Which of the followings are common disorders that tend to be comorbid with borderline personality disorder?

Cross-sectional and longitudinal evidence

Cluster B PDs have been the main topic of study for most cross-sectional studies investigating the relationship between SUDs and PDs. In the National Epidemiologic Survey on Alcohol and Related Conditions, ASPD and BPD were found to be comorbid with SUDs at an odds ratio higher than all other psychiatric disorders investigated [Grant et al., 2016]. Compared to schizotypal, avoidant, and obsessive-compulsive PDs, BPD was more frequently comorbid with SUDs in the Collaborative Longitudinal Personality Disorders Study [McGlashan et al., 2000]. In partial explanation of these differences in the comorbidity of PDs with SUDs, a twin study on cannabis use disorder found that the genetic risk associated with ASPD and BPD traits explained 32%–60% of the variance, while avoidant and dependent PD traits explained 16% and 11%, respectively [Gillespie et al., 2018]. From a symptom perspective, Cluster B PD symptoms are uniquely associated with alcohol use disorder [AUD] beyond what is accounted for by major personality traits [Trull et al., 2004]. SUDs also appear to run in families affected with BPD [Ruocco et al., 2018]. Importantly, the high level of comorbidity between SUDs and BPD does not appear to be due to overlapping symptoms [i.e., problematic substance use as an indicator of impulsivity in BPD; Trull et al., 2018].

Cross-sectional studies, however, are limited in the inferences that can be drawn about the causal link between SUDs and PDs. There is good reason to suspect that PDs could precede the development of SUDs: PDs have an early onset [i.e., at least by early adulthood] and are pervasive, inflexible, enduring, and distressing and/or impairing [American Psychiatric Association, 2013]. Given its intransigent quality, it is reasonable to surmise that the pathological personality traits underlying PDs may predispose people for addiction. Only a small number of studies have investigated longitudinal relationships between the onset of SUDs and PDs, but in those that have, a nuanced relationship between SUDs and PDs is evident. Most research findings suggest that the presence of PDs increases the likelihood of SUD onset and contributes to its maintenance. In a multiyear longitudinal study, specific PDs [i.e., BPD, ASPD, and schizotypal PD] were positively related to SUD persistence, while mood and anxiety disorders were not [Fenton et al., 2012]. Another study found that PDs are the comorbid disorders most related to the transition from substance use initiation to dependence, although the confidence intervals overlapped with that of mood disorders [Lopez-Quintero et al., 2011]. Compared to obsessive-compulsive PD, BPD has been shown to be more related to increased vulnerability for the onset of substance dependence, a finding that is particularly interesting given that this was true irrespective of its remission status [Walter et al., 2009]. A longitudinal study based on data contained in the Taiwan National Health Insurance Research Database found that a PD diagnosis conferred the highest risk for a subsequent diagnosis of a SUD, above that associated with affective psychoses, neurotic disorders, schizophrenia, and adjustment reaction [Chiu et al., 2018].

In summary, these findings underscore the high diagnostic comorbidity between SUDs and PDs. Not only are Cluster B PDs especially comorbid with SUDs but also the presence of these diagnoses appears to connote a vulnerability to later developing a SUD. Both the cross-sectional and longitudinal associations between Cluster B PDs and SUDs suggest that common individual difference factors [e.g., symptom dimensions, personality traits, and neurocognitive variables] cutting across the diagnoses could account for their strong associations.

Antisocial Personality Disorder

One of the two Cluster B personality disorders that appear to have a genetic component, the antisocial personality often begins with signs in childhood, including lying, stealing, truancy, vandalism, fighting, running away from home, and cruelty. Adult signs are the failure to honor obligations, failure to conform to norms, and repeated antisocial acts. The antisocial personality appears unable to tolerate boredom and may be depressed. Individuals may also engage in domestic violence or criminal acts. Their self-image is that of a rule-breaker where life is hostile, and they thrive on defiance. Their fictitious goal is to successfully defy the world as their highest obligation is to the self, and rules prevent getting their needs met. Their method is that “might makes right,” and they have a total lack of empathy for others. Three to four times more common in males, the impairments of the antisocial personality are dysphoria, substance abuse, and inability to sustain lasting close, warm, responsible relationships.

Personality disorders

Undiagnosed personality disorders are common in those with chronic headaches. Common personality disorders and personality traits observed are Cluster B personality disorders [borderline personality, histrionic personality, anti social personality and narcissistic personality] and Cluster C personality disorders [dependent personality, avoidant personality and obsessive-compulsive personality]. Patients with Cluster B and C personality disorders are more prone to have co-morbid headache. These individuals develop maladaptive behavioral patterns to cope with day to day stressors. Those who have a history of childhood physical or sexual abuse have difficulty trusting others and have strained relationships. Such abuse can manifest as anger and some exhibit self harming behavior when under stress. They are also prone to mood swings. Among the Cluster C group, anxiety related symptoms predominate. Free floating anxiety and their reaction to stress are seen with headache. The personality disorder group generally shows changes in the manifestations of symptoms according to the environment.

Influence of the Presence of Multiple Psychiatric Diagnoses on the Threshold

Comorbid conditions that increase the risk for attempted suicide include alcohol abuse, substance abuse, posttraumatic stress disorder, and cluster B personality disorders. In depressed inpatients, these conditions are more common among suicide attempters.

Studies have suggested that when alcoholism and depression are comorbid, suicide attempt risk is greatly increased, even when the presence of an antisocial personality disorder or other personality disorders are controlled for. Furthermore, depressed alcoholics usually report more suicidal ideation than nonalcoholic depressed patients, even when the severity of other depressive symptoms is similar. Apart from the biological pathways previously noted, other mechanisms may mediate the relationship between alcohol and suicide. For example, alcoholism may lead to unemployment, financial problems, and interpersonal problems. Psychologically, it may increase loneliness and aggression and it may inhibit coping mechanisms, all of which may lower the threshold for suicidal behavior.

Suicide attempts are also reported to be more common in depressed patients with comorbid borderline personality disorder [BPD] than in depressed patients without BPD. Moreover, subjects with major depression and comorbid borderline personality disorder are more likely to make multiple suicide attempts, and the attempts are no less medically damaging than those made by patients with major depression alone. Thus, the potential lethality of suicide attempts in patients with comorbid disorders and/or BPD should not be underestimated.

Posttraumatic stress disorder [PTSD] is frequently comorbid with depression, and when they co-occur the risk for suicidal behavior is enhanced. The relationship between PTSD and suicidal behavior appears to be mediated by the presence of cluster B personality disorder [CBPD], with both PTSD and CBPD arising as a result of earlier traumatic experiences. The assessment and treatment of comorbid conditions such as PTSD and CBPD in the context of depression may contribute to the reduction of suicide risk in this vulnerable population.

Differentiating mood from personality disorders

The personality disorders have many similarities to, and in some ways blend with and modify expression of, primary Axis I disorders. Similar to BPAD, cluster B personality disorders present with significant mood instability, impulsivity, and irritability, and may even have significant anxiety that can sometimes be misinterpreted by patients as “racing thoughts” [a cardinal symptom of BPAD] [Clark et al., 1994]. However, in the context of personality disorders, racing thoughts [although upsetting] are not as disorganized, nor are they associated with significant pressured speech, decreased need for sleep, or episodic euphoria seen in BPAD. Personality disorders can also be characterized by an enduring sense of emptiness and fractured sense of identity [American Psychiatric Association, 2000]. The stress these “existential” symptoms generate may be greatly exacerbated by the presence of AUD, characterized by futile “self-medication” of painful and seemingly immutable affects [Colder, 2001]. Indeed, manifestations of mood instability in externalizing personality disorders and BPAD, combined with shared phenomenologic, developmental, and genetic features, may all reflect common neurobiologic underpinnings, i.e., these conditions may represent different degrees of expression of a unified underlying pathogenesis [Akiskal et al., 1985].

Comparable to the close relationship of BPAD to cluster B personality disorders, elements of MDD are shared with cluster C personality disorders [Clark et al., 1994]. Cluster C individuals often have high levels of anxiety that can progress to worsening mood [Clark et al., 1994]. A “depressed” mood in this context, however, does not represent true MDD unless that depression clearly extends beyond an acutely stressful event and is expressed with some consistency throughout the entire depressive episode [American Psychiatric Association, 2000]. Even so, as with patients with other forms of anxiety/depression, the presence of stressful life events requires close attention in the AUD patient, since such acute stresses represent a high risk for self-medication [Colder, 2001]. Furthermore, as with cluster B and BPAD, the nature of cluster C and depression are pathophysiologically closely related and have been found to be mediated by shared neurobiologic [impaired monoaminergic neurotransmission] and psychosocial mechanisms [Cloninger et al., 1993].

Therefore, given the significant neurobiologic relationship between them, the presence of personality traits or a disorder should not exclude the possibility of a related mood disorder, as mood and personality are strongly intertwined [Skodol et al., 1999]. Even so, the clinician must clarify that patients with a personality disorder truly warrant an additional mood diagnosis, especially if AUD is also present. This is because the appropriate treatment for personality disorders is often different, with psychopharmacology playing much less of a role than psychotherapy [Evershed, 2011].

15.7 Psychiatric co-morbidity

A critical aspect of the effective treatment of substance use disorders is to identify and treat psychiatric co-morbid disorders. Some co-morbid psychiatric problems are more common in women [46]:

Bipolar disorders

Panic disorder

PTSD

Cluster B personality disorders

Bulimia

Depression

In addition, genetic markers have been identified with a number of psychiatric disorders in which there is a higher incidence of substance use [47]. They include:

Low P3 amplitude [schizophrenia, ADHD]

Conduct disorder [CD]

Antisocial personality [ASPD]

Decrease in dopamine receptor density [D2]

Serotonin [5-HT] systems

Pharmacologic treatment of these disorders enhances recovery from substance use and also poses additional problems for the fetus including need for treatment of the neonate in special intensive care units for symptoms of withdrawal [48]. This is especially true for benzodiazepines, which have a higher rate of teratogenicity and withdrawal, especially when combined with alcohol [49]. Risks and benefits of pharmacologic treatment are most important when treating co-morbidity in pregnancy.

5.03.5.6.4 Parental Characteristics

Given the unique stressors and dysfunction often seen in families of youth with bipolar spectrum disorders [West et al., 2014], the moderating effects of parental environment on treatment outcomes have been examined. Children of parents with lower incomes and higher baseline depressive symptoms showed greater improvement in depressive symptoms in a randomized study comparing CFF-CBT to TAU [Weinstein et al., 2015]. In terms of predictors of treatment responses to MF-PEP, children [ages 8–12 years] of parents with Cluster B personality disorder symptoms exhibited smaller improvements in mood symptoms [MacPherson et al., 2014]. A separate RCT comparing the relative efficacy of FFT for adolescents [FFT-A] to enhanced usual care found that adolescents [ages 13–17 years] in FFT-A whose parents were more openly critical, hostile, and emotionally overinvolved showed greater reductions in both depressive and manic symptoms than adolescents in enhanced usual care [Miklowitz et al., 2009]. This difference in outcomes between FFT-A and enhanced usual care was not found among adolescents whose parents were not openly negative, signaling the efficacy of FFT-A particularly for families experiencing greater emotional distress. In a trial of CFF-CBT for pediatric bipolar spectrum disorder, high parental stress predicted drop out, whereas low baseline parental coping strategies predicted increased retention [Isaia et al., 2018].

Personality disorder

One study which examined suicidal behaviour in those with major depression and comorbid personality disorder concluded that those with borderline personality disorder symptoms are at risk for serious suicide attempts. The presence and severity of personality disorder has been positively related to indicators of suicidality [Corbitt et al 1996]. This supports previous research findings that the presence of personality disorder may increase the risk of suicidal behaviour, especially in borderline personality disorder. Group differences also supported previous findings that major depression with comorbid borderline personality disorder carries a higher risk for attempted suicide than major depression alone. Therefore, it is important to consider the severity of comorbid cluster B personality disorder characteristics [see Ch. 19, Table 19.1] when assessing suicide risk in those with major depression, even those who have not been categorised as having a personality disorder. This provides a salutary warning contradicting the clinical folklore that those with borderline personality disorder tend to make frequent, trivial suicidal gestures which are not highly life-threatening. Recent research findings suggest that if borderline personality disorder is comorbid with depressive disorder it can lead to serious suicide attempts. Research supports the hypothesis that the higher levels of suicidality findings in borderline personality disorder are due to a vulnerability for suicidal behaviour in these patients. The threshold for such behaviour is lowered in the presence of comorbid stressors such as major depression [Malone et al 1993].

In a recent study Haw et al [2001] explored the nature and prevalence of psychiatric and personality disorders in self-harm patients and found that ICD-10 psychiatric disorders were diagnosed in 92% of patients, with comorbidity of psychiatric disorders in 47%. The most common diagnosis was affective disorder [72%]. Personality disorder was identified in 46% of patients interviewed at follow-up, with comorbidity of psychiatric and personality disorder in 44%. This study confirms that psychiatric and personality disorders, and their comorbidity, are common in self-harm patients.

The Three Orientations

In this section, I review the three major types of orientation that people might utilize to strive toward their idealized self: moving against, moving away, and moving toward [Horney, 1945]. Following each orientation, I present how each of Horney’s orientations are similar to one of the DSM-IV-TR’s [American Psychiatric Association, 2000] three major clusters of personality disorders [cluster A: emotional withdrawal and odd behavior; cluster B: exaggerated, dramatic emotionality; and cluster C: anxious, resistive submissiveness]. This section is then followed by the current research conducted on the three clusters of personality disorders and religion/spirituality.

Medication

The psychopharmacologic management of difficult patients is quite complex and uncertain, again suggesting that borderline personality disorder [the referent paradigm of difficulty] is not simply a “border on” depressive disease. Based on the neuropsychiatric and psychopharmacologic literature, four clusters of personality disorder symptoms have been proposed as targets for pharmacotherapy.88 The four clusters reflect difficulty with cognition or perceptual organization, impulsive and aggressive behavior, mood stability and dysphoria, and suppression of anxiety [see Figure 38-2]. The personality disorder symptoms within each cluster might have a common neurobiological substrate that can serve as a rationale for treatment selection.

The impulsive–aggressive dimension and the mood-instability dimension are the two most relevant to cluster B personality disorders and, hence, the difficult patient. Anger, aggression, and behavioral disinhibition constitute primary impairments in this domain, and they are thought to reflect dysfunction in the serotoninergic neurotransmitter system. Selective serotonin reuptake inhibitors [SSRIs] should be considered first-line agents for treating impulsivity and aggression in personality-disordered patients. However, if these patients do not respond well to adequate trials of SSRIs, augmentation with a mood stabilizer or an anticonvulsant can be considered, because there is empirical support for the use of divalproex sodium in this patient population.

The mood-instability dimension also appears to be most closely tied to the cluster B disorders and consists of mood dysregluation, depression, dysphoria, and emotional lability. These behaviors may have broad neurotransmitter underpinnings, possibly related to dysfunction in serotoninergic, cholinergic, or noradrenergic systems. SSRIs should be considered first-line agents for treating these symptoms. If augmentation is needed, buspirone or a long-acting benzodiazepine, such as clonazepam, can be considered. If rage is a prominent component of the mood dysregulation, antipsychotic agents should be considered.

When using the four-personality symptom clusters as a guide to pharmacotherapy for the difficult—personality-disordered—patient, the clinican should be mindful that the heterogeneity of DSM personality disorders results in patients having symptoms from several symptom clusters. For example, patients with borderline personality disorder tend to demonstrate behaviors from the impulsive–aggressive and mood-instability clusters, but some also exhibit symptoms within the cognitive–perceptual cluster. This reinforces the concept of selecting pharmacotherapy based on specific target symptoms rather than on a given personality disorder diagnosis. Experienced clinicians tend to use the symptom clusters as medication targets to avoid “chasing” single symptoms [to prevent situations in which a patient is prescribed four or more medications without a clear rationale]. Clinical experience also suggests following guidelines [for dose and duration] for all medications to minimize treatment adjustments.

In terms of specific recommendations to the consultee, a trial of medication can be quite helpful in particular instances [see Figure 38-2]. With patients exhibiting dangerous rage or other dangerous behavior, such as self-injury, antipsychotic medication titrated to a sedating dose may be life-saving.

Miscellaneous medications, ranging from methylphenidate to levodopa, have been reported to help difficult patients,11 and there seem to exist single case reports touting almost any conceivable drug.89 Given the present state of knowledge, it seems appropriate for the consultant to remember that mind and body are not separate, and that many seemingly insoluble problems respond to a search for, and aggressive treatment of, co-morbid psychiatric conditions, especially affective disorders and substance abuse. Common and uncommon medical conditions mimic personality disorders [just for illustration, three random instances in the literature are narcolepsy, Wolfram's syndrome, and Addison's disease90–92]. Also, over the lifetime of any given patient, the relationship with a supportive physician is as healing as any drug.