The Adverse Link Between BPD and Addiction

TW: mentions of drugs, alcohol, self-harm & suicide.

You might be as shocked as I am to find out that about 78% of adults with Borderline Personality Disorder (BPD) develop some sort of addiction in their lives. It is so prevalent that among those in treatment for addictions, about 26.7% have BPD (Tomko et al, 2014). It has been found that people with BPD tend to drop out of treatment more frequently and have shorter phases of abstinence. As someone who has worked in treatment centres for addiction, I can see how important it is to acknowledge these statistics as more specialised treatment needs to be offered to these individuals. 

Dual Diagnosis: BPD and Substance Dependence

Understanding how BPD and addiction often develop together can usually be traced back to the symptoms of BPD. People with BPD may turn to substances as a way to cope with overwhelming emotions or escape from a painful reality. Several key factors link BPD symptoms to a higher risk of addiction:

Self-Medicating

BPD often brings deep feelings of emptiness and extreme boredom, making substances an easy way to cope. Drugs or alcohol can numb painful emotions and provide temporary relief or excitement in an otherwise dull or overwhelming emotional landscape.

Genetics

There may also be a genetic link between BPD and addiction. A genetic predisposition to BPD could increase the likelihood of developing substance use issues (Few et al, 2014).

Impulsive Behaviour

Research, such as that by Mitolo et al. (2024), shows that people with BPD can have structural changes in brain areas responsible for impulse control and emotional regulation. This lack of impulse control can lead to reckless substance use or even behavioural addictions.

Upbringing

Many people with BPD grow up in neglectful environments (Porter et al, 2020), where a lack of parental supervision can lead to early exposure to drugs and alcohol. Additionally, trauma during childhood is common in people with BPD, and substances may be used to escape or numb the pain from these traumatic experiences.

Self-Harm

Feelings of low self-worth, combined with emotional pain, can sometimes lead people with BPD to use substances as a form of self-harm or punishment. This destructive behaviour can further deepen the cycle of addiction.

By understanding how these factors intersect, we can better see why individuals with BPD are at a higher risk of developing addiction, often using substances as a way to cope with the intense emotions and challenges that come with the disorder.

Understanding Addiction

In the 18th and 19th centuries, addiction was often associated with moral degradation. People who struggled with substance use, particularly alcohol (often referred to as “drunkenness”), were labelled as irresponsible or socially deviant. There was little understanding of the physiological or psychological factors that contributed to addiction, and treatment often focused on punishment, shame, or strict religious and social reform.

It wasn’t until the 20th century that addiction began to be viewed more as a medical condition. Early medical models, however, still focused heavily on the addictive nature of substances themselves, without much understanding of the underlying psychological, social, or environmental factors. Addicts were often blamed for their own condition, and the idea that addiction was a voluntary choice remained widespread until more comprehensive theories of addiction emerged in the late 20th century.

One of these was Bruce Alexander’s famous “Rat Park” experiment in the late 1970s. His study looked at how environments play a major role in addiction. Rats kept in isolated, barren cages with access to drug-laced water became addicted. However, when placed in “Rat Park,” a stimulating environment filled with social interaction and plenty of space to explore, the rats barely touched the drugs. This showed that addiction isn’t just about the drug itself—it’s heavily influenced by factors like living conditions, social connections, and overall well-being.

For someone with BPD, it’s easy to see how substance use could start as a way to numb emotional pain or add excitement to life. The relief substances provide can quickly lead to repeated use, which eventually turns into dependency. Having an addiction comes with a plethora of additional problems as well as exacerbating symptoms of BPD. Understanding addiction in this way highlights the importance of looking beyond just the substance and addressing the deeper issues behind it.

How Substances Exacerbate Symptoms of BPD

Alcohol

Temporarily, alcohol can increase your confidence and feelings of excitement but the long term effects have no benefits. I can speak from experience that using alcohol exacerbates symptoms. I used to drink quite heavily, binge drinking at weekends and rarely having a day off from half a bottle of wine on weeknights. There came a time in my life that I was so low I was contemplating suicide. I would wake up in a very low mood most days (alcohol is a depressant after all), struggle to be motivated and I hated the way I looked in the mirror. Alcohol made me gain weight and it destroyed my skin and sleep. After one month of quitting alcohol, I couldn’t believe the positive changes in my overall mood, motivation, my skin and sleep. Not to mention the extra time and money I had, I could not go back to drinking that way again.

Alcohol can impair judgement and cause aggressive or erratic behaviour, making it harder to navigate personal relationships. Drinking alcohol caused me to have more frequent arguments, miscommunications, and emotional turmoil in my relationship. I would then feel ashamed or guilty afterward. 

(If you’re dependent on alcohol and planning to quit, it’s crucial to seek medical advice from your doctor. Quitting cold turkey can be very dangerous to your body, so proper medical support is important for a safe recovery!)

Cannabis

When it comes to using cannabis for Borderline Personality Disorder (BPD), opinions are pretty divided. Some people say it helps reduce anxiety, depression, and aggression. Cannabis interacts with GABA, a neurotransmitter that helps calm the mind and cut down on overthinking. But, since everyone’s brain chemistry is different and there are so many different strains of cannabis, the effects can vary a lot.

When you use cannabis high in THC, your brain gets flooded with cannabinoids, which can sometimes overstimulate the amygdala—the part of the brain that processes fear and anxiety. Research by Childs et al. (2017) found that taking 7.5mg of THC reduced stress-related negative emotions, but upping the dose to 12.5mg had the opposite effect, increasing anxiety and stress. This becomes a real problem for regular users who build up a tolerance. To feel the same effects, they may start taking higher doses, which can actually end up making them feel worse.

On the other hand, CBD-rich products don’t cause paranoia or have psychoactive effects. CBD doesn’t bind directly to endocannabinoid receptors like THC does, and studies suggest it even has antipsychotic properties, making it a potentially safer option for managing symptoms.

Opiates

Opiates, in natural or synthetic form, reduce pain. Around 27 million people worldwide are affected by opioid use disorders, which include prescription opioids like oxycodone, hydrocodone, and morphine. Of these, a significant portion (approximately 15-20 million people) are specifically addicted to prescription opioids. An estimated 10-12 million people globally are addicted to heroin, a form of illicit opioid (United Nations Office on Drugs and Crime, 2021, WHO, 2021).

Opiates may temporarily relieve emotional pain, but over time, they can lead to emotional numbing, withdrawal symptoms, and mood swings. These fluctuations can heighten the emotional instability that is already characteristic of BPD. Opiates may also lower inhibitions increasing the likelihood of engaging in risky actions, such as self-harm or more drug use.

Opiate use can lead to increased social withdrawal, erratic behaviour, and dependency which can be damaging to relationships. They can create a false sense of calm and attachment, which may make people with BPD feel even more distressed when that sense of safety is removed during withdrawal or as tolerance builds.

Since people with BPD often use substances to cope with intense emotional pain, they are at a higher risk of developing an addiction. This can create a cycle where drug use worsens BPD symptoms, leading to more drug use in an attempt to self-medicate (Scamaldo et al, 2021).

Overall, while opiates may seem to offer short-term relief, they tend to amplify the emotional, behavioural, and interpersonal difficulties associated with BPD in the long run.

Cocaine

Cocaine is a powerful stimulant that spikes dopamine levels, giving you extreme highs followed by intense crashes. For someone with BPD, this can really crank up those mood swings, making emotional instability even worse. You might feel emptiness or rage more intensely than usual. Plus, cocaine lowers your inhibitions, so risky behaviours like overspending, unprotected sex, or more drug use can easily happen.

Another downside is that cocaine can trigger paranoia, anxiety, and even psychosis, especially in larger doses. Since people with BPD already deal with intense anxiety and fear of abandonment, cocaine just amplifies those feelings, making it even harder to manage relationships and emotions.

Cocaine use can also lead to erratic behaviour, social isolation, and damaged relationships. If you have BPD, which is often marked by unstable relationships and a deep fear of abandonment, this can make it even tougher to maintain close connections. On top of that, cocaine can increase irritability and aggression, making it harder to control anger or handle conflicts, leading to more frequent outbursts and strained relationships.

In short, while cocaine may provide a temporary boost, it usually makes BPD symptoms much harder to manage in the long run.

Caffeine

It’s a bit ironic that I’m writing this while drinking coffee, but I definitely notice the negative effects of caffeine when I have too much. Caffeine is a stimulant that can increase anxiety, jitteriness, and restlessness—things that are already common for people with BPD. This added anxiety can make it harder to regulate emotions.

Caffeine can also amplify mood swings by giving you a temporary energy boost, followed by a crash, which can leave you feeling more depressed, irritable, or emotionally unstable. If you’re having an anxious or stressful day, it’s probably best to skip the caffeine. It can trigger feelings of paranoia or panic, which, let’s be honest, no one wants.

One of the biggest issues with caffeine is how it messes with your sleep, especially if you drink it later in the day. Since people with BPD often struggle with sleep patterns, caffeine-induced insomnia can lead to fatigue and irritability, making emotional management even harder. I personally stick to one good coffee after lunch. If I drink it any later, I’m lying in bed for hours trying to fall asleep!

In Summary, substances may increase:

• Anxiety

• Depression

• Irritability and aggression

• Fear of abandonment

• Feelings of guilt and shame

• Paranoia

• Psychosis

• Suicidal ideation

• Chances of developing Substance Use Disorder (SUD)

Action Plan for Someone with BPD and Substance Misuse Disorder:

If you have BPD and struggle with substance misuse, finding ways to cope with both challenges can feel overwhelming. But there are plenty of positive strategies that can help you manage both at the same time. Here are some ideas to get started:

1. Look for Dual Diagnosis Treatment

• Finding a treatment program that addresses both BPD and substance misuse is key. Dual diagnosis programs are designed to handle both issues at once, offering therapy, medical support, and practical tools that increase your chances of recovery and emotional balance.

2. Try Dialectical Behavior Therapy (DBT)

• DBT is a great option if you’re dealing with both BPD and substance misuse. It teaches skills like emotional regulation, distress tolerance, mindfulness, and how to have better relationships. These tools can help you manage cravings, reduce impulsive decisions, and replace harmful habits with healthier ones.

3. Identify and Avoid Triggers

• Take note of the people, places, and situations that set off emotional distress or make you want to use. Learning to avoid or better manage these triggers can make a big difference in reducing both emotional overwhelm and the urge to use substances.

4. Find Healthy Alternatives

• Replace substance use with positive activities like exercise, journaling, or creative outlets. These activities can act as healthy distractions and also provide a way to process and channel your emotions in a constructive way.

5. Practice Mindfulness and Grounding

• Mindfulness helps you stay present in the moment, which can reduce the impulsive urge to turn to substances when you’re feeling emotionally overwhelmed. Grounding techniques like deep breathing, meditation, or focusing on your surroundings can also help you stay calm and focused.

6. Build a Sober Support Network

• Surround yourself with people who support your recovery. This could be through group therapy, 12-step meetings like AA or NA, or spending time with sober friends and family. A strong support network can make it easier to stay sober and manage BPD symptoms.

7. Consider a Harm Reduction Approach

• If the idea of quitting substances cold turkey feels too overwhelming, a harm reduction approach might be helpful. This means cutting down on use or avoiding especially dangerous behaviours, while working toward full sobriety and emotional regulation over time.

8. Stick to a Routine

• Having a daily routine can provide structure and help you avoid the chaos that often comes with substance misuse and BPD. Include self-care, meals, exercise, and therapy or sober activities in your schedule to help you stay on track.

9. Work on Emotional Regulation

• Practice skills that help you manage intense emotions, like self-soothing, delaying reactions, or using distress tolerance techniques (for example, distracting yourself or using ice to calm down). These skills can prevent you from reaching for substances to cope with emotional triggers.

10. Celebrate Small Wins

• Recovery is a journey, and it’s important to celebrate the small victories along the way. Whether it’s staying sober for a day, using a coping skill instead of turning to substances, or reaching out for help, acknowledging your progress will motivate you to keep going.

11. Consider Medication-Assisted Treatment (MAT)

• For some people, medications like Suboxone, methadone, or medications for anxiety or depression can help manage cravings and stabilise your mood. Work with a doctor who understands both BPD and substance misuse to explore these options.

12. Have a Crisis Plan

• Create a plan for those moments when you feel overwhelmed and tempted to use. This could involve calling a trusted person, using a coping skill, or going to a safe space. Having a plan in place can reduce the likelihood of turning to substances impulsively.

Finding ways to cope with both BPD and substance misuse may feel tough, but with the right strategies, you can begin to manage your symptoms and make progress toward recovery. Remember, it’s all about finding what works best for you, one step at a time.

Sources:

Childs, E., Lutz, J. A., & de Wit, H. (2017). Dose-related effects of delta-9-THC on emotional responses to acute psychosocial stress. Drug and alcohol dependence, 177, 136-144.

Few, L. R., Grant, J. D., Trull, T. J., Statham, D. J., Martin, N. G., Lynskey, M. T., & Agrawal, A. (2014). Genetic variation in personality traits explains genetic overlap between borderline personality features and substance use disorders. Addiction, 109(12), 2118-2127.

Mitolo, M., D’Adda, F., Evangelisti, S., Pellegrini, L., Gramegna, L. L., Bianchini, C., … & Tonon, C. (2024). Emotion dysregulation, impulsivity and anger rumination in borderline personality disorder: the role of amygdala and insula. European Archives of Psychiatry and Clinical Neuroscience, 274(1), 109-116.

Porter, C., Palmier‐Claus, J., Branitsky, A., Mansell, W., Warwick, H., & Varese, F. (2020). Childhood adversity and borderline personality disorder: a meta‐analysis. Acta Psychiatrica Scandinavica, 141(1), 6-20.

Scamaldo, K. M., Tull, M. T., & Gratz, K. L. (2021). Motives for opioid use explain the relation between borderline personality disorder pathology and opioid use problems. Psychiatry Research, 296, 113609.

Tomko, R. L., Trull, T. J., Wood, P. K., & Sher, K. J. (2014). Characteristics of borderline personality disorder in a community sample: comorbidity, treatment utilization, and general functioning. Journal of personality disorders, 28(5), 734-750.

United Nations Office on Drugs and Crime. (2021). World drug report 2021. https://www.unodc.org/unodc/en/data-and-analysis/wdr2021.html

World Health Organization. (2021). Opioid overdose. https://www.who.int/news-room/fact-sheets/detail/opioid-overdose