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By Mary Carpenter
WOMAN A makes promises she can’t keep, lies about her accomplishments and veers from manically active to depressed inertia. Woman B can’t stop shopping or partying—once finding herself in a remote bus station with no money to get home. Both women come from upper middle-class families, have degrees from good colleges and work in the arts.
Both women have also struggled with addiction and sought help from AA and rehab programs —but an occasional drink still sends them over the edge. Both have received “dual diagnoses” of Substance Use Disorder along with Borderline Personality Disorder (BPD) —because the latter includes both impulsivity and a need to self-medicate the mood swings, according to the American Addiction Centers website.
“Borderline” refers to symptoms first thought to be “on the border” between neurosis and psychosis, which can include anxiety, paranoid thinking and anger. People with BPD, according to one theory, are born with a hard-wired disposition toward emotional vulnerability, which is exacerbated during an upbringing that “invalidates the child’s emotional responses by ignoring, dismissing, or punishing them,” writes British Columbia psychologist Andrew Chapman.
The treatment recommended by the National Institute on Drug Abuse specifically for people with both BPD and a co-occurring addiction —as well as for other self-harm behaviors—is Dialectical Behavior Therapy (DBT). Despite the complicated name, DBT therapy employs just two opposing goals: to help patients feel better accepted and at the same time to change their behavior. DBT combines validation of a patient’s thoughts and actions with disagreement that these are the best approach to problem-solving. (In the philosophical concept of dialectics, change occurs only in interaction or conflict between two opposing forces.)
Working to help patients regulate intense emotions and improve interpersonal relationships, DBT differs from therapies like Cognitive Behavior Therapy (CBT) in the “kind of change [each creates] for the client,” according to Indianapolis psychologist Aarika V. White. CBT, with its focus on recognizing and changing patterns of thinking and behaving, may be more helpful for depression, anxiety, OCD and phobias.
DBT evolved when interventions for treating suicidal women were so focused on changing their behaviors that patients felt criticized and misunderstood, and often dropped out of treatment altogether. In the late 1980s, University of Washington psychologist Marsha Linehan and colleagues developed a “standard DBT treatment package”—rather than a single treatment method conducted by a practitioner in isolation—that includes weekly individual therapy along with group sessions focused on skills training with the goal of behavior change.
The four main DBT strategies include mindfulness (sample exercise: pay attention to the breath); distress tolerance (sample, run up and down the stairs or move to a new location); interpersonal effectiveness to become more assertive in relationships while respecting yourself and others (sample: acknowledge another’s thoughts and feelings); and emotional regulation (sample: identify how you are feeling and do the opposite—if sad, plan to visit loved ones.)
DBT has the strongest empirical support for treating “parasuicidal women with BPD” but has also helped those with binge eating and other eating disorders, with PTSD, and sometimes with depression—in general, conditions that involve emotional vulnerability as well as behavior issues, such as difficulties with social interaction and substance abuse.
Because personality disorders in general are notoriously unresponsive to treatment, however, the BPD diagnosis can be stigmatizing and is often withheld for as long as possible. Meanwhile, many sufferers receive mood-stabilizing drugs to deal with the often-serious consequences of both the excesses of mania and the worrisome intensity of depression. In addition, many also receive prescriptions for anti-depressants, anxiolytics and anti-psychotics.
“Substance use disorder” can involve any “source which is capable of stimulating an individual.” Addiction characteristics listed in the DSM-5 (the manual for psychological diagnoses) include brain-reward dysfunction, preoccupation, risky use and impaired control— as well as causing significant problems in someone’s life, such as health issues or failure to meet responsibilities.
In the absence of psychotropic drugs, behavioral addictions can include gambling, shopping and social media activity. Food addiction remains controversial because its divergence from food enjoyment is inconsistent, and its effects—direct stimulation of the brain versus simply sensory enjoyment—remain unclear. People with a substance use disorder are twice as likely to have a mood or anxiety disorder—and vice versa.
Relapse rates within the first year following treatment for substance use disorder range between 40 and 60%. Medications can help treat specific addictions—to opioids, alcohol and nicotine —but not to stimulants or cannabis, and not behavioral addictions.
Many substance abuse rehab centers offer DBT or programs that incorporate many of the same behavioral elements. But “helping people change must include each individual finding personal and compelling reasons for change, as well as a pathway they can truly endorse,” according to a DC-area DBT-focused center. “While there are clear and specific tools (e.g., CBT, DBT, mindfulness) to be used in making change, they are not effective unless you have made the often very difficult decision to use them.”
Woman B tried DBT with “mixed feelings/results” but received the most help from a psychiatric PA (physician assistant) who reduced her “tangle of drugs” by half, she said. Woman A spent weeks in a behavior-focused residential rehab program but saw no improvement until she began mood-stabilizing medication and slowly created a wide circle of friends and family who could help her. Both women have regular relapses and require ongoing monitoring and support.
—Mary Carpenter regularly reports on topical issues in health and medicine.
