Summary of Gianoli, Jane, O’Brien, & Ralevski (2012): Treatment for Comorbid Borderline Personality Disorder and Alcohol Use Disorders

 

Gianoli, Jane, O’Brien, & Ralevski (2012) explain that there is a high degree of comorbidity between borderline personality disorder (BPD) and alcohol use disorders (AUDs). Research has demonstrated that this pattern of comorbidity may be associated with poorer prognosis for these individuals. Three psychotherapies have been specifically developed for patients with borderline personality disorder and substance use disorders (SUDs), but only one of these (Dynamic Deconstructive Psychotherapy) has been tested among patients with dual diagnoses of BPD and AUDs. Of all substance-use disorders, alcohol use disorders (AUDs) including both alcohol abuse and alcohol dependence are the most common among individuals with borderline personality disorder.

 

Borderline personality disorder is present in approximately 1% to 1.6% of the general population and in about 20% of the psychiatric population. Borderline personality disorder is thought to be about three times more common among females than males but this gender difference has not always been proven in community-based studies. Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) suggest that among patients with a lifetime diagnosis of borderline personality disorder, 58.3% also had lifetime diagnoses of alcohol use disorders. Rates of co-occurrence of lifetime borderline personality disorder among patients with alcohol use disorders ranged from 9.8% to 14.7% in this same study. A study found that among individuals with borderline personality disorder, the prevalence rate of alcohol use disorders was 48.8% and among patients with alcohol use disorders, the prevalence rate of borderline personality disorder was 14.3%. Comorbidity rates are even higher among female psychiatric patients, with 59% of women with borderline personality disorder also carrying a lifetime diagnosis of either alcohol abuse or dependence. Individuals diagnosed with both borderline personality disorder and alcohol use disorder have worse outcomes compared to those with either borderline personality disorder or alcohol use disorder alone. Borderline personality disorder traits are significantly predictive of future problems associated with alcohol use, even after controlling for other Axis I disorders (including other current substance use disorders) and nonborderline personality disorders.

 

There are surprisingly few treatments that have been developed or tested for concurrently treating borderline personality disorder and alcohol use disorders. Several randomized studies have found that targeting personality traits in brief coping skills interventions is effective in reducing alcohol and illicit substance use. An approach called, Personality-Guided Treatment for Alcohol Dependence (PETAD), was created that integrates cognitive therapy for addictive behaviors with strategic interventions for maladaptive personality features. Compared to those receiving standard cognitive therapy, those in the PETAD condition were more likely to stay in treatment, and had significantly more days of alcohol abstinence at their six-month follow-up visit. In another study, Linehan et al. (1999) examined the efficacy of Dialectical Behavior Therapy (DBT) with patients with borderline personality disorder and substance use disorders. In this particular study, patients were randomized to one year of either DBT-S or treatments as usual (TAU). At the 16-month follow-up, DBT-S patients reported better social and global adjustment compared to the TAU group.

 

Another psychotherapy has been developed for the concurrent treatment of personality disorders and substance use disorders called Dual Focus Schema Therapy (DFST). Unlike DBT-S, DFST was developed for the treatment of a broader range of personality disorders that are often comorbid with SUDs and AUDs. DFST includes a 24-week, manual-guided, individual cognitive-behavioral therapy integrating relapse prevention techniques while addressing chronic, maladaptive personality functioning and coping styles. The efficacy of DFST for specifically treating patients with borderline personality disorder and alcohol use disorder is unknown, but there are some encouraging findings regarding its efficacy among patients with dual diagnoses of personality disorders and SUDs. Both DBT-S and DFST appear to be promising approaches for the concurrent treatment of borderline personality disorder and substance use disorders.

 

The only form of psychotherapy that has been specifically tested for the concurrent treatment of borderline personality disorder and alcohol use disorders is Dynamic Deconstructive Psychotherapy (DDP), a time-limited, manual-based treatment based on object-relations theory, deconstructive philosophy and neurocognitive research. Analyses from a study comparing DDP and TAU found no significant differences between groups during the course of the study, however, there were statistically significant improvements found over time on measures of parasuicide behavior, alcohol misuse, and proportion of patients needing institutional care for those receiving DDP but not for those receiving TAU.

 

In summary, DBT-S and DFST appear to have only modest effects on drinking behavior. Further research is clearly needed for all three psychotherapies. It will be important for future studies to explore the effectiveness of these psychotherapies not only in bigger samples, but also in samples of patients with dual diagnoses specifically of borderline personality disorder and alcohol use disorders.

 

In treating individuals with alcohol use disorders, the main objective is relapse prevention. Thus, pharmacological strategies usually involve medications that deter alcohol use by moderating craving and/or producing adverse reactions when alcohol is consumed. The FDA approved medications for alcohol relapse prevention are disulfiram [acetaldehyde dehydrogenase (ALDH-1 and -2 inhibitor)], oral and injectable naltrexone (mu-opioid antagonist), and acamprosate (NMDA receptor modulator). Differentially, there are no FDA approved medications for the treatment of borderline personality disorder. Nevertheless, psychotropic medications, namely antidepressants, anticonvulsants, and antipsychotics, are often used to manage the anger, impulsivity and mood lability that are characteristic of borderline personality disorder. Of these medications, anticonvulsants, namely topiramate and lamotrigine, and second-generation antipsychotics, specifically aripiprazole and olanzapine, appear to be the most helpful. Antidepressants, although most commonly prescribed for patients with borderline personality disorder are only modestly effective in managing symptoms of borderline personality disorder. There are no published studies that have explored medication options to concurrently manage symptoms of borderline personality disorder and decrease alcohol consumption. A study was conducted utilizing disulfiram with individuals with borderline personality disorder and alcohol disorder. Two of the eight patients remained completely abstinent under supervised disulfiram therapy over their respective treatment period (4.5 and 14 months). These studies provided evidence that relapse prevention medications may be similarly effective in reducing alcohol consumption for individuals with and without comorbid borderline personality disorder. However, neither study reported on changes in borderline personality disorder symptoms. Therefore, while relapse prevention medications may help to control alcohol use, there is no evidence that they effectively manage borderline personality disorder symptoms. There is also emerging evidence that anticonvulsants and second-generation antipsychotics are most effective in the management of borderline personality disorder symptoms. Interestingly, the very same medications may be helpful in the treatment of alcohol use disorders. Of these classes of medications, most support has been found for topiramate and aripiprazole, however, encouraging findings have also been reported for lamotrigine and olanzapine.

 

Borderline personality disorder and alcohol use disorders are highly comorbid and this type of comorbidity has been associated with particularly negative prognosis. Yet, there are very few treatments that concurrently treat symptoms of both borderline personality disorder and alcohol use disorders. There have been three psychotherapies that have been designed to concurrently treat borderline personality disorder and substance use disorders. However, only one (Dynamic Deconstructive Psychotherapy) has been specifically evaluated for the concurrent treatment of borderline personality disorder and alcohol use disorders, and although it may be effective in reducing symptoms of borderline personality disorder, its efficacy in reducing alcohol consumption over time may be comparable to treatment as usual. There is evidence that some anticonvulsants and antipsychotics may significantly reduce anger (one core symptom of borderline personality disorder), and some like lamotrigine have been shown to reduce other core symptoms of borderline personality disorder including impulsivity and mood lability. Other studies have suggested that the same medications may also reduce alcohol craving and consumption in patients with alcohol use disorders/problems alone. Considering these results, further study of the role of anticonvulsants and second-generation antipsychotics is warranted, and further studies aimed at exploring other treatments that simultaneously treat both symptoms of borderline personality disorder and alcohol disorder are recommended. (Gianoli, Jane, O’Brien, & Ralevski, 2012)

 

Gianoli, M. O., Jane, J.S., O’Brien, E., & Ralevski (2012). Treatment for comorbid borderline personality disorder and alcohol use disorders: A review of the evidence and future recommendations. Experimental and Clinical Psychopharmacology, 12 (4). 333-344.

 

Cindy A. Geil, M.A.
WKPIC Doctoral Intern

 

 

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