|Type of paper:||Research paper|
|Categories:||Personality disorder Substance abuse|
Borderline personality disorder (BPD) is a serious mental illness that is evident in 1-3% of the general population. In addition, it is the most clinically diagnosed personality disorder present in 10% of patients in outpatient settings, 15-20% of patients in inpatient settings, and 30-60% of patients diagnosed with personality disorders (Lane, Carpenter, Sher, & Trull, 2016). People with BPD represent a particularly high-risk group for substance dependence given their susceptibility to impulsive behaviors and emotion dysregulation in an effort to regulate negative affect. One particularly common maladaptive behavior is alcohol use. Around half of BPD patients meet the criteria for alcohol use disorder (AUD) and nearly 15% of people with AUD meet criteria for BPD (Rolland et al., 2015). Reinforcement models of alcohol use assert that people drink to heighten positive affect and minimize negative affect (Lane et al., 2016).
As both AUDs and personality disorders are complex to treat, patients with comorbidity represent a challenging population for clinicians and treatment providers. When there is a pathology of personality this is more often linked to difficulties in the therapeutic relationship, poor compliance and high drop-out rates (Rolland et al., 2015). Despite the link between BPD and AUD, little is known regarding how BPD people consume alcohol. Most of those with BPD experience drinking-related issues, but it is unclear what elements of their drinking habits such as too much, too quickly, or too often distinguish them from groups less likely to experience problems. Similarly, previous studies have also not examined how their consumption relates to their reasons for use or the immediate effects of use.
The intention of this paper is to shed light on alcohol use and BPD. It reviews significant overlapping models of etiology, such as pharmacological vulnerability, affect regulation, and deviance proneness of SUDs, including AUD. These models highlight the interplay between various aspects that appear to be related to and contribute to both AUD and BPD. Additionally, knowing more about the etiological factors related to BPD and AUD, and treatment techniques suitable for this population would increase the available knowledge of the link between AUD and BPD.
Theoretical Models to Understand the Association between BPD and AUD
During the last century, several aetiological models have been proposed to explain addictive behavior. Diverse psychological schools of thought and social and public views have influenced these models. The biopsychosocial model articulated by George Engel in 1977 can best explain the most influential modern scientific perspective concerning the causes of addiction (Kienast, Stoffers, Bermpohl, & Lieb, 2014). The model tries to unify competing for addiction theories into an integrated conceptual framework considering the complex and different interactions between biological, psychological and social elements of addiction. The model recognizes that there are many pathways to addiction and that the respective significance of each pathway depends on any single person.
Personality was perceived to be the primary aetiological aspect in the 'moral' model of addiction, where it was postulated that an 'immoral' character was involved in the problems of addiction and the resulting behavioral deviations. The 'symptomatic' and 'cognitive-behavioral' model of addiction has also assumed the essential role of personality in the addiction (Kienast et al., 2014). Based on this model, drug and alcohol use is considered a symptom of an underlying psychiatric disorder, predominantly linked to personality pathology. Further, the cognitive-behavioral model regards AUD as a disorder of behavior, beliefs or cognitive schemata to which the person is strongly predisposed by underlying personality pathology (Kienast et al., 2014).
The pharmacological vulnerability model developed from the observation that individual differences exist in the effects of alcohol, mainly the relationship between personality and alcohol sensitivity (). These differences have been shown to prospectively forecast alcohol problems. Likewise, it has continuously been established that the personality trait of impulsivity is linked to the stress-reducing features of alcohol (Lane et al. 2016). Hence, impulsive people may subjectively experience more stress-reduction when using alcohol. Moreover, impulsivity may affect the decision to use alcohol and overuse in situations where many would discontinue alcohol use. Notably, impulsivity is a predominant feature of BPD.
According to Kienast et al. (2014), the negative affect regulation model suggests that alcohol use may represent attempts to alleviate negative affect and, consequently, alcohol use may become negatively reinforcing. Findings posit that negative affect is strongly linked to BPD in terms of both reactivity and intensity as measured by psychophysiological and self-report measures (Lane et al. 2016). People with BPD appear to experience more negative affect than non-BPD people do. Hence, given these high levels of negative affect and susceptibility to negative affect instability, people with BPD may be particularly vulnerable to engage in alcohol abuse. Nevertheless, it is important to note that, the most vital attribute of negative affect in BPD is not its absolute level, but its instability over time, and especially, its ability to intensify fast and without warning. Lane et al. (2016) add that the assessment of affective instability in BPD patients needs a more modulated measurement technique than what traditional clinical assessment instruments such as retrospective and cross-sectional assessments can avail. Moreover, affective instability is a time-dependent and dynamic process. for example, an approach like ecological multiple assessments (EMA) can provide numerous assessments of mood per day over a long time and unearth acute increases in negative affect from one occasion to the next (Lane et al. 2016). Mainly, this is the only way to assess precisely the dynamics of mood states, extreme variations in mood, and environmental causes of mood changes.
Finally, the deviance proneness model opines that temperamental attributes, particularly those associated with impulsivity, may interact in a transactional way with deficits in parental control, leading to socialization problems. Mainly, deficits in socialization are linked to numerous problems like delinquent behavior, poor academic achievement, and substance abuse (Rolland et al., 2015). Based on these findings, parenting and family aspects are hypothesized to play a crucial role in the development of BPD, and BPD people tend to engage in various behaviors that violate social norms, especially, alcohol abuse.
Etiological Factors related to BPD and AUD
Various issues such as suicidal or self-harm behavior, trauma or abuse, and personality traits arise while dealing with primary care patients with AUD and BPD. First, BPD is associated with elevates suicide risk. Doyle et al. (2016) examined the relative risk of suicide in a group of patients diagnosed with BPD. The researchers observed a relative risk of 37 compared to patients without mental illness, and a borderline significant doubled risk (p=.05) compared with all the other patients diagnosed with other forms of personality disorders (Doyle et al., 2016). Further, these results indicated that a clinically significant level of comorbid alcohol use increased the already heightened risk of suicide among patients diagnosed with BPD. Notably, the diagnostic criteria for BPD encompassing repeated non-fatal self-harm, affective instability, impulsivity, and mood disorder have consistently been linked to suicidal behavior.
Self-harming behavior among individuals with a diagnosis of BPD tends to be uncertain in intent where impulsivity and emotional instability are common. Mainly, this is complicated further because often the level of intent of self-harm can change rapidly and attempting to forecast accurately a rare event like suicide is rarely possible. Hence, improving the skills of clinicians through training, to identify and assess BPD and personality traits elements could help in minimizing the risk of suicide (Doyle et al., 2016). Additionally, a standardized assessment instrument like the Standardized Assessment of Personality may be useful as a first-stage screen for case identification, which could be utilized regardless of the gender or age of patients and could be integrated into primary care consultation (Doyle et al., 2016).
Similarly, trauma or abuse is a relevant factor in understanding the co-occurrence of BPD and AUD. Literature indicates that both physical and sexual abuses are relatively prevalent among BPD individuals. On one hand, various psychosocial outcomes characteristic of BPD such as affective instability, dissociative experiences, and lack of trust may result from traumatic experiences mainly in childhood. As such, many researchers conceptualize BPD psychopathology as an adaptation to an environment that is characterized by the lack of nurturing and reliable caregivers, betrayal, and fear (Kienast et al., 2014). Additionally, it is important to note that the experiences of trauma likely produce biological alterations in a person. Hence, it is conceivable that trauma may be a contributing aspect to some of the neurological findings in BPD patients.
Finally, personality trait is another potential etiological factor to consider as it serves as a predisposition or vulnerability to BPD pathology (Kienast et al., 2014). The presence of a particular personality trait may make it more likely that a person will exhibit BPD features. According to Lane et al. (2016), the personality traits that have been most linked continuously to BPD are affective instability and impulsivity. For example, a BPD patient's rapidly changing mood states, irritability, or going from baseline mood to intense dysphoria evidence the trait of affective instability. In addition, impulsivity is reflected in their tendency to react quickly, erratic behavior and susceptibility to substance use such as alcohol.
Treatment of Alcohol-related BDP
Co-occurring BPD worsens the outcome of alcohol recovery, including unplanned discharges and numerous measures of problem drinking. Correspondingly, co-occurring AUD is linked to more severe BPD psychopathology and poor response to psychotherapy. In this paper, various forms of psychotherapy treatment have been suggested that are developed specifically for this co-occurring group of patients. These interventions include dialectical behavior therapy (DBT), dynamic deconstructive psychotherapy (DDP), and dual-focused schema therapy (DFST).
Dialectical Behavior Therapy (DBT)
DBT has undoubtedly found its place in clinical social work practice throughout the world in treating personality disorders such as BPD. It is an evidence-based treatment model that was developed specifically for BPD by Marsha M. Linehan, Ph.D. (Spagenski, 2016). The model has three structural elements namely Behaviorism, Zen principles of Mindfulness, and Dialectics. In particular, dialectical behavioral therapy means discovering the central equilibrium between two contrasting views, by creating a balance between the dialectics. Mainly, in the patients' thought process, two perspectives contradict each other, and divergence in thinking occurs resulting in instability (Spagenski, 2016). When the contradictory perspectives are identified in therapy, then the therapist recognizes, calls to light the dialectic, substantiates patients' thoughts in a validating way, and helps patients with finding a middle ground. Notably, this approach is effective in treating BPD, a disorder ma...
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