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Addiction and Personality Disorders: Effects of Alcohol on Your Symptoms

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Alcohol use disorder—the clinical name for the signs, symptoms, and behaviors commonly called “alcoholism” or “alcohol addiction”—often happens at the same time as other mental health conditions, such as personality disorders. The effects of alcohol may trigger the onset of mental health symptoms, alcohol use may feel like a way to manage symptoms associated with a diagnosis, or characteristics of another mental health disorder may lead to the development of alcohol use disorder.

What Is Personality? And What Is a Personality Disorder?

When describing “personality” in a psychological or clinical sense, the description covers patterns and significant characteristics in your thoughts, feelings, and behaviors. Biological, social, cultural, and environmental factors shape your personality.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is the resource mental health professionals use to evaluate, diagnose, and classify mental health conditions. A mental health professional references DSM-5 criteria both to examine whether someone has a personality disorder and to evaluate a person’s substance misuse to determine if they have an addiction, like alcohol use disorder.

According to the DSM-5: 1

A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

According to the DSM5, about 9% of American adults have a personality disorder, which causes significant dysfunction in 2 or more areas of a person’s life, specifically:2

  • Thinking of self and others
  • Responding emotionally
  • Controlling the self
  • Relating to others

Personality disorders fall into 1 of 10 categories:3

  1. Antisocial
  2. Avoidant
  3. Borderline
  4. Dependent
  5. Histrionic
  6. Narcissistic
  7. Obsessive-compulsive
  8. Paranoid
  9. Schizoid
  10. Schizotypal

Personality disorders also fall into three clusters: 4

  1. Cluster A contains paranoid, schizoid, and schizotypal personality disorders.
  2. Cluster B includes antisocial, narcissistic, borderline, and histrionic personality disorders.
  3. Cluster C has avoidant, dependent, and obsessive-compulsive personality disorders.

When diagnosing, evaluating, and treating a personality disorder, a mental health professional may use this criteria to inform how they approach an individual’s care.

What Is Alcohol Addiction? And Why Does It Co-Occur With Other Conditions?

The National Epidemiologic Survey on Alcohol and Related Conditions found that those diagnosed with a personality disorder are 5 times more likely to have alcohol use disorder than the general population, with 42% of those individuals developing a lifetime dependence on alcohol. Research suggests personality disorders are highly comorbid or co-occurring among those with alcohol use disorder that would be classified as “severe.”5

Alcohol use disorder has 11 DSM-5 characteristics which include: 6

  • Profound cravings and urges to use alcohol,
  • A history of wanting to or trying to stop using alcohol unsuccessfully
  • Using more alcohol than intended, such as drinking more often or having more drinks than you mean to
  • Using alcohol even after you know you are experiencing direct negative side effects from it, such as a specific health condition

The mental health professional who assesses you for alcohol use disorder evaluates how many of the 11 criteria you have experienced in the last year and how they have manifested to determine if your diagnosis is mild, moderate, or severe.

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Studies indicate that about half of all people with alcohol use disorder have a dual diagnosis, meaning they also have another mental health condition. 7 While the conditions do not necessarily cause one another, they can play a role in how the other develops. For example, someone with acute emotional pain, feelings of loneliness, or anxiety about being rejected may begin to use a substance to reduce the intensity of these feelings, either alone or in a social setting. Chronic misuse to manage these symptoms could eventually develop into addiction.

On the other hand, because alcohol alters the brain’s structure, the development of an alcohol use disorder can potentially lead to the onset of personality disorder symptoms in an individual who is at high risk for the condition.

Who Is at Risk for Co-Occurring Alcohol Addiction and Personality Disorders?

Researchers have discovered multiple factors contributing to a person developing a co-occurring disorder, such as alcohol use and personality disorders. The effects of alcohol can change personality disorder onset.

Heredity, or family history, is a major contributor, especially to personality disorders. It is unclear if there are specific genes that “pass down” personality disorders or addiction. Some of the genetic traits that make a person more likely to have these conditions may be genetic, such as impulsivity.

However, studies also indicate that living with family members who have this family history in your home of origin—especially in the case of addiction—is a key part of the heredity. This suggests that behaviors that can lead to addiction, such as self-medicating mental health symptoms rather than seeking treatment, may be learned instead of inherited genetically. 8

Family history does not predict or guarantee that you will have either a personality disorder or addiction. Other factors can also contribute, including:8

  • Existing personality disorder—Having a personality disorder increases the risk of developing a substance use disorder like alcohol use disorder, usually due to a pattern of “self-medicating” the symptoms of the personality disorder with alcohol.
  • Heavy and prolonged alcohol use—Studies indicate that chronic alcohol use may have a triggering effect on the genes associated with personality disorders. Heavy use of alcohol may affect the onset of personality disorder symptoms. If the symptoms already exist, alcohol effects may make the symptoms more intense.
  • Living environment—Instability, mistreatment, and neglect have been linked to the development of mental health conditions. This may include living with others who have a substance use disorder, untreated mental health issues, or both. It may also mean living in a home where your physical and emotional needs go unmet.
  • History of traumaTraumatic events can contribute to the onset of a personality disorder or the development of alcohol use disorder.
  • Untreated conditions—Underlying and untreated physical conditions can sometimes facilitate the development of mental health conditions. For example, chronic pain is closely tied to the development of alcohol use disorder.

Alcohol Addiction and Borderline Personality Disorder

Borderline personality disorder (BPD) is characterized by an instability of perception, including of yourself and self-worth, relationships, and affect. Diagnosing borderline personality disorder must include 5 of the following 9 criteria:9

  1. Efforts to avoid abandonment, either real or perceived
  2. Patterns of intense and unstable relationships
  3. Confusion over self-image and sense of self
  4. Impulsive behaviors
  5. Recurrent self-harm or suicidal gestures
  6. Change in affect—or the way you present yourself—often connected to your mood at the time
  7. Chronic feelings of emptiness or purposelessness
  8. Intense outbursts of anger
  9. Paranoid ideation—which manifests as worries or preoccupations that do not align with the concerns of reality—or severe dissociative disorder—which manifests as a complete mental separation from what is happening around you

If you have BPD, your relationships may feel unstable or volatile, even with the people closest to you. You may worry obsessively that someone will hurt or leave you. The affection others give you may not feel like it matches what you give to them. You may feel as though you need to control how others see you so that they will value your friendship and affection. You may also find that you are often the one who leaves relationships—despite your worries that others will leave you—in order to protect yourself.9

Borderline personality disorder and alcohol use disorder can present together. Studies show of those with a lifetime diagnosis of BPD, 58% have alcohol use disorder. Additionally, 14.3% of those with alcohol use disorder have a borderline personality disorder.10

BPD and alcohol misuse may cause an increase in impulsive behaviors, mood changes, and paranoid feelings.

Alcohol Addiction and Antisocial Personality Disorder

Antisocial personality disorder is a conduct disorder that describes a pattern of behaviors considered to violate the laws and morals that society as a whole universally agrees upon.

To be diagnosed with antisocial personality disorder, you must be an adult. The diagnosis cannot be given to children under the age of 15. Children exhibiting signs of antisocial personality disorder may be given a different conduct disorder diagnosis and be assessed again after age 15.

A mental health professional evaluates antisocial personality disorder based on 7 criteria. The diagnosis requires that a minimum of 3 of the following criteria be present: 11

  1. A pattern of law or rule breaking
  2. Deceitfulness that benefits the individual, including lying, stealing, or cheating
  3. Impulsive behavior
  4. Reckless behavior that shows a disregard for one’s own safety or the safety of others
  5. Irresponsible behavior
  6. Aggressive behavior that may lead to verbal or physical fights with others
  7. Lack of remorse for the negative consequences of one’s behavior

If you have an antisocial personality, you may find that people take to you easily and that you don’t have a difficult time getting what you want. You may find rules to be restrictive and consider them optional in many cases. You may push boundaries to reach goals, feel good, or please someone you want to impress. A disproportionate number of people with antisocial personality disorder interact with the criminal justice system because they do not necessarily see the harm in bending or outright breaking rules.12

Studies of adolescents with antisocial personality disorder and alcohol misuse often show comorbidity. As they grow into adulthood, the two disorders do not go away. Instead, many acquire another condition, like depression.13

Alcohol Addiction and Avoidant Personality Disorder

If you have an avoidant personality disorder (APD), you internalize negative emotions. You may not feel comfortable in social settings and may withdraw from others to avoid embarrassment or rejection.

To be diagnosed with avoidant personality disorder, 4 or more of the following DSM-5 criteria must be met:5

  1. You avoid activities at work that require interacting with groups of employees with the purpose of avoiding criticism or rejection of yourself or your work
  2. You avoid getting involved with people as friends or romantic partners unless you have some assurance that they accept you or will accept you
  3. You avoid intimate relationships with the purpose of avoiding possible negative experiences such as rejection or ridicule of your emotions, body, or past
  4. You spend a lot of time preoccupied with the idea being rejected or ridiculed when you are around other people, to the point that you may have a difficult time feeling involved in activities or engaging in conversations
  5. You feel inadequate in new relationships with acquaintances or friends, potential romantic partners, coworkers, and others
  6. You feel inferior to others
  7. You avoid taking risks, specifically engaging in new activities, because you fear embarrassment

Avoidant personality disorder and alcohol use disorder are often comorbid. Depression may be an additional mental health diagnosis that co-occurs alongside alcohol use disorder or APD. There is little recent research on APD or the effects of alcohol and this type of personality disorder. However, avoidant personality traits overlap with many mental health and substance use disorder characteristics.14

Alcohol Addiction and Narcissistic Personality Disorder

There are two types of narcissistic personality disorder (NPD): vulnerable or grandiose. The two can manifest almost as opposites, with vulnerable NPD being characterized with introversion and lack of interpersonal connection and grandiose NPD being characterized with a need to be seen and recognized for any good trait without a sense of modesty or restraint.

A person must have 5 of the DSM-5 criteria to be diagnosed with NPD. While the label “narcissistic” is often used casually, only a mental health professional can evaluate and interpret how the DSM-5 are present in an individual, and whether the existing criteria meet the clinical threshold for a diagnosis of NPD. The criteria are as follows:15

  1. You have an expectation that you will be recognized as important, with a disproportionate sense of your personal importance in social groups, organizations, or populations
  2. You focus obsessively on your success, power, beauty, or brilliance and may be unable to acknowledge mistakes or character flaws
  3. You believe you are special and have a strong desire to associate with notable people, such as celebrities, world leaders, or thought leaders
  4. You like and crave to be admired by others
  5. You feel as if you deserve or have earned being treated differently from your peers, such as being given advantages like having alcohol use at work overlooked, receiving awards or incentives, or being admitted into exclusive circles
  6. You value your own interests over others’, specifically when working toward a goal
  7. You find it difficult or impossible to feel that others’ needs or emotions are as important or real as your own, which can make it difficult to form meaningful relationships or damage relationships you already have
  8. You feel envy of people who have beauty, intelligence, fame, wealth, or other things you believe should be offered to you, while also believing that other people envy what you already have
  9. You prioritize your ideas, daily schedule, and so on above others’, which creates a pattern of behavior that translates as arrogant, condescending, patronizing, cold, or entitled

Narcissistic personality disorder and alcohol can affect the intensity of your symptoms. Studies indicate that NPD is the most frequently co-occurring personality disorder with alcohol use disorder.12 Statistics from one study found that 28.9% of men and 11% of women have co-occurring narcissistic and AUD.16

What Are the Risks of Untreated Alcohol Addiction and Personality Disorders?

There are short-term and long-term risks of when an alcohol use disorder or personality disorder is not diagnosed or treated.

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Short-term risks include:17,18

  • Worsening of personality disorder symptoms
  • Worsening of alcohol use disorder symptoms
  • Self-injury which may be accidental or purposeful
  • Hurting someone else, accidental or intentional
  • Isolation and estrangement from family and friends
  • Misusing other substances after exposure to alcohol
  • Experiencing interactions between alcohol and medications used in personality disorder therapy, such as antidepressants, mood stabilizers, antipsychotics, and anti-anxiety medications like Xanax

Long-term risks include:18

How Are Co-Occurring Alcohol Addiction and Personality Disorders Treated?

The goal in treating personality disorders is not to change a person’s personality. However, it is to manage the symptoms associated with the personality disorder that interferes with someone functioning at work, home, or socially.

Existing alcohol use disorder is treated simultaneously with a personality disorder. You may be evaluated for a personality disorder or other mental health conditions when entering alcohol abuse treatment.

Treatment centers taking patients with co-occurring alcohol use disorder and personality disorders utilize specific therapies, including the following:19

  • Dialectical behavior therapy (DBT)
  • Mentalization-based therapy
  • Schema-focused therapy
  • Transference-focused therapy
  • Systems training for emotional predictability and problem-solving (STEPPS)
  • Psychoeducation
  • Family therapy
  • Early recovery and relapse prevention skills therapy
  • Medication, when appropriate

Alcohol abuse treatment centers create an individualized program based on your personal experiences, as well as your physical and psychological health needs, at intake. Your plan may include some or all the therapies mentioned here, or you and your doctor may utilize other treatment models. The goal is to treat any symptoms of concern so that you can recover from alcohol dependence and addiction, as well as achieve your personal goals.

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Resources

  1. S. National Library of Medicine. (2021). Personality disorders. MedlinePlus.
  2. Hanna Chaim, C., Santana, G. L., de Vries Albertin, P., Silveira, C. M., Siu, E. R., Viana, M. C., Pang, W. Y., & Andrade, L. H. (2021, March 23). Alcohol use patterns and disorders among individuals with personality disorders in the Sao Paulo Metropolitan Area. PloS One, 16(3), e0248403.
  3. Fariba, K. & Sapra, A. (2021). Avoidant Personality Disorder. Treasure Island (FL): StatPearls Publishing.
  4. American Psychiatric Association. (2021). What Are Personality Disorders?
  5. Sansone, R. A., & Sansone, L. A. (2011). Personality Disorders: A Nation-Based Perspective on Prevalence. Innovations in Clinical Neuroscience, 8(4), 13-18.
  6. National Institute on Alcohol Abuse and Alcoholism. (2020). Understanding Alcohol Use Disorder.
  7. National Institute on Mental Health. (2021). Substance Use and Co-Occurring Mental Disorders.
  8. S. National Library of Medicine. (2021). Dual Diagnosis. MedlinePlus.
  9. Biskin, R. S., & Paris, J. (2012, November 06). Diagnosing Borderline Personality Disorder. Canadian Medical Association Journal, 184(16), 1789-1794.
  10. Trull, T. J., Freeman, L. K., Vebares, T. J., Choate, A. M., Helle, A. C., & Wycoff, A. M. (2018). Borderline personality disorder and substance use disorder: an updated review. Borderline Personality Disorder and Emotion Dysregulation, 5, 15.
  11. Fisher, K.A. & Hany, M. (2021, May 21). Antisocial Personality Disorder. Experimental and Clinical Psychopharmacology, 20(4), 333-344.
  12. Gianoli, M. O., Jane, J. S., O’Brien, E., & Ralevski, E. (2012). Treatment for comorbid borderline personality disorder and alcohol use disorders: a review of the evidence and future recommendations. Experimental and Clinical Psychopharmacol, 20(4), 333-344.
  13. Choi, T. K., Worley, M. J., Trim, R. S., Howard, D., Brown, S. A., Hopfer, C. J., Hewitt, J. K., & Wall, T. L. (2016, April 30). Effect of adolescent substance use and antisocial behavior on the development of early adulthood depression. Psychiatry Research, 238, 143-149.
  14. S. National Library of Medicine. (2021). Antisocial Personality Disorder. MedlinePlus.
  15. Miltra, P. & Fluyau, D. (2021). Narcissistic Personality. Treasure Island (FL): StatPearls Publishing.
  16. Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., Ruan, W. J., Pulay, A. J., Saha, T. D., Pickering, R. P., & Grant, B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 69(7), 1033-1045.
  17. Videler, A. C., Hutsebaut, J., Schulkens, J., Sobczak, S., & van Alphen, S. (2019). A Life Span Perspective on Borderline Personality Disorder. Current Psychiatry Reports, 21(7),
  18. National Institute on Drug Abuse. (2020). The Science of Drug Use and Addiction: The Basics.
  19. Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What Works in the Treatment of Borderline Personality Disorder. Current Behavioral Neuroscience Reports, 4(1), 21-30.
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