BPD and addictions: why they go together so often and what protects.

Introduction

If you live with BPD (borderline personality disorder), or love someone who does, you may have noticed something worrying: alcohol or drug use appears in the history of many people with this diagnosis. And if you're in that situation, I want you to know two things from the start: it's not a character flaw, and it can be treated.

Research confirms it. A review of 70 studies (Trull et al., 2018) found that about 45% of people with BPD currently have a substance use disorder, and about 75% have one at some point in their lives. This article explains why it happens, what factors help reduce this vulnerability and what treatments exist.

How common is it?

The numbers can be read in both directions:

• Among people with BPD: about 45% have a substance use disorder at the time of evaluation, and about 75% have a substance use disorder over their lifetime. With alcohol, about 46% of people with BPD have a current disorder.
• Among people with addictions: about 22% meet criteria for BPD. The figure changes depending on the substance: around 17% for alcohol, 22% for cocaine and 34% for opioids.

Another review (Kienast et al., 2014) describes similar figures, with about 78% of people with BPD developing a substance-related disorder.

These percentages describe what is observed in studied populations. They do not say that you, or your family member, will develop an addiction. They indicate where it is advisable to pay attention.

Why are they related?

Two elements appear in the explanations of both disorders: emotional dysregulation and impulsivity (Trull et al., 2018).

In BPD, emotions come with great intensity and it is difficult to calm them down. When that happens, substances work like an escape button: they turn off, even for a while, a discomfort that feels unbearable. That immediate relief reinforces the behavior, and thus the pattern is established. Researchers describe it as a process of negative reinforcement: you consume yourself to stop feeling something.

Impulsivity provides the other half. When there is difficulty pausing between feeling and acting, in a moment of crisis, consumption is more likely to appear.

The circle that makes everything worse

The relief is short-lived and the cost comes later. When BPD and consumption coincide, the evolution is usually more difficult: greater impulsivity, more clinical instability, more suicidal behavior and more abandonment of treatment (Kienast et al., 2014). Using intensifies BPD symptoms, and BPD symptoms push back toward using.

That's why the useful question is not "why isn't it controlled?", but "what is this person trying to shut down?"

What helps protect

An honest precision: there are few studies that directly measure "protective factors against addiction in BPD." What we do have is evidence about the skills that are related to fewer symptoms and less problematic consumption:

1. Tolerance to discomfort. A meta-analysis (Mattingley et al., 2022) found that lower distress tolerance is associated with more problematic use and more BPD symptoms. Being able to sustain a difficult emotion without escaping is a skill that can be trained.

2. emotion regulation and pause. Learning to name what you feel and wait before acting reduces the need to resort to the substance. It is the mechanism that research indicates is common to both disorders.

3. Self-pity. In a 2023 study (Southward et al.), of three protective factors evaluated, only self-compassion predicted fewer BPD symptoms the following month. That study measured BPD symptoms, not consumption, so I take that as a clue and not a definitive conclusion.

4. Early and integrated treatment. It is recommended to address BPD and consumption at the same time, not one after the other (Kienast et al., 2014).

Maintaining BPD treatment also protects

This is the point I want to highlight the most. If consumption appears when emotion overflows, then BPD treatment is also a form of prevention: each session trains the skills that make escape less necessary.

Stopping treatment when you feel better is understandable, but it is just the time when symptoms can return and, with them, the risk of resorting to the substance. Improvement is a sign that the treatment is working, not that it is no longer needed.

Treatments that exist

The review by Kienast et al. (2014) describes three psychotherapeutic approaches for BPD with addiction:

• Dialectical Behavior Therapy for substance disorders (DBT-SUD): showed improvements in withdrawal and functioning. In a randomized clinical trial with women with BPD and drug dependence (Linehan et al., 1999), those who received this therapy reduced consumption more than with usual treatment, both during the year of treatment and at follow-up, and remained in treatment longer.

• Schema therapy with a dual approach: mixed results across studies.

• Dynamic deconstructive psychotherapy: moderate effects.

The evidence is still limited: there are few randomized trials, and several with small samples. That is why treatment must be decided with a professional who knows your case, and often includes psychiatric support.

Yes there is hope

One of the most important studies is that of Zanarini et al., from McLean Hospital. They followed 290 people with BPD for ten years. More than 90% of those who met criteria for a substance disorder at baseline achieved remission (Zanarini et al., 2011). Relapses occurred in about 35-40% of cases.

A follow-up after 24 years (2025) confirmed the pattern: remission is frequent (between 64 and 91% in alcohol and between 71 and 100% in other drugs), and relapses also exist. Relapse does not mean failure. It means that the process needs more support.

If you are a family member or couple

• Stop asking why he can't control himself. Ask how you can help him get treatment.

• Validate the pain, without validating the behavior. "I see how much you are suffering" and "this is hurting you" can be said together.

• It encourages continuing treatment, especially at times when the person "already feels well."

• Also seek support for yourself. Accompanying someone with BPD and consumption is exhausting.

• If there is immediate risk to life, contact your local emergency services.

Frequently asked questions

"Does having BPD mean I will develop an addiction?"

No. Vulnerability is greater, but it is not a destiny. Many people with BPD never develop an addiction, and emotion regulation skills are protective.

"Should addiction or BPD be treated first?"

It is recommended to attend to both at the same time, with a plan that prioritizes according to the risks at each moment.

"If I'm better, can I stop therapy?"

This decision should be made together with your therapist. Stopping cold turkey is usually the point where symptoms return.

"Is consuming alcohol or drugs contraindicated during BPD treatment?"

It is discouraged. When consumption coincides with BPD, the evolution is usually more difficult: greater impulsivity, more instability and more abandonment of treatment (Kienast et al., 2014). Additionally, alcohol and drugs affect exactly what therapy works on: regulating emotions and pausing before acting. They can also interact with psychiatric medications, so the psychiatrist must know what is being consumed. And if there is physical dependence, especially on alcohol, quitting cold turkey can be dangerous: it should be done with medical supervision. If there is consumption, the most useful thing is to tell your treatment team without hiding it: it is not about punishment, but about adjusting the treatment to what is really happening.

"Is dialectical behavioral therapy the only one that works?"

No. It is the most studied for this combination, but there are other approaches, and the choice depends on each person.

The next step

If any of this resonated with you, the question is not "do I have addiction and BPD?", but rather "what function does use serve in my life and what do I need to get through the discomfort in another way?" A professional psychological assessment allows us to map this pattern and put together a treatment tailored to you.