Personality disorders can be among the most disorienting conditions for patients and their families to deal with. Old friends and loved ones can seem like complete strangers, and turning to drugs or alcohol to hide the pain is a common outcome. How to address personality disorders and co-occurring substance abuse entails understanding what personality disorders are, how they change people, and how drug addiction fits into the mix.
The fifth (and most recent) version of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) defines personality disorders as when patients experience “significant impairments in [themselves] and interpersonal functioning,” as well as other personality traits that occur at the same time. In order for this to be a case of personality disorder, the symptoms have to be stable and consistent over a period of time, and they have to be distinct from any natural changes in the patient’s development or effects of the patient’s environment and living situation. Lastly, personality disorders cannot be the direct result of a substance problem or a general medical disorder.
According to the DSM-5, there are 10 different types of personality disorders, and three categories (Clusters A, B, and C) in which these types fit. Cluster A is known as the odd, eccentric cluster; people with paranoid personality disorder or schizoid personality disorder would fit into this category. Cluster B is the dramatic, erratic cluster, for antisocial personality disorder or borderline personality disorder. Lastly, Cluster C is for personality disorders based on anxiety or fear, such as avoidant personality disorder or obsessive-compulsive personality disorder, which is not obsessive-compulsive disorder.
A brief overview of the 10 types of personality disorders is outlined below.
Paranoid personality disorder: This disorder is characterized by a pathological distrust of others, even close friends and family members. The patient is always suspicious and will interpret and distort experiences to validate their fears of persecution. The primary ego defense in this personality disorder is projection: attributing inappropriate thoughts and emotions to others. Paranoid personality disorder is mostly heritable.
Schizoid personality disorder: Patients are detached and aloof to the point where their attention is exclusively on their own inner life, and they have no interest in the outside world. There is little to no desire for intimate or social relationships. Patients do not care about social norms and the needs of others, and there is rarely, if ever, an appropriate emotional response to stimuli.
Schizotypal disorder: This involves eccentric speech, behavior, or appearance; unusual perceptions of standard experiences; and unexpected thought patterns. This could manifest as odd beliefs, suspiciousness, and obsessive thoughts. Patients with schizotypal personality disorder tend to avoid social contact and believe other people to be harmful. This is different from schizoid personality disorder, in that people with schizoid personality disorder have no interest in social interaction, while people with schizotypal personality disorder may actively fear meeting other people. People with this condition have a higher-than-average probability of developing schizophrenia later in life.
Antisocial personality disorder: This is one of the better known personality disorders in Cluster B. This condition occurs much more in men than it does in women, and it is infamous for how it causes patients to have no empathy or regard for the feelings of other people. Patients pay no attention to social rules. They are often very aggressive, act without forethought, feel no guilt for their actions, and are completely inflexible in their behavior. People with antisocial personality disorder tend to have criminal records or long histories of being in and out of jail.
Borderline personality disorder: Patients generally struggle to have a sense of their own identity, so they often feel empty and abandoned. People with borderline personality disorder tend to have long histories of intense but short-lived relationships, largely due to the emotional instability, violent outbursts, and threats of suicide that characterize the condition. The term borderline comes from an old theory that the condition was on the “borderline” of neurotic disorders and psychotic disorders. Modern research has theorized that BPD is the result of childhood sexual abuse, and it is more common in women.
Histrionic personality disorder: Similarly, people with histrionic personality disorder base their wellbeing on the approval and attention of other people, resorting to dramatizing (or histrionics) to boost their self-worth. This often looks like an obsessive interest in appearance or inappropriately solicitous behavior. There is a lot of impulse behind these actions, which results in patients putting themselves at risk for exploitation or manipulation. Social and romantic relationships are typically superficial, primarily because patients with histrionic personality disorder are very sensitive to criticism and cannot process rejection or failure in a healthy way. The more rejected a patient feels, the more histrionic they become, and so on.
Narcissistic personality disorder: Patients have a very exaggerated sense of self-importance, believing they are entitled to the admiration of others. There is a deep sense of envy of other people, which surfaces as an expectation that others will be similarly envious of the patient themselves. People with this degree of narcissism are usually not empathetic of others’ feelings and will readily lie to get what they want.
The last group of personality disorders is Cluster C, the avoidant and dependent types.
Avoidant personality disorder: Patients deeply believe that they are socially awkward and unwanted, resulting in a legitimate fear of embarrassment or rejection. They try not to meet other people unless they are absolutely confident of acceptance. This carries over into intimate relationships. People with avoidant personality disorder usually have histories of abusive criticism in early childhood, which manifests as anxiety and avoidance later in life. They struggle to engage fully in social situations because they are hyperaware of the nuances of their own reactions. The greater this awareness, the more inferior they feel; the more inferior they feel, the greater the awareness, and so on.
Dependent personality disorder: Patients with this condition have a deep need to be cared for by others to the point of being completely dependent on others for everyday and important decisions. There is a desperate fear of abandonment, borne from a self-perception of inadequacy; because of this, patients have no sense of personality responsibility and idealize their caregivers as sources of comfort and power. Dependent personality disorder is a Cluster C personality disorder, but patients here often gravitate towards patients with a Cluster B personality disorder because the patients in the latter group crave the high regard they are given by Cluster C patients. Dependent personality disorder patients often appear childlike and helpless with no objective insight into their own strengths and weaknesses.
Anankastic (obsessive-compulsive) personality disorder: This personality disorder is characterized by an excessive obsession with perfectionism, to the point where it inhibits normal functioning. Patients are prohibitively preoccupied with details, lists, rules, organizations, and order, devoting themselves to work to the detriment of rest and relationships. The underlying anxiety behind anankastic personality disorder is a believed lack of control over the world, so patients often overcompensate with the things they can control. This leads to a desperate need to control others, a fear of taking risks or improvising, and no patience for nuance. This likely puts significant strain on relationships with coworkers and family members because of perceived “flaws”, which reinforces the obsessive-compulsive behaviors of the disorder.
Psychology Today clarifies that the characteristics of the generally established variety of personality disorders is “more the product of historical observation than of scientific study.” As a result, patients with a personality disorder will rarely present with symptoms that neatly fit into one category (although this is very possible); a more likely scenario is that the patient will have a mix of symptoms across categories, and a doctor will have to make a determination as to which of the symptoms are most prevalent in order to return a comprehensive diagnosis upon which a treatment plan can be based. As an example, a patient with a Cluster A personality disorder is likely to present with symptoms that cover paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.
Despite how nebulous this can be, personality disorders are important for healthcare professionals because the disorders precipitate mental health disorders, and they can change the presentation and treatment of pre-existing mental health conditions. Even on their own, personality disorders cause significant distress and dysfunction to healthy living, and often require treatment in their own right, let alone as a piece of a larger mental health question.
In 2017, the European Psychiatry published an article on the topic of “The Relationship between Personality Disorders and Substance Abuse Disorders.” Researches noted that the connection between personality disorders and co-occurring substance abuse is “frequently observed” in clinical settings, and studies have found that diagnoses of personality disorders appear to increase the likelihood of the development of other conditions; this includes drug addiction.
Past research has found that anywhere between 65 percent and 90 percent of patients evaluated for substance abuse have at least one co-occurring personality disorder. There appears to be a high degree of overlap between alcohol dependence and Cluster C disorders, and illegal drugs (primarily cocaine) for Cluster B conditions. A review of pre-existing literature on the subject reveals that Cluster B is the category with the most evidence of a connection to substance abuse, perhaps because it is also the category in which the disorders are most likely to make patients act compulsively; this is an important risk factor in the development of an addiction.
Drug and alcohol abuse does not cause personality disorders, but addiction is a significant factor in the development and effects of a number of personality disorders. Innovations in Clinical Neuroscience writes that as many as 66 percent of patients diagnosed with borderline personality disorder have a psychological dependence on drugs, alcohol, or both, so much so that substance abuse and BPD are “common bedfellows.” Similarly, according to the National Institute on Alcohol Abuse and Alcoholism, people with the aggression and lack of empathy of antisocial personality disorder have higher rates of alcohol abuse and alcoholism than the general population.
The overlap speaks to the links between substance abuse and personality disorders. Patients typically tend to relieve the emotional weight of their respective disorders by using drugs or alcohol. For example, patients who have avoidant personality disorder might abuse chemical substances to try and bury their pathological feelings of social incompetence. Patients whose personality disorders leave them with a negligible sense of self-worth might drink to mask the deep emptiness they feel.
Personality disorders can be very difficult to treat because the beliefs and behaviors that they compel in patients are so deeply ingrained that the patients might even refuse to consider that they have a disorder. For example, patients with borderline personality disorder can be hostile and aggressive toward their therapist while also being excessively needy.
Getting patients with any kind of personality to start working their way out of the patterns of personality disorder entails deep psychotherapy sessions. Dialectical Behavior Therapy (DBT), a development of Cognitive Behavioral Therapy, has been touted as a comprehensive treatment for patients with personality disorders. Its connections to Cognitive Behavioral Therapy open up possibilities for treating patients with present with co-occurring substance use disorders.
The Behavior Research and Therapy journal published the results of a study that found that DBT is effective in reducing the symptoms of borderline personality disorder, specifically the depression, stress, and suicidal ideation caused by the disorder. The implications of this success has led to DBT being used to modify behavior in other psychiatric symptoms and in substance use disorder.
Dialectical Behavior Therapy works by teaching patients how to accept emotions that cause them significant distress. This acceptance comes in the form of coping strategies, and practicing mindfulness (being in the moment and not focusing on past traumas). The ultimate goal of DBT is to help the patient accept who they are instead of trying to find validation in other people and to make positive changes in life as part of that acceptance. These concepts also make DBT a useful intervention for patients with personality disorders who have co-occurring substance abuse problem, according to researchers writing in Addiction Science & Clinical Practice.
Behavior modification therapy like DBT is effective in treating personality disorders with co-occurring substance abuse, but it is only part of the picture. Medications may be necessary to further address the anxiety, depression, and obsessive behaviors that come with personality disorders. Examples include:
Psychotherapy and medication will help patients with personality disorders and substance abuse a great deal, but comprehensive treatment of the co-occurring disorders involves ongoing work, usually lasting years. This can entail group and family therapy sessions, aftercare support, and consistent treatment. Put together, these interventions can help those with personality disorders control their symptoms, avoid substance abuse, and focus on their self-care and wellbeing.