875061 APY Australasian PsychiatryDonald et al.

Australasian
Invited Article Psychiatry
Australasian Psychiatry

Substance use and borderline 1­–4

© The Royal Australian and
New Zealand College of Psychiatrists 2019

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DOI: 10.1177/1039856219875061
https://doi.org/10.1177/1039856219875061

hope in the face of complexity journals.sagepub.com/home/apy

Fiona Donald   Spectrum Personality Disorder Service, Eastern Health, Richmond, VIC, and; Eastern Health Clinical School,
Monash University, Box Hill, VIC, Australia
Shalini Arunogiri  Turning Point, Eastern Health, Richmond, VIC, and; Monash Addiction Research Centre and Eastern Health
Clinical School, Monash University, Box Hill, VIC, Australia
Dan I Lubman  Turning Point, Eastern Health, Richmond, VIC, and; Monash Addiction Research Centre and Eastern Health
Clinical School, Monash University, Box Hill, VIC, Australia

Abstract
Objective: Impulsivity and emotional dysregulation are common characteristics of patients presenting with co-
occurring borderline personality disorder (BPD) and substance use disorder (SUD). This article aims to provide an
overview of the clinical approaches psychiatrists should consider when treating patients with these conditions.
Conclusions: Co-occurring BPD and SUD can be effectively treated within a staged, transdiagnostic approach with
an emphasis on the therapeutic alliance.

Keywords:  borderline personality disorder, substance use disorder, comorbidity, dual diagnosis, addiction

A
lcohol and drug use is common among people
with borderline personality disorder (BPD),1 with
population surveys identifying that between 21%
and 81% report a co-occurring substance use disorder
(SUD).2 BPD is also common (30%) among patients
treated with long-term prescription opioids for chronic
non-malignant pain.3 Co-occurring SUD is associated
with greater BPD severity and poorer treatment out-
comes, including greater levels of substance use, unsafe
injecting, self-harm, suicidal behaviour and treatment
non-compliance, higher rates of relapse and poorer psy-
chosocial outcomes. It is therefore not surprising that
patients with co-occurring BPD and SUD present con-
siderable challenges to clinical services, further com-
pounded by the stigma, negative attitudes and practices
associated with responding to this population.4
Underlying pathology: impulsivity
and emotional dysregulation
As illustrated in the accompanying case (see Box 1),
impulsivity and emotional dysregulation are characteris-
tics of BPD and are also risk factors for the development
and maintenance of SUD.5 Reports of developmental
trauma are common in BPD, although it should be
emphasised that trauma does not feature in the histories
of all patients.6 Similarly, patients with SUD report high
rates of trauma, which is associated with heavier pattern
of substance use.7 Attachment issues are often evident
and may help explain the common co-occurrence of
impulsivity and/or difficulties with emotional regula-
tion seen in people diagnosed with both BPD and SUD.8
Given these issues, building the therapeutic relationship
is a critical step in developing trust and maintaining
patients in therapy. A staged approach is recommended,
with stabilisation of the substance use or self-harm a key
early focus. A transdiagnostic approach (as illustrated in
the accompanying case), focussing on the emotional
dysregulation and/or impulsivity that underlies symp-
toms such as substance use or self-harm, provides
patients with core skills to help build their self-efficacy
rather than targeting symptom reduction alone.
Corresponding author:
Dan Lubman, Turning Point, 110 Church St, Richmond, VIC
3121, Australia.
Email: dan.lubman@monash.edu

1
 Australasian Psychiatry 00(0)

Box 1.  Case study.

Jane*, is a 26-year-old woman, who presented to a specialist addiction service seeking treatment for use of multiple
substances, in the context of mental health problems. (Jane is a pseudonym and written consent was provided by the patient.)
Jane reported a psychiatric history that included periods of self-reported ‘depression and mania’ from mid-adolescence. Self-
harm (cutting) was reported from mid-adolescence to about two years prior to the current presentation. Jane further reported
a suicide attempt and acute inpatient admission at the age of 19 associated with a drug-induced psychosis in the context
of polydrug use of cannabis, methamphetamines and MDMA. A psychological assessment in the first weeks of treatment
identified two key issues: emotional regulation difficulties including significant mood swings, angry outbursts and frequent
tearfulness without apparent proximal cause and impulsivity associated with polydrug use.
At the start of her treatment, Jane described a pattern of ‘reckless’ polysubstance use, including weekly or biweekly use of
MDMA, methamphetamine and ketamine, and also frequent ‘panic attacks’. Jane also reported smoking a gram of cannabis
daily, as well as drinking four standard drinks most days, with weekend binges of about 8–12 standard drinks. Jane reported
being a non-smoker of tobacco. Jane was at the time of treatment using methamphetamines and MDMA orally, smoking
cannabis and drinking alcohol.
Initially, treatment was focused on harm reduction with psychoeducation around the potential risks of each substance and
work on limiting risk such as not using methamphetamines or MDMA when alone but rather in the presence of trusted others.
Jane completed 12 sessions of Acceptance and Commitment based psychological therapy. The focus was on mindfulness and
on naming, validating and self-soothing difficult emotions (emotional regulation). The indiscriminate polydrug use resolved
early in treatment. Over this period, Jane reported developing alternative ways to regulate her emotions with a particular
emphasis on naming and noticing emotions and re-regulating early, for instance, before anxiety reached the level of panic.
However, Jane continued to report frequent ‘emotional outbursts’ and difficulties with anger. She was referred to the team’s
psychiatrist mid-way through treatment, who recommended lamotrigine to target mood instability. She commenced on 50 mg,
subsequently titrated to 100 mg and then to 150 mg by her GP over a three-month period.
At the end of treatment Jane was working full-time. Jane had reduced her substance use to a quarter of a gram of cannabis
three days per week, and three to four standard drinks of alcohol per week, with some substance use-free days each week.
No other substance use was reported at the conclusion of the treatment.
*Pseudonym

Subsequent treatment can focus on identity and self
issues, although explicit treatment of trauma, such as
exposure work, should only be considered within the
context of long-term therapy.
Treatment recommendation:
psychotherapy with adjunct
psychopharmacology as needed
Current Australian guidelines on the management of
BPD suggest that psychotherapy is the first-line treat-
ment, with psychopharmacology an adjunctive option.9
Stabilisation of substance use should be a target before
the commencement of therapy. Inpatient treatment for
withdrawal may be indicated, and even where such
treatment is not necessary, pre-treatment may involve
establishing a baseline of use and then using a motiva-
tional interviewing approach to generate patient ‘buy in’
for reducing their use. Motivational interviewing refers
to therapeutic techniques that encourage patients to
identify their own reasons for change rather than a
didactic approach where the therapist ‘explains’ the dis-
advantages of using substances.10 Harm reduction
should also be addressed early and includes informing
patients about the risks associated with their substance
use and helping them manage those risks (rather than
an insistence by the therapist on abstinence). Indeed,
issues such as risk of blood-borne viruses, overdose and
other harms to physical health should be explicitly
addressed. Harm reduction may include referral to a nee-
dle exchange programme11 for people with injecting
drug use or prescription of take-home naloxone for
patients at risk of opioid overdose (now available in a
nasal spray).12 Where motivational interviewing is effec-
tively used, some reduction in use or changes associated
with harm reduction may be achieved.
Pharmacological treatment may be indicated in the
context of co-occurring BPD and SUD for specific man-
agement of targeted symptoms. First-line pharmacolog-
ical options should include medications that support
recovery from SUD, including pharmacotherapies for
alcohol (such as naltrexone, acamprosate or disulfiram),
which have demonstrated safety and efficacy even in
the setting of personality comorbidity.13 Similarly, opi-
oid agonist pharmacotherapies should be considered in
the setting of opioid dependence. Second-line medica-
tion approaches include the off-label use of mood stabi-
lisers (e.g. valproate, lamotrigine, lithium) for targeted

2
Donald et al.
improvement of affective dysregulation, although the
evidence supporting remission of BPD itself is weak.14
Prescription of mood stabilisers requires informed con-
sent regarding this off-label indication and related
affordability considerations. With all medication treat-
ments, the presence of comorbid SUD confers addi-
tional risks that prescribers need to keep in mind,
including interaction with substances used (including
other prescribed medications), cumulative sedative
effects, toxicity in overdose and potential misuse and
diversion (particularly with atypical anti-psychotics
such as quetiapine). Risk-mitigating strategies include
having one prescriber and one pharmacy, limited dis-
pensing (e.g. weekly pick-up) and regular urine drug
screening. It can also be prudent to set a date for review
of medication regimens to clarify efficacy and response,
as deprescribing can in itself be a therapeutic interven-
tion that enables collaborative decision-making and
patient autonomy, while limiting the risks of long-term
polypharmacy.15
The three modalities for treatment of BPD and SUD most
commonly available in Australia for use with adults are
dialectical behaviour therapy, mentalisation-based treat-
ment and acceptance and commitment therapy (ACT).
All of these therapies address elements of emotional dys-
regulation and impulsivity (albeit through different
approaches) and have been found to be effective for
BPD, with emerging evidence for their effectiveness for
co-occurring BPD and SUD.16,17 For example, ACT-based
psychotherapy, as delivered in the case study (Box 1) bal-
ances the need for behavioural interventions, such as
monitoring diaries, planning and setting limits, with
acceptance and change strategies (i.e. willingness and
cognitive defusion) focused on underlying impulsivity
and emotional dysregulation.
Challenges in assessment and
treatment for co-occurring BPD
and SUD
Where there has been a long-term history of SUD it
may not be possible to disentangle the effects of intox-
ication/withdrawal from the mood instability charac-
teristic of BPD, making a definitive diagnosis of BPD
impossible. A longitudinal history drawing on collat-
eral information, including periods of abstinence, may
help with diagnosis, although collateral information is
not always available. In relation to treatment, at the
heart of the issues that this group faces are relational
problems often arising from insecure attachment. For
instance, interpersonal conflict may lead to emotional
dysregulation with associated impulsive self-harm or
substance use. Attachment difficulties may also com-
plicate the therapeutic relationship. Patients with BPD
may find the beginning of therapy challenging as
attachment needs are activated. Consideration of these
attachment-based issues is essential. Developing a
working alliance with shared change-oriented treat-
ment goals may also take considerable time. Indeed,
Livesley suggests that developing a working alliance is
not a preliminary to treatment with people with BPD,
but may constitute the substance of the work.18 The
balance between validation and change-oriented inter-
ventions also needs to be carefully considered.
Validation refers to empathetic acceptance of the
patient and the patient’s difficulties, whereas change-
oriented interventions focus on changing current
behaviours, for instance, by developing alternative
coping strategies to replace self-harm or substance use.
Patients with BPD typically respond well to validation,
although change-oriented interventions need to be bal-
anced with validation.
Strong countertransference reactions including anger,
frustration or indifference are commonly reported by cli-
nicians working with people with BPD, especially in the
context of SUD.19 Indeed, strong emotional reactions on
the part of clinicians are to be expected. All clinicians
working with this group are likely to benefit from regu-
lar, expert supervision. Where expect supervision is not
available, peer-based supervision may be helpful.
Secondary consultation from a specialist, tertiary service
may also be an option in some instances.
Chronic suicidal thinking is not uncommon for people
with a diagnosis of BPD, and distinguishing between
chronic patterns of suicidal ideation and acute suicidal
risk can be challenging. The risk of self-harm and/or sui-
cide often escalates with heightened impulsivity in the
context of intoxication. Therefore, the interaction
between substance use and risk needs to be explicitly
discussed within treatment and recognised within a
safety plan. Therapists should be particularly alert to
changes in typical affect, self-reported mood or life cir-
cumstances as well as anniversaries of traumatic events,
as any of these may indicate an increase in acute risk of
suicide in the context of chronic suicidal thinking.
Trauma work is not recommended within brief interven-
tions and should only be attempted after a considerable
period of stabilisation. Trauma work that involves expo-
sure to memories of sexual assaults or the specifics of
other traumatic events may be particularly destabilising
and may increase acute suicidal risk.
Conclusions
As the accompanying case study illustrates, therapeutic
progress is achievable for co-occurring BPD and SUD,
even within a 12-session intervention. The limitations
of this single case include self-reported substance use
without biological verification and a lack of long-term
follow-up, with ongoing diagnostic uncertainty. In
real-world settings, in the context of relapsing-
remitting and stress-sensitive conditions such as BPD
and SUD, diagnostic clarity is often only achieved with
the benefit of hindsight. Nevertheless, the staged man-
agement outlined in the case demonstrates a pragmatic
approach within an overall transdiagnostic framework.
For instance, an immediate priority is reduction of risk
3

associated with polydrug use, alongside a focus on the
emotional dysregulation and impulsivity that are likely
to underlie a patient’s substance use. In the accompa-
nying case, comprehensive treatment of BPD was not
attempted. This approach was communicated to the
patient early in therapy and appeared to accord well
with the patient’s goals. Indeed, although this patient
group can be viewed as highly complex it is important
to acknowledge that substantial reductions in sub-
stance use can be achieved within relatively brief inter-
ventions. This experience of treatment success is of
therapeutic value for patients, kindling hope that can
be built on within further treatment for BPD.
Disclosure
The authors declared the following potential conflicts of interest with respect to the research,
authorship, and/or publication of this article: DIL has provided consultancy advice to Lundbeck
and Indivior, and has received travel support and speaker honoraria from Astra Zeneca,
Indivior, Janssen, Lundbeck, Servier and Shire.
Funding
The authors received no financial support for the research, authorship, and/or publication of
this article.
ORCID iD
Fiona Donald: https://orcid.org/0000-0002-5212-5580
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