Personality Disorders and Substance Use Disorders: What Is the Connection?

It’s important for people with personality disorders and co-occurring addictions to get treatment for both conditions. Otherwise, recovery can be very difficult.

Personality disorders often co-occur with substance use disorder, the clinical term for drug or alcohol addiction. In particular, people with borderline or antisocial personality disorders are more likely to also struggle with substance use. 

In general, around 10% to 15% of people have a personality disorder. However, these disorders are present in anywhere from 35% to 73% of people who are treated for addiction. People who struggle with both addiction and a personality disorder tend to have more severe substance use concerns, which can make recovery more difficult but makes treatment vital.

The Connection Between Personality Disorders and Substance Use Disorders

Personality disorders can make many parts of day-to-day life difficult, so some people turn to substances as a way to cope with these difficulties. For some, this may be a way to cover feelings of emptiness or social isolation. For others, it may be a way to heighten thrill-seeking behaviors and impulsivity. For those with high levels of anxiety and depression, substance use can be a way to self-medicate. Unfortunately, substance use can cause symptoms to worsen.

The exact cause of personality disorders is unknown. However, there are risk factors that can play a part in the development of personality disorders. Childhood trauma plays a significant role, especially in those with borderline and antisocial disorders — conditions that can cause intimacy and trust issues.

Genetics seems to play a role as well, especially in schizotypal, borderline personality disorder (BPD) and antisocial personality disorders. Affected genes may include those that regulate serotonin, dopamine and norepinephrine, which are each important for regulating emotions.

Cultural norms may also play a role in the development of personality disorders, as they may dictate acceptable outlets for emotion. For example, China and Japan have a low prevalence of antisocial personality disorders but a high level of avoidant, dependent and obsessive-compulsive disorders.

Treating Co-Occurring Substance Use and a Personality Disorder

Untreated personality disorders can make addiction treatment and recovery much more difficult. For the treatment of either condition to be effective, both disorders must be addressed at the same time.  Treatment for people with personality disorders and co-occurring addictions generally consists of medications to help ease withdrawal, if needed. Naltrexone can be effective for decreasing cravings during and after detox for those struggling with these co-occurring conditions. In addition, antidepressants or other medications may be prescribed for existing depression or anxiety.

Psychotherapy is crucial for people with personality disorders and addictions. Often, a person’s personality disorder exacerbates their substance use. Addressing both in therapy is critical for these individuals. Therapy can be difficult for people with these disorders, but it provides necessary skills for negotiating daily tasks and relationships. It can also be difficult for some to take their medications as scheduled or directed.

Cognitive behavioral therapy (CBT) often provides helpful tools for these clients during rehab treatment. CBT aims at modifying thoughts and behaviors to allow more healthy living patterns. It is a shorter-term therapy that can help clients develop coping tools, avoid relapse and create healthier habits.

Longer-term therapies can include dialectical behavioral therapy (DBT), dual focused schema therapy (DFST) and dynamic deconstructive therapy (DDP). These can be helpful when therapy can take place for six months or more. Alternatively, a therapist may choose to use certain parts of these therapies if they fit a client’s needs.

In general, DBT can be effective in reducing substance use in people with personality disorders. It teaches clients how to build a life worth living, helping them envision, pursue and work toward goals that allow them to cope with life’s ordinary problems.

Dual focus schema therapy is a longer therapy as well, lasting approximately 24 weeks. It incorporates relapse prevention while helping clients address negative beliefs about themselves and build more positive styles of coping. This therapy is quite effective with people who struggle with personality disorders and co-occurring substance abuse.

Dynamic deconstructive psychotherapy, another long-term therapy, can be effective for people with borderline personality disorder and addiction. It helps clients connect more fully with their experiences and develop deeper, more authentic relationships with others. During this therapy, clients reflect upon their experiences and learn to integrate, accept and realistically develop close relationships with others while maintaining their own sense of self.

What Is a Personality Disorder?

Personality disorders can be thought of as pervasive and enduring patterns of traits, experiences and behaviors that are very different from cultural norms. These traits are inflexible and difficult to change, and they can lead to significant impairment for the person as well as those around them. Personality disorders usually first appear during adolescence or early adulthood.

Personality Disorder Types

There are 10 different personality disorders, which are categorized in three clusters that share characteristics or attributes.

Cluster A

Cluster A personality disorders center around odd or eccentric behaviors. People with a Cluster A personality disorder are often viewed as peculiar or suspicious, resulting in difficulty in interpersonal relationships. Cluster A personality disorders and characteristics include:

• Paranoid: This personality disorder is marked by a deep-seated distrust of others, causing a person to believe other people may deceive them.
• Schizoid: This disorder is marked by feelings of social isolation and indifference toward other people. People with this disorder are often described as cold or withdrawn and rarely have close relationships with other people. They may be introspective and preoccupied with fantasy.
• Schizotypal: This type is characterized by odd speech, behavior or appearance. They may hold strange beliefs and have a hard time forming relationships.

Cluster B

Cluster B is characterized by dramatic or erratic behavior. People with this disorder type tend to have intense experiences or emotions and engage in highly dramatic and impulsive behaviors. They may be inclined toward rule-breaking behaviors. Cluster B includes:

• Antisocial: This personality type appears most often in childhood. People with this disorder often disregard rules and social norms. They may not experience remorse for their actions or empathy for others.
• Borderline: This disorder type is marked by instability. People with this disorder have unstable relationships with others and themselves. They may exhibit impulsive behaviors and engage in dramatic gestures with others.
• Histrionic: The hallmark of this disorder is excessive emotionality and attention-seeking. People with this disorder will engage in socially inappropriate behavior in order to get attention.
• Narcissistic: This disorder causes a fragile sense of self but also involves self-centeredness, an inability to empathize with others and a grandiose self-image.

Cluster C

Cluster C is characterized by anxious or fearful behaviors. Cluster C includes:

• Avoidant: This personality disorder is characterized by a pattern of social inhibition and avoidance around others. This is often due to underlying fears of inadequacy and being the subject of criticism.
• Dependent: People with dependent personality disorder types are fearful. They do not wish to be alone and will often fear being alone, and they often engage in behaviors designed to try to get others to take care of them.
• Obsessive-compulsive: This type involves a preoccupation with orderliness, perfection and control in relationships and other parts of life. This is different from obsessive-compulsive disorder.

FAQ

• What is the most common personality disorder associated with addiction? All personality disorders are associated with addiction. However, borderline personality disorder may create the highest risk for addiction, especially alcohol addiction. The disorder also puts people at grave risk for self-harming behaviors.

Personality Disorder Symptoms

People with personality disorders will often have an unstable or inconsistent sense of self, and they will also have difficulty in their relationships with others. Empathy is difficult, and they may not be able to recognize or adhere to boundaries or social norms. They are often overemotional, detached or inconsistent in their relationships with others, and they may be irresponsible or abusive in these relationships.

For example, people with borderline personality disorder have an inconsistent sense of self and unstable relationships with others. They may go to extreme lengths to hang onto a relationship and avoid abandonment, often using suicidal gestures to do so. They may display intense anger followed by intense neediness as they deal with ongoing feelings of emptiness.

With narcissistic personality disorder, a person experiences an ongoing need for admiration from others. A narcissist has difficulty relating or empathizing with other people. They may have an exaggerated sense of themselves and a sense of entitlement. However, a fragile sense of self is the underlying driver of many of these behaviors.

People with personality disorders often do not believe that they have a problem. Instead, they may believe that their problems are caused by others. Being around them can seem confusing and frustrating, and they often have inconsistent, abusive, detached, overemotional or irresponsible parenting styles that make life difficult for their partners and children.

Personality disorders are often underdiagnosed because they can be difficult to recognize. They may appear as symptoms of depression, anxiety or substance use rather than symptoms related to a personality disorder. If a person starts receiving treatment for one of these other mental health disorders, it may take several sessions for their personality disorder to be recognized as the true concern.

Effects of Alcohol and Drug Use on Personality Disorders

Research shows that people typically develop personality disorders before developing addiction. In general, substance use co-occurs most often in people with antisocial, borderline, avoidant or paranoid personality disorder. 

People with co-occurring personality disorders and addictions also tend to have poorer therapeutic outcomes. They often have problems with therapist relationships, finding motivation to change, adhering to medication and continuing treatment. These individuals also tend to have more severe addiction problems, poorer social functioning, a higher risk of suicide and less motivation for change. However, not all personality disorders are affected in the same way by substance use issues. People with antisocial, borderline or schizotypal personality disorder may be more likely to use alcohol, cannabis and nicotine.

Alcohol use is prevalent among those with personality disorders, and it may begin as a way to self-soothe. However, alcohol use can worsen personality disorder symptoms. It can:

• Increase impulsivity and suicidality
• Impair emotional regulation
• Increase depression and anxiety
• Interfere in withdrawal and the therapeutic process
• Make relapse more likely

Antisocial and borderline personality disorders also have a strong correlation with cannabis use. There is some evidence that marijuana use can increase aggression in people with these disorders. Borderline personality disorder types often use aggression toward themselves, including various methods of self-harm. Antisocial personality types will often act out against others. Marijuana use among those with personality disorders can also lead to other addictions. Frequent or high doses of marijuana are also related to psychosis and the development of schizotypal personality disorder.

Treating Co-Occurring Personality and Substance Use Disorders

Personality disorders and co-occurring addictions can be difficult to treat, but recovery is possible — especially when both conditions are treated at the same time. People who receive care for co-occurring disorders at specialized rehab facilities are more likely to move on to healthier, more productive living patterns. In the New Jersey area, you can find this help at The Recovery Village Cherry Hill at Cooper.

Our licensed, accredited treatment center provides both inpatient and outpatient services for addiction and a variety of mental health disorders. Contact us today to speak with a knowledgeable representative and learn more about treatment programs that can work well for your needs.