Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

In Brief

Fall 2014 • Volume 8 • Issue 3

An Introduction to Co-Occurring 

Borderline Personality Disorder and 

Substance Use Disorders

This In Brief is for health and human services 

professionals (e.g., social workers, vocational counselors, 

case managers, healthcare providers, probation officers). 

It is intended to introduce such professionals to borderline 

personality disorder (BPD)—a condition with very high 

rates of suicide and self-harm that often co-occurs with 

substance use disorders (SUDs). This In Brief presents 

the signs and symptoms of BPD, with or without a 

co-occurring SUD, alerts professionals to the importance 

of monitoring clients with BPD for self-harm and suicidal 

behavior, and encourages professionals to refer such 

clients for appropriate treatment. This In Brief is not meant 

to present detailed information about BPD or treatment 

guidelines for BPD or SUDs.

How Common Is BPD?1

Estimates of BPD prevalence in the U.S. population 

range from 1.6 percent to 5.9 percent. BPD affects 

approximately 10 percent of all psychiatric outpatients 

and up to 20 percent of all inpatients.

What Is Borderline Personality 

Disorder?

BPD is one among several personality disorders (e.g., 

narcissistic personality disorder, paranoid personality 

disorder, antisocial personality disorder). According to the 

Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition (DSM-5),1

 personality disorders are generally 

characterized by: 

■ Entrenched patterns of behavior that deviate 

significantly from the usual expectations of behavior 

of the individual’s culture.

■ Behavior patterns that are pervasive, inflexible, and 

resistant to change.

■ Emergence of the disorder’s features no later than 

early adulthood (unlike depression, for example, 

which can begin at any age).

■ Lack of awareness that behavior patterns and 

personality characteristics are problematic or that 

they differ from those of other individuals.

■ Distress and impairment in one or more areas of a 

person’s life (often only after other people get upset 

about his or her behavior).

■ Behavior patterns that are not better accounted for by the 

effects of substance abuse, medication, or some other 

mental disorder or medical condition (e.g., head injury).

BPD is a complex and serious mental illness. Individuals 

with BPD are often misunderstood and misdiagnosed. A 

history of childhood trauma (e.g., physical or sexual abuse, 

neglect, early parental loss) is more common for individuals 

with BPD.1,2 In fact, many individuals with BPD may have 

developed BPD symptoms as a way to cope with childhood 

trauma. However, it is important to note that not all 

individuals with BPD have a history of childhood trauma. It 

is also important to note that some of the symptoms of BPD 

overlap with those of several other DSM-5 diagnoses, such 

as bipolar disorder and posttraumatic stress disorder (PTSD). 

Therefore, a diagnosis of BPD should be made only by a 

licensed and experienced mental health professional (whose 

scope of practice includes diagnosing mental disorders) and 

then only after a thorough assessment over time.

Individuals with BPD often require considerable attention 

from their therapists and are generally considered to be 

challenging clients to treat.3,4,5 However, BPD may not be the 

chronic disorder it was once thought to be. Individuals with 
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In Brief

BPD often respond to appropriate treatment and may have 

a good long-term prognosis,1,5 experiencing a remission of 

symptoms with a relatively low occurrence of relapse.6,7

The DSM-5 indicates that BPD is diagnosed more 

often in women than in men (75 percent and 25 percent, 

respectively).1

 Other research, however, has suggested 

that there may be no gender difference in prevalence in 

the general population,5,6 but that BPD is associated with a 

significantly higher level of mental and physical disability 

for women than it is for men.6

 In addition, the types of cooccurring conditions tend to be different for women than for 

men. In women, the most common co-occurring disorders 

are major depression, anxiety disorders, eating disorders, and 

PTSD. Men with BPD are more likely to have co-occurring 

SUDs and antisocial personality disorder, and they are more 

likely to experience episodes of intense or explosive anger.8,9

What Are the Symptoms of BPD?

The DSM-5 classifies mental disorders and includes specific 

diagnostic criteria for all currently recognized mental 

disorders. It is a tool for diagnosis and treatment, but it 

is also a tool for communication, providing a common 

language for clinicians and researchers to discuss symptoms 

and disorders. According to the DSM-5, the symptoms of 

BPD include: 1

■ Intense fear of abandonment and efforts to avoid 

abandonment (real or imagined).

■ Turbulent, erratic, and intense relationships that 

often involve vacillating perceptions of others (from 

extremely positive to extremely negative).

■ Lack of a sense of self or an unstable sense of self.

■ Impulsive acts that can be hurtful to oneself (e.g., 

excessive spending, reckless driving, risky sex).

■ Repeated suicidal behavior or gestures or 

self-mutilating behavior. (See the section below on 

suicide and nonsuicidal self-injury.)

■ Chronic feelings of emptiness.

■ Episodes of intense (and sometimes inappropriate) 

anger or difficulty controlling anger (e.g., repeated 

physical fights, inappropriate displays of anger).

■ Temporary feelings of paranoia (often stress-related) 

or severe dissociative symptoms (e.g., feeling 

detached from oneself, trancelike).

Anyone with some of these symptoms may need to be 

referred to a licensed mental health professional for a 

complete assessment. Exhibit 1 presents some examples 

of how a person with BPD might behave.

Suicide and nonsuicidal self-injury

BPD is unique in that it is the only mental disorder diagnosis 

that includes suicide attempts or self-harming behaviors 

among its diagnostic criteria.3

 The risk of suicide is high 

among individuals with BPD, with as many as 79 percent 

reporting a history of suicide attempts10 and 8 percent to 

10 percent dying by suicide—a rate that may be 50 times 

greater than the rate among the general population.11

More than 75 percent of individuals with BPD engage in 

deliberate self-harming behaviors known as nonsuicidal 

self-injury (NSSI) (e.g., cutting or burning themselves).12

Unlike suicide attempts, NSSI does not usually involve a 

desire or intent to die. Sometimes the person with BPD does 

not consider these behaviors harmful.4

 One study involving 

290 patients with BPD found that 90 percent of patients 

reported a history of NSSI, and over 70 percent reported the 

use of multiple methods of NSSI.10 Reasons for NSSI vary 

from person to person and, for some individuals, there may 

be more than one reason. The behaviors may be: 4,13,14

■ A way to express anger or pain.

■ A way to relieve pain (i.e., shifting from psychic 

pain to physical pain).

■ A way to “feel” something.

■ A way to “feel real.”

■ An attempt to regulate emotions.

■ A form of self-punishment.

■ An effort to get attention or care from others.

NSSI may include: 4,13,14

■ Cutting.

■ Burning.

■ Skin picking or excoriation.
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An Introduction to Co-Occurring Borderline Personality Disorder and Substance Use Disorders

Fall 2014, Volume 8, Issue 3

■ Head banging.

■ Hitting.

■ Hair pulling.

Exhibit 1. Examples of Symptomatic Behavior (BPD) 

■ Patterns of intense and unstable relationships

John comes in to see his case manager, George, and announces that he plans to marry a woman he met at a speed-dating 

event the night before. George has heard this same story from John at least once a month for the past 4 months.

■ Emotions that seem to change quickly from one extreme to another

Suzie has been working with a vocational rehabilitation counselor, Tony, for 2 weeks to prepare for job retraining. One day, 

just after Tony gets everything set up for Suzie to begin her training, Suzie storms out of the office screaming at him, “You’re 

just trying to get rid of me! You don’t understand me at all! I hate you!” Later, when Tony calls to suggest that maybe Suzie 

would prefer to work with another counselor, Suzie begins to cry and says, “Please don’t drop me, Tony! I need you!”

■ Evidence of self-harm or self-mutilation

José is a probation officer. During his weekly appointment with his client, Annie, José notices a pattern of recent cuts across 

her left forearm. José asks her about them, and Annie becomes defensive and says, “Okay, I cut myself sometimes, so what? 

It’s none of your business. I’m not hurting anybody!”

■ Pattern of suicidal thoughts, gestures,* or attempts

Maria is a nurse. As she looks over the health history of her new patient, Sally, she notices that Sally has been hospitalized 

three times in the past 4 years after suicide attempts, and that she has seen six different therapists. Sally tells her, “Yeah, I 

get suicidal sometimes. I just can’t seem to find the right therapist who can help me.”

■ Intense displays of emotion that often seem inappropriate or out of proportion to the situation

Regina is a social worker at a domestic violence shelter. She notices one of her clients, Elena, sitting in the living room 

with a sketchpad in her lap. Regina asks if she can see what Elena is drawing. Elena turns the sketchpad around to reveal 

a beautiful, detailed drawing of the shelter house. Regina admires it and says how beautiful it is, then says, “That’s funny, 

I thought that the house number was on the right side of the door.” Elena, who had been smiling, takes the sketchpad from 

Regina, looks at the drawing, then rips it from the pad and begins tearing it up, saying, “You’re right, it’s all wrong! I’ll 

have to start all over again!”

*Regarding the word gestures: It is dangerous to dismiss or label any suicidal behavior as a gesture. Anyone who exhibits 

suicidal thoughts or behaviors of any kind needs to be assessed by a licensed mental health professional.

What Are the Symptoms of SUDs?

SUDs involve patterns of recurrent substance use that 

result in significant problems, which fall into the following 

categories:1

■ Impaired control—taking more of the substance than 

intended, trying unsuccessfully to cut down on use, 

spending an increasing amount of time obtaining and 

using the substance, craving or having a strong desire 

for substance use

■ Social impairment—failing to fulfill obligations at 

work, school, or home; continuing substance use in 

spite of the problems it causes; giving up or reducing 

other activities because of substance use

■ Risky use—using the substance(s) in situations in which 

it may be physically dangerous to do so (e.g., driving) or 

in spite of physical or psychological problems that may 

have been caused or may be made worse by substance 

use (e.g., liver problems, depression)

■ Pharmacological criteria—displaying symptoms 

of tolerance (need for increased amounts of the 

substance to achieve the desired effect) or withdrawal

(a constellation of physical symptoms that occurs 

when the use of the substance has ceased)
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In Brief

What Is the Relationship Between 

BPD and SUDs?

One study15 found that the prevalence of BPD among 

individuals seeking buprenorphine treatment for opioid 

addiction exceeded 40 percent, and another16 found that 

nearly 50 percent of individuals with BPD were likely to 

report a history of prescription drug abuse. A large survey6

found that 50.7 percent of individuals with a lifetime 

diagnosis (i.e., meeting the criteria for a diagnosis at 

some point during the individual’s life) of BPD also had 

a diagnosis of an SUD over the previous 12 months. This 

same survey found that for individuals with a lifetime 

diagnosis of an SUD, 9.5 percent also had a lifetime 

diagnosis of BPD. This is a significantly higher incidence 

of BPD than that in the general public, which ranges from 

1.6 percent to 5.9 percent.1

One longitudinal study17 found that 62 percent of patients 

with BPD met criteria for an SUD at the beginning of the 

study. However, over 90 percent of patients with BPD and 

a co-occurring SUD experienced a remission of the SUD 

by the time of the study’s 10-year follow-up. (Remission 

was defined as any 2-year period during which the person 

did not meet criteria for an SUD.) The authors also looked 

at whether there were recurrences of SUDs after periods 

of remission and found that the rate of recurrence was 40 

percent for alcohol and 35 percent for drugs. The rate of 

new onsets of SUDs, while lower than expected, was still 

21 percent for drugs and 23 percent for alcohol. Another 

study18 found that individuals with BPD had higher rates of 

new SUD onsets even when their BPD symptoms improved 

(compared with new SUD onsets for individuals with other 

personality disorders).

A client with BPD and a co-occurring SUD presents some 

particular challenges. BPD is difficult to treat, partly 

because of the pervasive, intractable nature of personality 

disorders and partly because clients with BPD often do 

not adhere to treatment and often drop out of treatment. 

The impulsivity, suicidality, and self-harm risks associated 

with BPD may all be exacerbated by the use of alcohol or 

drugs.19 In addition, the presence of BPD may contribute 

to the severity of SUD symptoms,20 and the course of SUD 

treatment may be more complicated for clients who also 

have BPD.21

Who Can Best Provide Treatment 

for People With BPD and SUDs?

Individuals who display some of the symptoms of BPD (as 

described above) should be referred to an experienced licensed 

mental health professional for a thorough mental health 

assessment and possible referral to treatment. It is important to 

know whether referral sources have experience treating clients 

with BPD. If individuals display symptoms of substance 

misuse, they should also be assessed for a co-occurring SUD.

Individuals with BPD sometimes trigger intense feelings 

of frustration and even anger in their therapists and 

other providers.12 Clients with BPD often have difficulty 

developing good relationships, including productive 

working relationships with therapists and other providers 

(e.g., healthcare workers, case managers, vocational 

counselors). Some individuals with BPD may move from 

therapist to therapist (or other professionals) in an effort to 

find “just the right person.”

Individuals who have an SUD may receive treatment from 

an individual counselor or therapist or from an outpatient 

treatment program. However, a co-occurring diagnosis of 

BPD may complicate SUD treatment. It is important for 

the professionals treating the person for either diagnosis to 

work in consultation with each other.

Treatment for BPD—especially with a co-occurring SUD—

sometimes involves a team approach. Depending on the 

treatment plan, a person may have an individual therapist, a 

group therapist, a substance abuse counselor, a psychiatrist, 

and a primary care provider; treatment may need to be planned 

and managed through the coordinated efforts of all providers. 

Regular consultation among all providers can ensure that 

everyone is working toward the same goals from each of their 

professional perspectives. For example:

■ In individual therapy sessions, a therapist may help 

the client learn to tolerate gradually increasing levels 

of uncomfortable emotions (e.g., stress, anxiety) so 

that the client may begin to have more control over 

those emotions.

■ A psychiatrist may consider the use of medication for 

the client or evaluate currently prescribed medications 

to determine adherence and their effect on the client’s 

ability to engage in the emotional work of therapy.
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An Introduction to Co-Occurring Borderline Personality Disorder and Substance Use Disorders

Fall 2014, Volume 8, Issue 3

■ A substance abuse counselor may work with the client 

to achieve abstinence, identify relapse triggers that may 

come up as the client does emotional work in therapy, 

and identify coping strategies for remaining abstinent.

■ A vocational counselor may need to work with the 

client on distress tolerance as it relates to employment 

issues, such as applying for jobs or beginning a new 

job. This may mean helping the client understand the 

importance of being at interviews, vocational training 

classes, or work on time (even if emotional problems 

make that difficult) and helping the client develop 

strategies to achieve a pattern of good work habits.

Some people with BPD may consciously or unconsciously 

attempt to sabotage treatment by providing conflicting 

information to providers or by trying to turn one provider 

against another. Consultation among all providers can help 

deter this.

What Treatments Are Available for 

Individuals With BPD and SUDs?

Many studies have been done on treatment approaches for 

BPD or SUDs, but very few have involved participants 

with co-occurring BPD and SUDs.22,23,24 However, based 

on the studies that have been done on co-occurring BPD 

and SUDs, a few approaches seem to show promise. 

Perhaps the most researched approach is Dialectical 

Behavior Therapy, which has been adapted for treatment 

of co-occurring BPD and SUDs (Dialectical Behavior 

Therapy-S [DBT-S]).

It is important to note, however, that DBT-S and other 

promising approaches involve structured, manualized 

treatments that are quite intensive and require a significant 

amount of training and resources (e.g., staffing, space, 

finances) that may not be available in all areas.25 Many 

therapists work on their own with individuals who have 

BPD, using the best techniques that their training and 

experience have to offer—hopefully in regular consultation 

with an experienced clinical supervisor. Therapists 

often adapt psychotherapy to better meet the needs of 

an individual client, sometimes combining different 

therapeutic approaches or mixing techniques.4

 However, 

for clients with both BPD and SUDs, the therapist may 

need to work with an SUD treatment provider to provide 

comprehensive care.

Pharmacotherapy for BPD and SUDs

The Food and Drug Administration (FDA) has not 

approved any medications for the treatment of BPD. 

However, individuals with BPD may take medications 

to alleviate some of their symptoms.11,22 For example, 

selective serotonin reuptake inhibitors may be prescribed 

for depressed mood, irritability, anger, and impulsivity.11

There are several FDA-approved medications for SUD 

treatment. For alcohol use disorder, these include 

acamprosate, disulfiram, and naltrexone.26 For opioid use 

disorder, approved medications include buprenorphine, a 

combination of buprenorphine and naloxone, methadone, 

and naltrexone.27 Some of these medications may be 

prescribed on a short-term basis (e.g., to ease withdrawal 

symptoms, lessen cravings), and others may be prescribed 

for long-term use (e.g., to facilitate longer periods of 

abstinence).26,27

Individuals may receive their prescriptions and medication 

management from a psychiatrist, from other types of 

healthcare providers, or from both (or, in the case of 

methadone, from an opioid treatment program). Individuals 

may take medication as one part of a treatment plan that 

also includes attending individual therapy, group therapy, 

group skill-building sessions, or a mutual-help group (e.g., 

12-step program), or some combination of these.

What Are Some Things To 

Remember When Working With 

Someone Who Has Co-Occurring 

BPD and SUDs?

Some of the same guidelines that have been identified as 

necessary for mental health professionals who work with 

clients who have these two diagnoses may also be helpful 

for all human services professionals. Working with a client 

who has co-occurring BPD and SUDs requires:

■ Strong (but not rigid) professional boundaries—Be 

clear with the person about the expectations in the 

working relationship (e.g., length of appointments, 

level of support, contact outside regular appointments). 

Be aware of special requests to make exceptions 
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In Brief

to the usual rules for working with clients. These 

requests sometimes escalate over time. If in doubt 

about making an exception to the rules, discuss the 

situation with a supervisor who is knowledgeable 

about working with individuals who have BPD (within 

applicable confidentiality requirements).11

■ A commitment to self-care—If possible, schedule 

appointments with someone who has BPD right 

before lunch or before a break. Avoid scheduling 

back-to-back appointments with two individuals who 

have BPD. It is important to have some time between 

them to see clients with other diagnoses, to work on 

other tasks, or simply to take a break. Develop the 

habit of leaving work at work (i.e., don’t “replay” 

interactions with individuals who have BPD).

■ An awareness of how BPD may affect any kind 

of work with the individual—For example, fearing 

abandonment and avoiding abandonment are 

characteristics of BPD and may manifest in some 

unexpected ways. For example, if the professional 

relationship has focused on the person with BPD 

completing certain goals, that person may thwart 

his or her own progress to avoid the feelings of 

abandonment that would result from ending the 

working relationship.

■ Knowledge about what skills the individual who 

has BPD is learning in therapy—The person may 

need assistance applying those new skills to broader 

life situations. For example, perhaps one skill the 

person has learned is how to break down a seemingly 

overwhelming task into a series of small steps. Work 

with the person to apply that particular skill to the 

situation at hand.

Conclusions

It is important to remember that:

■ Most human services professionals will encounter 

clients with BPD in the course of their work.

■ Individuals with BPD often have co-occurring 

diagnoses (e.g., depression, SUDs).

■ BPD is often characterized by intense emotional displays 

and impulsive acts (e.g., self-harm, suicide attempts).

■ Working with an individual with BPD (with or without 

a co-occurring SUD) can be challenging.

■ Individuals with BPD (with or without a co-occurring 

SUD) deserve to receive appropriate treatment and 

deserve to be treated with compassion and respect.

■ Individuals with BPD often respond to appropriate 

treatment and experience a remission of symptoms 

with a relatively low occurrence of relapse.

■ Individuals with BPD (with or without a co-occurring 

SUD) may have a team of professionals who provide 

different aspects of care (e.g., therapist, psychiatrist).

■ It is important for all professionals involved in the care 

of an individual with BPD to communicate and work 

together.

Resources

SAMHSA resources

National Registry of Evidence-based Programs and 

Practices

http://nrepp.samhsa.gov

Treatment Improvement Protocols (TIPs) 

(see back page for electronic access and ordering information)

TIP 36: Substance Abuse Treatment for Persons With Child 

Abuse and Neglect Issues

TIP 42: Substance Abuse Treatment for Persons With 

Co-Occurring Disorders

TIP 44: Substance Abuse Treatment for Adults in the 

Criminal Justice System

TIP 50: Addressing Suicidal Thoughts and Behaviors in 

Substance Abuse Treatment

Web resources

American Psychiatric Association

http://www.psych.org

American Psychological Association 

http://www.apa.org

Borderline Personality Disorder Resource Center 

http://bpdresourcecenter.org
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An Introduction to Co-Occurring Borderline Personality Disorder and Substance Use Disorders

Fall 2014, Volume 8, Issue 3

National Education Alliance for Borderline Personality 

Disorder 

http://www.borderlinepersonalitydisorder.com

National Institute of Mental Health

http://www.nimh.nih.gov

National Institute on Drug Abuse 

http://www.drugabuse.gov

Notes

1 American Psychiatric Association. (2013). Diagnostic and statistical 

manual of mental disorders (5th ed.). Arlington, VA: American 

Psychiatric Publishing.

2 Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C., 

Zanarini, M. C., et al. (2004). Childhood maltreatment associated 

with adult personality disorders: Findings from the Collaborative 

Longitudinal Personality Disorders Study. Journal of Personality 

Disorders, 18(2), 193–211.

3 Dimeff, L. A., Comtois, K. A., & Linehan, M. M. (2009). Cooccurring addiction and borderline personality disorder. In 

R. K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.), Principles 

of addiction medicine (4th ed., pp. 1227–1237). Philadelphia: 

Lippincott Williams & Wilkins.

4 National Institute of Mental Health. (2011). Borderline personality 

disorder. NIH Publication No. 11‐4928. Bethesda, MD: Author.

5 Substance Abuse and Mental Health Services Administration. (2011). 

Report to Congress on borderline personality disorder. HHS 

Publication No. (SMA) 11‐4644. Rockville, MD: Substance Abuse 

and Mental Health Services Administration.

6 Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., 

Saha, T. D., et al. (2008). Prevalence, correlates, disability, and 

comorbidity of DSM-IV borderline personality disorder: Results 

from the Wave 2 National Epidemiologic Survey on Alcohol and 

Related Conditions. Journal of Clinical Psychiatry, 69, 533–545.

7 Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, 

K. R. (2005). The McLean Study of Adult Development (MSAD): 

Overview and implications of the first six years of prospective 

follow-up. Journal of Personality Disorders, 19(5), 505–523.

8 Sansone, R. A., & Sansone, L. A. (2011). Gender patterns in borderline 

personality disorder. Innovations in Clinical Neuroscience, 8(5), 

16–20.

9 Tadíc, A., Wagner, S., Hoch, J., Başkaya, Ö., von Cube, R., Skaletz, C., 

et al. (2009). Gender differences in axis I and axis II comorbidity in 

patients with borderline personality disorder. Psychopathology, 42,

257–263.

10 Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Fitzmaurice, G., 

Weinberg, I., & Gunderson, J. G. (2008). The 10-year course of 

physically self-destructive acts reported by borderline patients and 

axis II comparison subjects. Acta Psychiatrica Scandinavica, 117,

177–184.

11 American Psychiatric Association. (2001). Practice guideline for 

the treatment of patients with borderline personality disorder. 

American Journal of Psychiatry, 158, 1–52.

12 Black, D. W., & Andreasen, N. C. (2011). Introductory textbook 

of psychiatry (5th ed.). Washington, DC: American Psychiatric 

Publishing.

13 Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons 

for suicide attempts and nonsuicidal self-injury in women with 

borderline personality disorder. Journal of Abnormal Psychology, 

111(1), 198–202.

14 Kleindienst, N., Bohus, M., Ludäscher, P., Limberger, M. F., 

Kuenkele, K., Ebner-Priemer, U. W., et al. (2008). Motives for 

nonsuicidal self-injury among women with borderline personality 

disorder. Journal of Nervous and Mental Disease, 196(3), 

230–236.

15 Sansone, R. A., Whitecar, P., & Wiederman, M. W. (2008). The 

prevalence of borderline personality among buprenorphine patients. 

International Journal of Psychiatry in Medicine, 38(2), 217–226.

16 Sansone, R. A., & Wiederman, M. W. (2009). The abuse of 

prescription medications: Borderline personality patients in 

psychiatric versus non-psychiatric settings. International Journal 

of Psychiatry in Medicine, 39(2), 147–154.

17 Zanarini, M. C., Frankenburg, F. R., Weingeroff, J. L., Reich, 

D. B., Fitzmaurice, G. M., & Weiss, R. D. (2011). The course of 

substance use disorders in patients with borderline personality 

disorder and axis II comparison subjects: A 10-year follow-up 

study. Addiction, 106(2), 342–348.

18 Walter, M., Gunderson, J. G., Zanarini, M. C., Sanislow, C. A., Grilo, 

C. M., McGlashan, T. H., et al. (2009). New onsets of substance 

use disorders in borderline personality disorder over 7 years 

of follow-ups: Findings from the Collaborative Longitudinal 

Personality Disorders Study. Addiction, 104, 97–103.

19 van den Bosch, L. M. C., Verheul, R., & van den Brink, W. (2001). 

Substance abuse in borderline personality disorder: Clinical and 

etiological correlates. Journal of Personality Disorders, 15, 416–424.

20 Morgenstern, J., Langenbucher, J., Labouvie, E., & Miller, K. J. 

(1997). The comorbidity of alcoholism and personality disorders 

in a clinical population: Prevalence rates and relation to alcohol 

typology variables. Journal of Abnormal Psychology, 106(1), 

74–84.

21 Center for Substance Abuse Treatment. (2005). Substance abuse 

treatment for persons with co-occurring disorders. Treatment 

Improvement Protocol (TIP) Series 42. HHS Publication 

No. (SMA) 13‐3992. Rockville, MD: Substance Abuse and 

Mental Health Services Administration.

22 Gianoli, M. O., Jane, J. S., O’Brien, E., & Ralevski, E. (2012). 

Treatment for comorbid borderline personality disorder 

and alcohol use disorders: A review of the evidence and 

future recommendations. Experimental and Clinical 

Psychopharmacology, 20(4), 333–344.
In Brief

In Brief, An Introduction to Co-Occurring Borderline Personality Disorder and Substance Use Disorders

23 Kienast, T., & Foerster, J. (2008). Psychotherapy of personality 

disorders and concomitant substance dependence. Current 

Opinion in Psychiatry, 21, 619–624.

24 Pennay, A., Cameron, J., Reichert, T., Strickland, H., Lee, N. K., 

Hall, K., et al. (2011). A systematic review of interventions for 

co-occurring substance use disorder and borderline personality 

disorder. Journal of Substance Abuse Treatment, 41(4), 363–373.

25 Zanarini, M. C. (2009). Psychotherapy of borderline personality 

disorder. Acta Psychiatrica Scandinavica, 120, 373–377.

26 Center for Substance Abuse Treatment. (2009). Incorporating alcohol 

pharmacotherapies into medical practice. Treatment Improvement 

Protocol (TIP) Series 49. HHS Publication No. (SMA) 13‐4380. 

Rockville, MD: Substance Abuse and Mental Health Services 

Administration.

27 Center for Substance Abuse Treatment. (2005). Medication-assisted 

treatment for opioid addiction in opioid treatment programs. 

Treatment Improvement Protocol (TIP) Series 43. HHS Publication 

No. (SMA) 12‐4214. Rockville, MD: Substance Abuse and Mental 

Health Services Administration.

In Brief 

This In Brief was written and produced under contract numbers 270-09-0307 and 270-14-0445 by the Knowledge Application 

Program, a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Substance Abuse and Mental Health 

Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Christina Currier served as the 

Contracting Officer’s Representative.

Disclaimer: The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the 

views, opinions, or policies of SAMHSA or HHS.

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Recommended Citation: Substance Abuse and Mental Health Services Administration. (2014). An Introduction to 

Co-Occurring Borderline Personality Disorder and Substance Use Disorders. In Brief, Volume 8, Issue 3.

Originating Office: Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for 

Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, 

MD 20857.

HHS Publication No. (SMA) 14-4879

Printed 2014

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