Personality disorders are persistent patterns of behavior and coping that lead to chronic problems with maladjustment.
Psychological trauma in childhood and other problems with development are thought to contribute to the development of a personality disorder. There may also be genetic factors.
Personality disorders are resistant to change. They represent a lifelong constriction in the range of available coping strategies. People with personality disorders are unaware of problems with their behavior and tend to use projection and blaming in a defensive fashion in order to avoid introspection.
In this sense, people with addiction resemble those with personality disorders. There is considerable overlap in the incidence of addiction and personality disorders; the difference is that the distortions of personality caused by addiction will gradually improve with recovery. When addiction and a personality disorder are both present, adopting a lifestyle of recovery and continued growth can be very difficult.
Antisocial personality disorder is commonly complicated by addiction for several reasons. There may be a shared genetic vulnerability. Also, people with antisocial personality tend to have difficulty learning from painful experience and to take risks. Their ability to relate to other people is significantly impaired, and relationships are shallow and exploitive. People with the disorder often become involved in criminal or abusive behaviors.
The presence of antisocial personality disorder makes success in recovery unlikely. It should be noted that this situation does not constitute a dual diagnosis in the typical sense of the term. In fact, the modifications in addiction treatment that are made for people with dual diagnosis are the opposite of what a person with antisocial personality disorder needs in order to get better. Highly confrontational and structured programs such as the therapeutic community approach of the sixties or recent prison-based “boot camp” programs are more likely to be successful for a person with this disorder who is addicted.
People with paranoid, schizoid, or schizotypal personal ity disorders have traits that resemble symptoms of schizophrenia. They have difficulty with socialization and with self-esteem, and sometimes do poorly in traditional alcohol and drug treatment or unmodified 12-step programs. Dual diagnosis programming is often helpful for an addict with one of these personality disorders.
Narcissistic, dependent, histrionic, and compulsive personality disorders involve various neurotic traits which lead to impaired interpersonal functioning and difficulties with jobs and academic achievement, but often do not preclude successful treatment in traditional alcohol and drug programs.
Borderline personality disorder is a complex condition that resembles a number of other severe psychiatric disorders and is unique in its responsiveness to medication and therapy. It is characterized by instability in relationships, poor stress tolerance, repeated self-destructive behavior that includes suicide gestures and attempts, severe anxiety, periods of depression, and, often, brief episodes of psychosis. Eating disorders such as bulimia or compulsive overeating may be present. Substance abuse may occur in episodes or may lead to the development of addiction. It is thought that borderline personality disorder arises from a combination of genetic vulnerability to depression and early childhood trauma. A history of such trauma, especially sexual abuse, is common in people with this disorder.
Those with borderline personality disorder have deficits in their concept of self and trouble with everyday coping. They are very sensitive to rejection or abandonment. They often respond to emotional threats by projecting their negative feelings on others or splitting the world into all good or all bad.
As a result, they can appear manipulative and emotionally destructive.
In a traditional alcohol and drug program they may respond to the stress of treatment by shifting their focus to perceived flaws in the staff or by becoming involved in treatment romances. If there is a history of sexual or other severe childhood abuse, people with borderline disorder may engage in repetitive self-mutilation, such as cutting themselves superficially or burning themselves with cigarettes. These acts arecarried out in order to reduce uncomfortable feelings of anxiety and detachment, but are disturbing to others, particularly staff members in a treatment setting. Following stabilization and a period of treatment in a dual diagnosis program, however, many with borderine personality disorder and addiction do well in traditional alcohol and drug treatment settings and 12-step groups.
Borderline personality disorder is treated with a combination of medications to control the unstable moods and psychotherapy. Therapy may be cognitively based, especially at first, or intensive and insight-oriented. A long course of treatment, on the order of many years, is usually necessary.
Many people with borderline personality disorder - unlike those with other personality disorders - do achieve a satisfactory resolution of symptoms over time, especially if there is an opportunity for a stable work or family setting for a number of years.
Elizabeth Connell Henderson, M.D.
Appendix A: Regulation of Addictive Substances
Appendix B: Sources of Additional Information