability to appraise social input accurately as safe or threatening. The amygdala, central to the “fight or flight” response, chemically activates the sympathetic branch of the autonomic nervous system and contributes to the high emotional sensitivity, high emotional reactivity, and slow return to baseline that makes children with these traits especially vulnerable to the early caregiving environment.

Environmental factors consistent with the diagnosis include sexual abuse as a child, usually by a non-caregiver, experience of a significant loss of or separation from a caregiver, and poor fit between child and caregiver.6 Additional research emphasizes the critical role played by an invalidating family environment in which the child’s feelings, desires, beliefs, and sensations are unduly criticized, ignored, and/or controlled. The ensuing interactive feedback loop between caregiver and child creates mutual invalidation patterns, which then fuel misunderstanding and alienation in the entire system.

Therapeutic tool

With the diagnostic picture more clearly defined, we can address the issue of effective intervention. While several well-established treatment models exist for BPD, this article will focus on Dialectical Behavior Therapy (DBT) because of its high compatibility with 12-Step principles and because of research indicating its efficacy in reducing drug use in dually diagnosed individuals.


Developed by Marsha Linehan, PhD, ABPP, a psychologist at the University of Washington, the DBT model integrates cognitive-behavioral treatment concepts with dialectics, “the reconciliation of opposites in a continual process of synthesis.”8 Discussing DBT, Linehan states that “the most fundamental dialectic is the necessity of accepting patients as they are within a context of trying to teach them to change.” The strategy of tempering change efforts with radical acceptance also grew out of Linehan’s longtime practice of Zen, with its emphasis on balance and mindfulness practices.