Borderline personality disorder
REVIEW Open Access
Borderline personality disorder and substance use disorders: an updated review Timothy J. Trull*, Lindsey K. Freeman, Tayler J. Vebares, Alexandria M. Choate, Ashley C. Helle and Andrea M. Wycoff
Abstract
For decades, clinicians and researchers have recognized that borderline personality disorder (BPD) and substance use disorders (SUDs) are often diagnosed within the same person (e.g., (Gunderson JG. Borderline personality disorder: A clinical guide. Washington, D.C.: American Psychiatric Press, 2001; Leichsenring et al., Lancet 377:74-84, 2011; Paris J. Borderline personality disorder: A multidimensional approach. American Psychiatric Pub, 1994; Trull et al., Clin Psychol Rev 20:235-53, 2000)). Previously, we documented the extent of this co-occurrence and offered a number of methodological and theoretical explanations for the co-occurrence (Trull et al., Clin Psychol Rev 20:235-53, 2000). Here, we provide an updated review of the literature on the co-occurrence between borderline personality disorder (BPD) and substance use disorders (SUDs) from 70 studies published from 2000 to 2017, and we compare the co-occurrence of these disorders to that documented by a previous review of 36 studies over 15 years ago (Trull et al., Clin Psychol Rev 20:235-53, 2000).
Keywords: Borderline personality disorder, Substance use disorder, Alcohol use disorder, Comorbidity
Background For decades, clinicians and researchers have recognized that borderline personality disorder (BPD) and substance use disorders (SUDs) are often diagnosed within the same person (e.g., [14]). Previously, we documented the extent of this co-occurrence and offered a number of methodological and theoretical explanations for the co-occurrence [4]. In this article, we provide an update on this co-occurrence by reviewing studies published be- tween 2000 and 2017, inclusive, and we compare the co-occurrence rates between BPD and SUDs with our previous review. First, we briefly introduce the distinc- tion between co-occurrence and comorbidity. Next, we provide some background and context on BPD symp- toms and we highlight the conceptual and potential etio- logical overlap of SUDs and BPD. Third, we review and compare the data on the rates of co-occurrence between BPD and SUDs from the present and a previous review [4]. Finally, we discuss the conceptual and clinical impli- cations of this co-occurrence to facilitate future research and treatment.
The issue of co-occurrence and comorbidity Psychiatric diagnostic comorbidity is a broad and com- plex issue, referring to both the co-occurrence of disor- ders within the same person and the covariation of disorders in a population [5]. Further, two distinct dis- eases or clinical disorders diagnosed in the same person represents true diagnostic comorbidity [5, 6]. Establish- ing true comorbidity among syndromes within psych- iatry is challenging given the relatively limited etiological information known, compared to many other conditions which are known to be distinct, and is easily influenced by diagnostic classification systems. Therefore, we focus our review on co-occurrence, or two syndromes exist- ing (i.e., overlapping) within the same individual at the same time, without assuming associations at the etio- logical level. BPD-SUD co-occurrence rates can still pro- vide some clues as to potential shared and distinct etiology, traits, and course.
Borderline personality disorder Borderline personality disorder (BPD), a severe personality disorder that develops by early adulthood, is characterized by emotion dysregulation, impulsive acts, disturbed interpersonal relationships, and suicidal and self-harm behaviors [7]. BPD is the most commonly diagnosed
* Correspondence: [email protected] Department of Psychological Sciences, University of Missouri-Columbia, 210 McAlester Hall, Columbia, MO 65211, USA
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Trull et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:15 https://doi.org/10.1186/s40479-018-0093-9
personality disorder in both inpatient and outpatient settings [2, 8], and recent estimates suggest that BPD is relatively prevalent in nonclinical populations as well (range 23%) [911]. Although BPD is presented as a categorical disorder
(i.e., present versus absent) in the DSM-5 [7], the evidence for dimensional approaches to pathological personality traits, and psychopathology more broadly, have a robust evidence base [12]. There are significant limitations with categorizing BPD, including heterogeneity within the categories, arbitrary cut-points, and high diagnostic co-occurrence [13, 14]. Dimensional approaches are con- sistent with the current state of classification research in the field, and this is also true for BPD. For instance, BPD can be conceptualized as maladaptive variants of general personality traits from the Five Factor Model, primarily represented by high neuroticism, antagonism, and disin- hibition [15]. This is largely consistent with the DSM Al- ternative Model (DSM-AM) representation of BPD [7]. However, given that the studies in this updated review uti- lized the categorical classification of BPD as is currently retained in DSM-5, we will focus on the categorical diag- noses of BPD (and SUDs). Nevertheless, we do discuss trait-based, dimensions that may be relevant to an under- standing of the co-occurrence and comorbidity of BPD and SUDs. Disorders with the highest rates of co-occurrence with
BPD are mood, anxiety, substance use, and non-BPD per- sonality disorders [2, 8, 10]. Considering both personality disorder and non-personality disorder co-occurrence, it appears that very few patients with a BPD diagnosis fail to meet criteria for another psychiatric diagnosis. These find- ings are consistent with the view that BPD represents a level of personality organization/dysfunction that cuts across existing diagnostic categories [16, 17]. Not surpris- ingly, substantial levels of impairment are associated with BPD; individuals diagnosed with BPD are prone to at- tempt suicide, seek and utilize health care services, and re- port significant levels of impairment in personal, role, and social functioning [13, 10].
Co-occurrence with substance use disorders (SUDs) As noted by Trull et al. [4], the co-occurrence of BPD and SUDs can be understood from both methodological and theoretical perspectives. First, the association be- tween these two disorders in studies may be due to methodological artifacts. For example, chronic, excessive use of substances as well as problems due to excessive use are potential indicators of the BPD diagnosis (i.e., the BPD impulsivity criterion [7]). To address this po- tential artifact, researchers have examined co-occurrence independent from these shared features and established that substantial co-occurrence remains (e.g., see [18, 19]). This suggests that co-occurrence between the two
disorders is not primarily a function of symptom overlap. Another potential methodological problem in assessing this co-occurrence is that many studies of substance-using sam- ples are cross-sectional, and the active or withdrawal phases of substance use are characterized by features that resemble criteria of BPD (e.g., affective instability, interpersonal prob- lems [7]). Thus, it is critical that assessors establish the experience of these BPD symptoms outside of any intoxica- tion or withdrawal phase of substance use. Finally, the co-occurrence may be primarily due to a shared third vari- able that is etiologically relevant to both disorders (e.g., childhood trauma, family history of disinhibitory psycho- pathology). Therefore, it is crucial to assess individuals for relevant third variables to rule out this potential explanation. Relatedly, one disorder may be more likely to develop from the other (or vice versa) or the two disorders may recipro- cally affect the maintenance of the other. Cross-sectional re- search designs cannot adjudicate the direction of causal influence; only longitudinal studies can address this issue. Concerning theoretical influences on co-occurrence,
both emotion dysregulation as well as impulsivity figure prominently in etiological accounts of both disorders [20]. For example, several criteria for BPD reference negative affectivity and affective instability (e.g., chronic feelings of emptiness, affective instability, anger dysregu- lation [7]). According to major theories of SUDs, emo- tion dysregulation also plays a role in the development of excessive substance use and problems related to use [20, 21]. This may be most pronounced in later stages of addiction that are characterized by withdrawal and heightened negative affect [22]. Specifically, the use of substances may be an attempt to regulate negative emo- tions, through a negative reinforcement process, and coping with negative affect is one of the leading motiva- tions relevant to substance use (e.g., [23]). As for impul- sivity, this major personality feature of BPD can lead to a number of negative consequences including substance abuse and dependence. Etiological theories of SUDs also implicate impulsivity, especially in the early stages of addiction, and there is evidence that those higher in im- pulsivity may be more likely to experience tension re- duction following substance use (i.e., a pharmacological vulnerability [20, 24]). In addition to examining the co-occurrence of BPD and SUDs, the examination of underlying factors like emotion dysregulation and impul- sivity that cut across these disorders can guide research in assessing shared etiology, treatment, and clinical course. With these issues in mind, we now turn to our updated review of the co-occurrence of BPD and SUDs.
Method Search protocol To obtain a current estimate of the co-occurrence be- tween SUDs and BPD we conducted a comprehensive,
Trull et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:15 Page 2 of 12
systematic literature search in English language journals from 2000 to 2013 (inclusive), with an updated search for articles from 2014 to 2017 (inclusive). A review of the articles from the initial search has been published [25]. For both the initial and updated search, search terms combined (borderline personality disorder OR BPD) with any of the following: (substance OR sub- stance use disorder OR abuse OR dependence OR alco- hol OR alcohol use disorder). The term structured interview was an option to refine search results. Searches queried PubMed and PsycINFO. In the up- dated search, Google Scholar was also queried. We reviewed titles and abstracts and evaluated articles that were returned from searches. We included the 40 studies from the initial search (20002013 [25]) and another 30 studies from our updated search (20142017). See Fig. 1 for PRISMA Flow Diagram of study selection and exclu- sion process [26].
Inclusion and exclusion criteria Inclusion criteria required each study to (a) use structured interviews using diagnostic criteria from the DSM-IV or DSM-5 to diagnose BPD, (b) use structured interviews using diagnostic criteria from the DSM-IV or DSM-5 to diagnose SUDs or sample adults in current treatment for
SUDs, and (c) present sample characteristics such that co-occurrence rates between BPD and SUDs could be cal- culated. We excluded studies that had constraints on samples such that other comorbidities were excluded in original samples (i.e., no current substance use, no bipolar disorder, no other Axis I disorders, etc.). We also excluded studies that recruited specifically for the co-occurrence between BPD and SUDs. In the event that multiple articles reported on the
same sample of participants, we included only the article with the largest sample size. Other articles with smaller subsets of the larger sample were excluded to avoid double counting such data.1 In total, data from 70 studies are reported here in Tables 1 and 2.
Results Borderline personality disorder among persons with substance use disorders Table 1 presents the rates of BPD diagnoses in those with SUDs, focusing on studies that include a SUD index sample that provides a count of individuals who were also diagnosed with co-occurring BPD. Studies are sorted and presented, in order, by setting: (a) solely in- patient; (b) solely outpatient; (c) forensic; (d) commu- nity; or (e) a combination of sampling methods.
Fig. 1 PRISMA Flow Diagram
Trull et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:15 Page 3 of 12
Table 1 Prevalence of comorbid BPD in individuals with SUD
Reference Sample Diagnostic Instrument
N with SUD % female Mean Age (SD)
N with BPD (%)
Anestis, Gratz, Bagge, & Tull, 2012 [40]
Inpatient – C SCID-I/P; DIPD-IV
176 35.8 36.12 (10.33) 53 (30.1)
Bardeen et al., 2014 [41] Inpatient (cocaine dependence) – C
DIPD-IV 58 45 44.5 (6.6) 22 (38.0)
Bornovalova et al., 2008 [42]
Inpatient – C SCID 76 32.9 42.2 (8.2) 24 (31.6)
Bottlender, Preuss, & Soyka, 2006 [43]
Inpatient (alcohol dependence) – C
SCID-II 237 18.1 42.0 (?-) 42 (17.9)
Dixon-Gordon, Tull, & Gratz, 2014 [44]
Residential SUD – C SCID-I; DIPD-IV
246 36.2 35.6 (10.1) 83 (33.7)
Dunsieth et al., 2004 [45]
Residential (sex offenders without paraphilias) – C
SCID 26 0.0 39.0 (6.1) 4 (15.4)
Gonzalez, 2014 [46] Inpatient Detoxification Unit – C
PAS 53 45.3 38.66 (8.45) 11 (21)
Gratz & Tull, 2010 [47] Inpatient (cocaine dependence) – C
SCID-IV; DIPD-IV
61 46.0 44.45 (7.05) 24 (39)
Kopetz et al., 2014 [48] Residential SUD – C SCID-I; SCID-II
211 32 45 (7.05) 58 (27.49)
Krieger et al., 2016 [49] Inpatient – C SCID-I; SCID-II
101 30.7 40.3 (12.6) 12 (11.9)
Modestin et al., 2001 [50]
Inpatient (opioid dependence) – C
SCID-II 100 0.0 29.7 (?-) 51 (51.0)
Preuss et al., 2001 [51] Inpatient (alcohol dependence) – C
SCID 135 20.7 41.8 (8.8) 23 (17.0)
Ross et al., 2003 [52] Inpatient – C SCID 100 19.0 37.1 (9.3) 39 (39.0)
Tull, Gratz, & Weiss, 2011 [53]
Inpatient – C DIPD-IV; SCID-I/P
94 44.7 36.0 (10.07) 31 (33.0)
Vergara-Moragues, González-Saiz, Lozano, & García, 2013 [54]
Inpatient (cocaine dependence) – C
PRISM 218 8.7 30 (13.8)
Webber et al., 2015 [55] Inpatient – C SCID-II 235 53 30.06 (8.41) 120 (51.3)
Yang, Liao, Wang, Chawarski, & Hao, 2015 [56]
Inpatient (heroin dependence) – C
SCID-I; SCID-II
1002 30.04 33 (6.8) 226 (22.6)
Zikos, Gill, & Charney, 2010 [57]
Inpatient (AUDs) – C SCID-I; SCID-II
138 33.0 44 (9.7) 19 (13.0)
Ball, 2007 [58]; Ball & Cecero, 2001 [59]
Outpatient (opioid dependence) C
SCID-II 78 54.0 (of those with PDs)
37.4 (5.9) 23 (29.5)
Barral et al., 2017 [60] Outpatient – C SCID-I; SCID-II
937 23.5 37.83 (10.05) 128 (13.7)
Becker, Añez, Paris, & Grilo, 2010 [61]
Outpatient (AUD-L) – L S-DIPD-IV 130 31.0 37.4 (10.5) 39 (30.0) – C
Casadio et al., 2014 [62] Outpatient – C SCID-II 320 26.3 40.9 (10.8) 48 (15)
Dammann et al., 2017 [63]
Outpatient (opioid dependence) – C
SCID-II 26 34.6 41 (6.8) 3 (11.5)
DeMarce, Lash, Parker, Burke, & Brambow, 2013 [64]
Outpatient – C SCID-I; SCID-II
183 0.04 50.1 (8.3) 16 (8.7)
Echeburua et al., 2005 [65]
Outpatient (alcohol dependence) – C
SCID-I IPDE
30 0.0 0 (0.0)
Echeburua, et al., 2007 [66] Outpatient (alcohol dependence) – C
SCID-I; IPDE
158 34.8 43.4 (?-) 8 (5.1)
Hunter-Reel, Epstein, Outpatient (AUD) C SCID-II 102 100 45.05 (9.19) 6 (5.88)
Trull et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:15 Page 4 of 12
Across settings Overall, the co-occurrence rates between current SUDs2
and current BPD in these studies ranged from 0 to 53.19%. Across all studies reporting current diagnoses, a total of 10,086 individuals were sampled with SUDs (or
receiving treatment for addiction), and 2228 (22.1%) of these individuals were also diagnosed with BPD. Please note that, throughout the rest of this article, we use the term % with xxx to indicate the total number of index (co-occurring) cases divided by the total number of
Table 1 Prevalence of comorbid BPD in individuals with SUD (Continued)
Reference Sample Diagnostic Instrument
N with SUD % female Mean Age (SD)
N with BPD (%)
McCrady, & Eddie, 2014 [67]
Kidorf et al., 2015 [68] Outpatient (opioid dependence) – C
SCID-I; SCID-II
125 53.6 39.1 (10.2) 34 (27.2)
Kok, de Haan, Wieske, de Weert, & de Jong, 2017 [69]
Outpatient – C SIDP-IV 102 19.6 40.7 (10.8) 2 (2)
Palmer et al., 2003 [70] Outpatient (opioid dependence) – C
SCID 107 53.0 43.1 (6.6) 40 (37.4)
Ralevski et al., 2007 [71] Outpatient (alcohol dependence) – C
SCID 225 2.7 47.0 (?-) 68 (30.2)
Zimmerman et al., 2005 [72]
Outpatient (MIDAS) – C SCID-I; SIDP-IV
85 15 (17.6)
Chapman & Cellucci, 2007 [73]
Incarcerated – C TAAD; SCID-II
58 with Alcohol Dependence 73 with Drug Dependence
100 14 (24.1) of those with alcohol dependence 21 (28.8) of those with drug dependence
Grella et al., 2008 [74] Incarcerated (prison- based substance abuse treatment program) – C
SCID-II 280 35.0 34.8 (?-) 37 (13.2)
Mir et al., 2015 [75] Incarcerated – C MINI; SCID-II
93 100 16 (17)
Fenton et al., 2011 [76] Community (NESARC) – C AUDADIS-IV 613 32.5 138 (22.49) of those with drug dependence
Whitbeck, Armenta, & Welch-Lazoritz, 2015 [77]
Homeless community – C CIDI; DIPD-IV
47 100 38.9 (10.22) 25 (53.19)
Comin et al., 2016 [78] Outpatient + Inpatient Detoxification Unit (cocaine dependence) – C
PRISM 143 18.18 34.28 (8.01) 34 (23.8)
Daigre et al., 2015 [79] Clinicala – C EuropASI; SCID-II
512 24.1 38.8 (10.1) 66 (12.9)
Hasin et al., 2006 [80] Inpatient & outpatient – L PRISM-IV 285 46.0 36.3 (8.8) 56 (19.5) – L
Malik, Chand, Marimuthu, & Suman, 2017 [81]
Inpatient & outpatient (AUD) – C
MINI; SCID-II
35 100 38.51 (7.42) 6 (17)
Ross et al., 2005 [82] Outpatient, residential, community (heroin dependence) – C
CIDI 825 35.0 29.5 (7.8) 388 (47.0)
Rubio et al., 2007 [83] Inpatient & outpatient (alcohol dependence) – C
SCID 247 0.0 40.3 (?-) 29 (11.7)
Torrens et al., 2004 [84] Inpatient & outpatient – C SCID 105 31.0 33.3 (7.7) 7 (6.7)
Torrens et al., 2004 [84] Inpatient & outpatient – C PRISM-IV 105 31.0 33.3 (7.7) 12 (11.4)
Wapp et al., 2015 [85] Inpatient & outpatient – C SCID-II; MINI 1205 47.1 35.6 (9.9) 172 (14.3)
NR denotes studies in which the raw count of individuals with BPD was not provided C Current diagnoses were reported. L Lifetime diagnoses were reported AUDADIS Alcohol Use Disorder and Associated Disabilities Interview Schedule, CIDI Composite International Diagnostic Interview, DIPD Diagnostic Interview for DSM-IV Personality Disorders, EuropASI European Addiction Severity Index, IPDE International Personality Disorder Examination, MINI Mini-International Neuropsychiatric Interview, PAS Personality Assessment Schedule, PRISM Psychiatric Research Interview for Substance and Mental Disorders, SCID Structured Clinical Interview for DSM-IV Disorders, SIDP-IV Structured Interview for DSM-IV Personality, TAAD Triage Assessment for Addictive Disorders aDid not specify if the sample was inpatient or outpatient
Trull et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:15 Page 5 of 12
T a b le
2 Pr ev al en
ce o f co -m
o rb id
SU D in
in d iv id u al s w it h BP D
Re fe re n ce
Sa m p le
D ia g n o st ic
In st ru m en
t N w it h
BP D
% fe m al e
M ea n A g e (S D )
N w ith
SU D (% )
Ta d i? et
al ., 20 09
[2 7]
In p at ie n t C ,L
M -C ID I; SC
ID -I;
SC ID -II
16 9
70 .0
32 .9 (9 .1 )
47 (2 8. 0)
– C
11 5 (6 8. 0)
– L
A sn aa n i et
al ., 20 07
[8 6]
O u tp at ie n t – C
SC ID ;S ID P- IV
23 7
72 .6
31 .6 (8 .6 )
10 5 (4 4. 3)
C h en
et al ., 20 07
[8 7]
O u tp at ie n t – C
SC ID -I; SC
ID -II ;I PD
E 18 4
10 0
31 .0 (8 .0 )
82 (4 4. 6)
C o m to is et
al ., 20 03
[8 8]
O u tp at ie n t – L
SC ID -I; PD
E 29
76 .0
25
(8 6. 2)
Fr ia s et
al ., 20 17
[8 9]
O u tp at ie n t – C
SC ID -I; SC
ID -II
10 2
91 .2
35 .9 9 (1 1. 9)
35 (3 4. 3)
H id al g o -M
az ze i, W al sh ,R o se n st ei n ,&
Z im m er m an ,2 01 5 [9 0]
O u tp at ie n t (M
ID A S)
– L
SC ID ;S ID P- IV
38 9
71 .7
32 .3 2 (1 0)
A U D s = 24 8 (6 3. 75 )
St im
u la n t u se
d is o rd er s = 11
(2 .8 3)
C an n ab is u se
d is o rd er s = 12 1 (3 1. 11 )
C o ca in e u se
d is o rd er s = 61
(1 5. 68 )
H al lu ci n o g en
s u se
d is o rd er s = 17
(4 .3 7)
O p io id
u se
d is o rd er s = 28
(7 .2 )
Se d at iv e u se
d is o rd er s = 16
(4 .1 1)
O th er
SU D s = 4 (1 .0 3)
Po ly su b st an ce
u se
d is o rd er = 38
(9 .7 7)
A n y SU
D = 28 1 (7 2. 24 )
Jo h n so n et
al ., 20 03
[9 1]
O u tp at ie n t – C
SC ID -I; D IP D -IV
24 0
72 .9
31 .9 (? -)
15 7 (6 5. 4)
La n e, C ar p en
te r, Sh er ,&
Tr u ll, 20 16
[9 2]
O u tp at ie n t – C
SC ID -I; SC
ID -II
56
18
(3 2. 1)
M ar az
et al ., 20 16
[9 3]
O u tp at ie n t – C
A U D IT ;S C ID -II
11 0
54 .5
34 .6 (9 .8 )
49 (4 4. 5)
w it h A U D
25 (2 2. 7)
w it h D U D
N ea cs iu
et al ., 20 15
[9 4]
O u tp at ie n t C ,L
SC ID -I; SC
ID -II
20
35 .4 (1 1. 6)
2 (1 0)
– C
17 (8 5)
– L
Pe rr o u d et
al ., 20 16
[9 5]
O u tp at ie n t – L
SC ID -II ;D
IG S
11 6
91 .4
31 .5 (9 .7 4)
67 (6 2)
w it h su b st an ce
d ep
en d en
ce 65
(6 0. 2)
w it h al co h o l d ep
en d en
ce
Ri ih im äk i, Vu o ril eh to ,&
Is o m et sä ,2 01 3
[9 6]
O u tp at ie n t – C
SC ID -I/ P; SC
ID -II
35 86 .0
37 .3 (1 3. 7)
10 (2 9. 0)
Tu rn er
et al ., 20 15
[9 7]
O u tp at ie n t – L
SC ID -I; SC
ID -II
46 a
91 .3
31 .5 5 (1 0. 36 )
32 (6 9)
w it h an y SU
D 23
(5 0)
w it h A lc o h o l A b u se
o r
D ep
en d en
ce 21
(4 5. 5)
w it h Su b st an ce
A b u se
o r
D ep
en d en
ce
W el ch
& Li n eh
an ,2 00 2 [9 8]
O u tp at ie n t – C
SC ID -I; PD
E; SC
ID -II
12 2
10 0
31 .0 (? -)
47 (3 5. 5)
w it h D U D
C h ap m an
& C el lu cc i, 20 07
[7 3]
In ca rc er at ed
– C
TA A D ;S C ID -II
50 10 0
14
(2 8. 0)
w it h A U D
21 (4 2. 0)
w it h D U D
W et te rb o rg ,L an g st ro m ,A
n d er ss o n ,&
En eb
rin k. ,2 01 5 [9 9]
Pr o b at io n / Pa ro le – C
SC ID -II ;M
IN I
11 0
33 .3 (7 .9 )
7 (6 3. 6)
w it h A U D
8 (7 2. 7)
w it h D U D
Ba sc h n ag el et
al ., 20 13
[1 00 ]
C o m m u n it y – C
SI D P- IV ;C
D IS ;M
IN I
51 80 .0 – o f th o se
w ith
SU D
38 .0 (9 .9 ) – o f th o se
w it h
SU D
35 (6 9. 0)
C ar p en
te r, W o o d ,&
Tr u ll, 20 16
[1 01 ]
C o m m u n it y (N ES A RC
) – L
A U D A D IS -IV
10 30
A lc o h o l u se
d is o rd er = 60 4 (6 3. 08 );
Trull et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:15 Page 6 of 12
T a b le
2 Pr ev al en
ce o f co -m
o rb id
SU D in
in d iv id u al s w it h BP D (C o n tin u ed )
Re fe re n ce
Sa m p le
D ia g n o st ic
In st ru m en
t N w it h
BP D
% fe m al e
M ea n A g e (S D )
N w ith
SU D (% )
A m p h et am
in e u se
d is o rd er = 90
(9 .4 3%
); C an n ab is u se
d is o rd er = 28 1 (3 0. 98 % );
C o ca in e u se
d is o rd er = 14 8 (1 6. 73 % );
H al lu ci n o g en
u se
d is o rd er = 75
(9 .6 7%
); In h al an t u se
d is o rd er = 25
(2 .9 3%
); O p ia te
u se
d is o rd er = 11 4 (1 3. 23 % );
Se d at iv e u se
d is o rd er = 86
(8 .4 3%
); Tr an q u ili ze r u se
d is o rd er = 69
(7 .8 8%
)
To m ko ,T ru ll, W o o d ,&
Sh er ,2 01 4
[1 0]
C o m m u n it y (N ES A RC
-R ev is ed
) –
L A U D A D IS -IV
10 30
57 .3
41 .8
80 5 (7 8. 2)
W id o m ,C
za ja ,&
Pa ris ,2 00 9 [1 02 ]
C o m m u n it y C
D IP D -R ;D
IB -R ;
D IS -II I-R
11 2
70 (6 2. 7)
w it h A U D
62 (5 5. 5)
w it h D U D
Ba ro n e, Fo ss at i, & G u id u cc i, 20 11
[1 03 ]
In p at ie n ts & o u tp at ie n ts – C
SC ID ;S C ID -I
14 0
61 .0
32 .3 9 (9 .5 4)
40 (2 9. 0)
w it h SU
D 40
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en t fo r A d d ic ti ve
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Trull et al. Borderline Personality Disorder and Emotion Dysregulation (2018) 5:15 Page 7 of 12
those receiving the other diagnosis, across all studies (i.e., a weighted average). Ten studies specifically reported the co-occurrence
rate of those with current BPD among individuals diag- nosed with current AUD/alcohol dependence, ranging from 0 to 30.2% (total n across studies = 1495; % with BPD = 16.99%). Four studies sampled those with current cocaine dependence and reported a co-occurrence rate with current BPD between 13.8 and 39% (total n across studies = 631; % with BPD = 22.03%). Seven studies sam- pled those with opioid dependence (including heroin de- pendence) and reported a co-occurrence rate with BPD between 11.5 and 51% (total n across studies = 2263; % with BPD = 33.80%).
Within settings Eighteen of the studies reported in Table 1 recruited ex- clusively from inpatient or residential treatment settings. Out of the overall sample reported in these studies with a current SUD or currently in treatment for addiction (n = 3267), 26.7% of individuals also met criteria for current BPD. Of the 14 studies that recruited exclusively from outpatient settings (total n = 2478), 15.8% also met criteria for BPD. Eight of the studies reported in Table 1 recruited participants from a combination of different settings (inpatient, outpatient, and/or community). These studies were not counted in the estimates of the inpatient and outpatient samples alone. Of the 3177 total individuals with current SUDs sampled in these combined setting studies, 23.5% were also diagnosed with BPD. Finally, three studies reported the co-occurrence between current SUDs and current BPD in forensic samples (total n = 446; 16.6% with BPD) and two studies reported the current co-occurrence rates in community samples (total n = 660; 24.7% with BPD).
Substance use disorders among persons with borderline personality disorder Table 2 presents the rates of SUDs in those with BPD, focusing on studies including a BPD index sample, as well as a count of individuals who were also diagnosed with concurrent SUDs. Once again, we organized studies by setting: solely inpatient, solely outpatient, forensic, community, and a combination of sampling methods.
Across settings Co-occurrence rates between BPD and current SUDs re- ported in these studies (excluding those reporting on AUD specifically) ranged from 10 to 72.7% (% with current SUD = 45.46%). Rates between BPD and lifetime SUDs reported in these studies ranged from 45.5 to 86.2% (% with lifetime SUD = 75.28%). Eleven studies reported the co-occurrence between BPD and AUD spe- cifically, ranging from 28 to 63.6% for current AUD
diagnoses (total n across studies = 761; % with current AUD = 46.39%) and 50% to 63.7% for lifetime AUD diag- noses (total n across studies = 1581; % with lifetime AUD = 59.46%). Finally, four studies reported the rates of a current drug use disorder (DUD;
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