Clinical Psychology Review, Vol. 20, No. 2, pp. 235–253, 2000Copyright © 2000 Elsevier Science Ltd.Printed in the USA. All rights reserved0272-7358/00/$–see front matterPII S0272-7358(99)00028-8235BORDERLINE PERSONALITY DISORDER AND SUBSTANCE USE DISORDERS: A REVIEW AND INTEGRATIONTimothy J. Trull, Kenneth J. Sher, Christa Minks-Brown,Jennifer Durbin, and Rachel BurrUniversity of Missouri-ColumbiaABSTRACT. The empirical literature on the comorbidity between borderline personality disorder(BPD) and substance use disorders (SUDs) is reviewed. BPD–SUD comorbidity data obtainedfrom studies published from 1987 to 1997 document the frequent co-occurrence of these diag-noses. Methodological issues and theoretical models for understanding this co-occurrence are dis-cussed. Finally, we present our conceptualization of the relations and interactions of the majorfactors influencing the development of BPD and contributing to the comorbidity between BPDand SUDs. © 2000 Elsevier Science Ltd. KEY WORDS. Borderline personality disorder, Substance use disorders, Comorbidity,Etiology, Theoretical models of comorbidity.BORDERLINE PERSONALITY DISORDER (BPD) and substance use disorders(SUDs) are two forms of psychological problems that are often diagnosed within thesame person. Despite the general acknowledgment of this co-occurrence, to date, asystematic and comprehensive review of this comorbidity is lacking. Further, few havediscussed the various methodological and theoretical explanations for the comorbid-ity. In order to better understand the nature of the observed comorbidity betweenBPD and SUDs, we describe the major features of BPD, discuss major etiological fac-tors that have been associated with BPD, review the existing data on the rates of co-morbidity between BPD and SUDs, and present methodological issues and theoreticalmodels for understanding this co-occurrence.Correspondence should be addressed to Tim Trull, Department of Psychology, University ofMissouri-Columbia, 210 McAlester Hall, Columbia, MO 65211. E-mail: [email protected] T. J. Trull et al.BORDERLINE PERSONALITY DISORDERBPD is a severe personality disorder that develops by early adulthood, and is charac-terized by a lack of control of anger, intense and frequent mood changes, impulsiveacts, disturbed interpersonal relationships, and life-threatening behaviors (AmericanPsychiatric Association, 1994). BPD is the most commonly diagnosed personality dis-order in both inpatient and outpatient settings (Widiger & Trull, 1993). In additionto its prevalence in clinical populations, recent estimates suggest that BPD is relativelyprevalent in nonclinical populations as well (range, 2–4%; Gunderson & Zanarini1987; Swartz, Blazer, George, & Winfield, 1990; Zimmerman & Coryell, 1989).A growing body of evidence suggests that a comorbid BPD diagnosis may serve as anegative prognostic factor in those suffering from a variety of Axis I conditions, includ-ing, for example, anxiety disorders and major depression (e.g., Nurnberg et al., 1989;Shea, Widiger, & Klein, 1992). This is an important finding because the BPD diagnosisrarely occurs in isolation.1 The highest rates of comorbidity occur between BPD andmood, substance use, and non-BPD personality disorders (Widiger & Trull, 1993). Fo-cusing on Axis II comorbidity, it appears that very few BPD patients fail to meet criteriafor another personality disorder (Widiger & Trull, 1993). These findings are consis-tent with the view that BPD represents a level of personality organization/dysfunctionthat cuts across existing diagnostic categories (Kernberg, 1984; Millon, 1981).Substantial levels of impairment characterize BPD. Individuals diagnosed with BPDare prone to attempt suicide, to seek out and utilize health care services, and to reportsignificant levels of functional impairment. Rates of completed suicide for BPD pa-tients are estimated to be between 5 and 7%, and case-based studies of completed sui-cides indicate that BPD is typically the most prevalent Axis II diagnosis (Duberstein &Conwell, 1997). Further, BPD appears to be an independent risk factor for suicidal be-havior over and above what can be accounted for by substance use disorder or otherAxis I psychopathology (Brodsky, Malone, Ellis, Dulit, & Mann, 1997). Studies assess-ing the degree of functional impairment among those with personality disorder fea-tures indicate that those with a BPD diagnosis or features exhibit a greater degree offunctional impairment than participants with other, non-BPD personality disorderfeatures (Hueston, Mainous, & Schilling, 1996; Nakao et al., 1992). Finally, of patientspresenting to primary care physicians, those with BPD features demonstrated one ofthe highest rates of health care utilization over the previous 6 months (e.g., visits to aphysician, emergency room visits, hospitalizations) among those with personality dis-order symptoms (Hueston et al., 1996).Borderline Personality Disorder: Etiology and DevelopmentBefore presenting data on the comorbidity between BPD and SUDs, we briefly over-view several major etiological factors that have been associated with BPD. These arealso relevant to an understanding of the co-occurrence of BPD and SUDs. Although a1Although it is widely acknowledged that BPD rarely occurs in isolation, researchers may notfully appreciate the implications. For example, relevant to the present article, studies addressingthe comorbidity between BPD and SUDs need to take into account the potential influence ofother co-existing disorders (e.g., antisocial personality disorder) that may themselves show highrates of co-occurrence with SUDs.Borderline Personality Disorder and Substance Use Disorders 237number of factors believed to be related to the etiology and development of BPD havebeen presented (e.g., see Paris, 1994; Zanarini & Frankenburg, 1997 for reviews), herewe will focus our discussion on three etiological factors that have received the most at-tention: family history, trauma/abuse, and personality traits.Family history. Family history studies provide potentially important information re-garding the etiology and development of BPD. Typically, these studies assess the prev-alence of a variety of mental disorders (including BPD) in the first-degree relatives ofBPD probands. Rates for disorders in these relatives that are higher than expected bychance (i.e., higher than the base rate in the general population) suggest some etio-logical linkage between these
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