The Challenge of Treating Co-Occurring Substance Use and Personality Disorders

15 July 2025

When it comes to mental health, nothing is ever black and white. If you've ever tried piecing together a puzzle with missing parts, you’ll understand how complex it can get. Now, imagine doing that while blindfolded—this is what it can feel like to treat co-occurring substance use and personality disorders.

Substance use disorders (SUDs) are already tough to treat on their own. Add personality disorders (PDs) into the mix, and you’ve got a cocktail of complications that can be extremely challenging for both patients and healthcare providers. These two conditions often feed off each other, creating a vicious cycle that’s hard to break. But, don’t worry. There’s light at the end of the tunnel.

In this article, we’re diving into the challenges of treating co-occurring substance use and personality disorders and why a tailored, integrated approach is often the best solution.

What Are Co-Occurring Disorders?

First off, let’s break it down.

Co-occurring disorders, also known as dual diagnosis, refer to the presence of both a mental health condition and a substance use disorder in the same individual. In this case, we're talking about personality disorders and substance use disorders happening side by side.

- A Substance Use Disorder (SUD) refers to the excessive use of drugs or alcohol, leading to significant impairment in daily life.
- A Personality Disorder (PD) involves long-term patterns of behavior, thoughts, and emotions that are significantly different from what’s typically expected in society. These patterns can lead to personal distress or problems in relationships, work, or other areas of life.

Now, it’s not uncommon for people to have both disorders. In fact, research shows that around 50-70% of people with personality disorders also have a substance use disorder. But, why is that?

Why Do Substance Use and Personality Disorders Often Co-Occur?

It’s like asking, “Which came first, the chicken or the egg?” When it comes to co-occurring disorders, it’s not always clear what triggers what. Sometimes, people use substances to cope with the symptoms of a personality disorder. Other times, prolonged substance use can lead to traits that resemble a personality disorder.

Let’s explore some reasons why these two conditions often show up hand-in-hand:

1. Self-Medication

People with personality disorders often experience intense emotional pain, unstable relationships, and a lack of impulse control. Drugs or alcohol can temporarily numb these feelings. Essentially, they’re self-medicating. However, instead of solving the problem, substance use usually makes things worse in the long run.

2. Impulsivity

Many personality disorders, such as Borderline Personality Disorder (BPD) and Antisocial Personality Disorder (ASPD), are marked by impulsive behavior. This lack of impulse control can make individuals more likely to engage in risky behaviors, including substance abuse.

3. Shared Risk Factors

Both personality disorders and substance use disorders may share similar genetic, environmental, and psychological risk factors. Trauma, childhood abuse, neglect, and family history of mental illness or addiction can all increase the likelihood of developing both conditions.

4. Worsening of Symptoms

Substance misuse can exacerbate the symptoms of personality disorders. For example, someone with Paranoid Personality Disorder may become even more suspicious and distrustful under the influence of drugs. This makes treatment incredibly challenging because the symptoms of both conditions are so intertwined.

The Complexities in Treating Co-Occurring Disorders

Here’s where things get complicated. Treating one disorder without addressing the other is like trying to put out a fire with a garden hose—it won’t get the job done. Both conditions influence and worsen each other, making it crucial to treat them simultaneously.

But, that’s easier said than done. Let’s talk about some of the challenges that come with treating co-occurring substance use and personality disorders.

1. Diagnostic Dilemmas

One of the first challenges is figuring out what’s going on. Diagnosing personality disorders can be tricky, especially when substance use is involved. Substance use can mask or mimic the symptoms of personality disorders. For example, someone who is intoxicated might seem more impulsive, aggressive, or emotionally unstable—traits that are also common in personality disorders.

This overlap can make it difficult for healthcare providers to accurately diagnose both conditions. It’s like trying to separate two intertwined vines—you have to be careful not to misidentify the symptoms.

2. Treatment Resistance

People with personality disorders are often resistant to treatment. Why? It’s partly because they may not believe they have a problem, or they might not trust healthcare providers. On top of that, the use of drugs or alcohol can cloud judgment, making it even harder for them to acknowledge the need for help.

It’s like trying to convince someone they need a parachute while they’re in free fall. Until they hit rock bottom, many don’t see the need for intervention.

3. Emotional Instability

Individuals with personality disorders often struggle with emotional dysregulation. This means their emotions can rapidly shift from one extreme to another, making them unpredictable. Add substance use to the mix, and things can spiral out of control quickly. For healthcare providers, this emotional instability can make therapy sessions volatile and difficult to manage.

4. Relapse Potential

The risk of relapse is higher when you’re treating both a substance use disorder and a personality disorder. Why? Well, even if someone manages to get sober, they’re still left with the symptoms of their personality disorder. If these symptoms aren’t addressed, the likelihood of turning back to drugs or alcohol for relief is high. It’s like trying to patch a leaking boat without fixing the hole—you’re bound to sink again.

Effective Approaches to Treatment

So, how do we treat these co-occurring disorders? The key lies in integrated treatment—a comprehensive approach that addresses both issues simultaneously. Here are some effective strategies that have proven to be helpful:

1. Integrated Therapy

Integrated therapy combines treatment for both substance use and personality disorders in a seamless way. Instead of treating them as separate issues, this approach acknowledges the connection between the two and targets both simultaneously.

For example, Dialectical Behavior Therapy (DBT), a type of cognitive-behavioral therapy, is particularly effective for people with Borderline Personality Disorder and co-occurring substance use disorders. DBT teaches skills like emotional regulation, distress tolerance, and mindfulness—tools that help individuals manage both their impulsive behaviors and cravings.

2. Medication-Assisted Treatment (MAT)

In some cases, medication can play an essential role in treating co-occurring disorders. Antidepressants, antipsychotics, or mood stabilizers may be prescribed to help manage the symptoms of personality disorders. Additionally, medications like buprenorphine or naltrexone can be used to reduce cravings and withdrawal symptoms in individuals with substance use disorders.

However, medication should always be part of a comprehensive treatment plan that includes therapy and other support systems.

3. Motivational Interviewing

Given that people with personality disorders are often resistant to treatment, Motivational Interviewing (MI) can be an effective tool. MI is a counseling technique that helps individuals find their own motivation to change. Instead of pushing them into treatment, it helps them understand the impact of their behaviors and encourages them to take responsibility for their recovery.

4. 12-Step Programs and Peer Support

Support groups, like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), can be beneficial for individuals with co-occurring disorders. These groups provide a sense of community and accountability, which can be especially helpful for those who feel isolated due to their mental health struggles.

Peer support groups also allow people to share their experiences with others who understand what they’re going through, offering a lifeline during difficult times.

5. Holistic Approaches

Sometimes, it’s not just about the mind—it’s about the whole person. Adding holistic approaches like yoga, meditation, and exercise into the treatment plan can help individuals manage stress and emotional dysregulation. These activities provide an outlet for coping with emotions in a healthy, substance-free way.

The Road to Recovery Is Long, but Not Impossible

Let’s be real: treating co-occurring substance use and personality disorders is not easy. It’s a long, winding road with plenty of bumps along the way. But, with the right treatment approach, it’s entirely possible for individuals to manage both conditions and live fulfilling lives.

The key is recognizing that both disorders need to be treated simultaneously, with a tailored approach that meets the unique needs of each individual. It’s not about choosing between treating the substance use or the personality disorder—it’s about treating the person as a whole.

If you or someone you know is struggling with co-occurring disorders, know that help is available. While the journey may be challenging, it’s a road worth traveling.