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Introduction

Borderline personality disorder (BPD) is a mental health problem involving difficulties in four main dimensions: (a) interpersonal instability, such as intense relationships and a strong fear of abandonment; (b) cognitive disturbances such as dissociation, identity disturbance and obsessive and paranoid ideas; (c) emotional and affective dysregulation; and (d) behavioural problems, including impulsivity and self-injurious and suicidal behaviours (American Psychiatric Association [APA], 2013). The prevalence of this pathology ranges from 0.50% to 5.90% of people (Grant et al., 2008; Tomko et al., 2014), although the data may vary depending on the assessment methods used and where the studies are conducted. In Spain, the prevalence is 0.017% of those surveyed, with a higher prevalence in young people than in adults, and a significant percentage of these individuals also suffer from another mental health problem (Aragonès et al., 2013). Although people with BPD manifest great suffering (Slotema et al., 2019), especially due to affective instability (Zimmerman et al., 2017) and emotional regulation problems (Fitzpatrick et al., 2021), they often seek treatment for other mental health problems or repeated suicide attempts (Gunderson et al., 2018). People with BPD often present anxiety disorders, mood disorders, stress disorders, other personality disorders, neurodevelopmental disorders such as attention deficit hyperactivity disorder and substance use disorders (SUD) (Grant et al., 2008; Tomko et al., 2014).

The literature indicates that a large proportion (25%) of people with BPD also suffer from a SUD (Trull et al., 2018), with 70.60% of them presenting alcohol use disorder, 62.70% cocaine use disorder, 45.80% cannabis use disorder, 26.80% opiate use disorder and 22.20% sedative use disorder (González et al., 2019). This comorbidity is associated with a worse course and outcome of the disorders (Kienast et al., 2014).

To date, specific treatments have been proposed for BPD and SUD individually (Meuldijk et al., 2017; Lo Coco et al., 2019), but few studies have addressed the joint treatment of both conditions and shown high rates of improvement (Trull et al., 2000). This group is particularly vulnerable due to their difficulties with emotional regulation, and the high incidence of self-injurious and suicidal behaviour.

Objective

The present study aims to find out which psychological treatments have been applied and obtained benefits in people with co-morbid BPD and SUD by means of a systematic review which can help to promote and disseminate the use of the treatments with the greatest benefits for patients with the characteristics described above.

Method

This qualitative systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard (Shamseer et al., 2015). The protocol for the systematic review was registered in PROSPERO (CRD42021228860) (Booth et al., 2012).

Bibliography search

The Cochrane Library, ProQuest Central, ISOC, Web of Science, Pubmed, Psicodoc and Scopus databases were consulted by two independent authors (MLM, LLT) for relevant records published up to 1 October 2020. Based on the PICO approach (Mamédio et al., 2007), the following question was asked: Is psychological therapy helpful in reducing psychological symptoms in people with borderline personality disorder and substance abuse disorder comparing them to the control group (active or inactive one, when it exists)?

The final search combined the proposed key elements. The following Boolean (using MeSH terms) expression was therefore used in WOS, Cochrane, ProQuest and Scopus: TITLE-ABS-KEY ("borderline personality disorder" AND "substance use disorder" OR "addiction" OR "dependence" OR "drug abuse" AND "treatment" OR "therapy" OR "intervention"), in PubMed; TITLE/ABS ("borderline personality disorder") AND ("substance use disorder" OR "addiction" OR "dependence" OR "drug abuse") AND ("treatment" OR "therapy" OR "intervention"), and in Psicodoc and ISOC; (“borderline personality disorder" AND "substance use disorder" OR "addiction" OR "dependence" OR "drug abuse" AND "treatment" OR "therapy" OR "intervention") en Psicodoc e ISOC.

All the recovered items were uploaded to Covidence (Covidence systematic review software, 2018), the online screening and data extraction tool. Duplicate articles were eliminated, after which two authors (MMG and MPM) reviewed the titles and abstracts of all the papers and excluded the articles that did not meet the inclusion criteria based on reading the title and abstract. The articles that were selected by either of the two authors, or which contained differences between their blinded decisions, were read in depth individually and blinded, and re-evaluated to judge their eligibility according to the inclusion and exclusion criteria. The same authors (MMG and MPM) inspected the reference lists of the selected studies to assess the inclusion of quality references that had not appeared in the initial searches. Handsearching followed a snowball sampling procedure to identify relevant articles in the reference lists of potentially useful documentation. Finally, as all disagreements were resolved by discussion between (MMG and MPM), it was not necessary for the third reviewer (LLT) to break the tie.

Cohen's Kappa (κ) (Orwin, 1994) was used to assess the index of inter-judge agreement, taking into account that values between -1 and 0.40 are considered unsatisfactory, values between 0.41 and 0.75 are considered satisfactory and ≥ values of 0.76 are considered satisfactory (Hernández-Nieto, 2002). Figure 1 shows the flow chart of the information used to answer the review question. Due to the highly heterogeneous nature of our results, and specifically the differences in the variables taken into account and the instruments used to evaluate them, we did not consider it appropriate to perform a subsequent meta-analysis of these data, since they could not be combined.

Inclusion and exclusion criteria

Studies that met the following criteria were included in the present systematic review: (a) The study evaluated the impact of psychological therapy on the improvement of mental health of people with borderline personality disorder and substance abuse disorder; (b) The average age of the participants was between 18 and 65; (c) the study was published in impact articles; (d) the full text of the article was accessible. The following were excluded: (a) patients whose treatment or therapy was not specified; (b) when the interventions were only pharmacological; (c) publications prior to 31 December 2004; (d) the language of publication was not English or Spanish, and (e) papers, books and works published in congresses or in reviews or any other publication that was not an original scientific article.

Finally, all the selected articles had to have appeared in the databases mentioned above (Cochrane Library, ProQuest Central, ISOC, Web of Science, Pubmed, Psicodoc and Scopus), taking into account the criteria mentioned above, without applying any time limit.

Quality assessment

Two authors (LLT and MMG) independently and blindly assessed the quality of the included studies using an adapted version of the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project (Wermelinger-Ávila et al., 2017). This tool consists of 19 items that assess 8 criteria: (a) study design, (b) blinding, (c) representativeness – selection bias, (d) representativeness – withdrawals and dropouts, (e) confounders, (f) data collection methods, (g) data analysis, and (h) reporting. The rating for each criterion ranges from 1 (low risk of bias; strong) to 5 (high risk of bias; weak). Based on the study by McMullan (McMullan et al., 2019), studies can have between 4 and 8 component ratings based on the 8 criteria. An overall rating is assessed according to the component ratings. For example, a study with 6 ratings could be rated as “strong” if there are no WEAK ratings and at least 3 STRONG ratings, “moderate” if there is one WEAK rating and less than 3 STRONG ratings, or “weak” if there are two or more WEAK ratings.

Data extraction

Tree authors (MMG, MPM and LLT) developed a data extraction form that was used to obtain relevant information from the included studies. This information included the first author and year of publication, participants, variables and instruments, study design, treatment and control, main results and conclusions and quality assessment rating (Table 1 and 2).

Results

Study selection and screening

The study selection process is shown in Figure 1. After the literature search, the application of the time criterion and the elimination of duplicate results, the total number of records was 127. The initial selection excluded 105 studies based on the title and abstract, and the full text of the remaining 22 papers were read in a second selection process. The reliability of the prior agreement between the two independent reviewers (MMG and MMP) on the screening of the full text was excellent (κ=0.90). Nine papers were excluded in the second screening (3 for not including treatment, 1 for not referring to BPD, one for focusing only on other disorders, 2 for not meeting the time criterion, 2 for being reviews and one as a proposed intervention that was not carried out) and as such 12 independent studies were eligible for inclusion. The degree of inter-judge agreement was also satisfactory in this second screening (κ=0.52).

Characteristics of the study

The characteristics of the study are summarized in Table 1. The 12 studies investigated included a total of 597 participants (64.15% women), who ranged in age from 18 to 65 years (M=34.53 years), although one study was considered to include adolescents (Santisteban et al., 2015). The age range was not specified in three articles (Ball et al., 2005; Ball, 2007; Gregory et al., 2008). In terms of diagnoses, 69.23% of participants had co-morbid BPD and SUD (Ball, 2007; Flynn et al., 2019; Gregory et al., 2008; Kaltenegger et al., 2020; Penzenstadler et al., 2018; Philips et al., 2018b; Santisteban et al., 2015; Van den Bosch et al., 2005). 30.77% of the studies indicated that apart from co-morbid BPD and SUD, the participants could have other comorbid personality, mood or anxiety disorders (Ball et al., 2005; Ball et al., 2011; Lana et al., 2016; Philips et al., 2018a).

Sample selection and research desing

As regards the sample, one of the studies did not specify how the participants were selected (Kaltenegger et al., 2020), while in the other studies the participants were selected purposively (98.68%). In specific terms, participants came from substance dependence treatment centres or mental health centres (n= 8) (Ball, 2007; Flynn et al., 2019; Gregory et al., 2008; Lana et al., 2016; Van den Bosch et al., 2005; Philips et al., 2018a; Penzenstadler et al., 2018; Philips, et al., 2018b), from homeless centres (n=1) (Ball et al., 2005) and from correctional facilities or courts (n=2) (Ball et al., 2011; Santisteban et al., 2015). Ten of the studies were longitudinal in design, and the other two were cross-sectional studies (Penzenstadler et al., 2018; Philips et al., 2018b). In all the longitudinal studies, a follow-up was conducted in addition to the pre-post-treatment assessment.

Variables

The aspects analysed in the participants were psychopathology in general and specifically related to substance use problems, as well as personality disorders, interpersonal problems, suicidal risk and behaviours, affect, characteristics associated with autism, intelligence, neuropsychological variables and therapeutic adherence (Table 1). Instruments with adequate psychometric properties which were well adapted to the topic, target and use were used, as well as semi-structured interviews created on an ad hoc basis to complement the data.

Inclusion and exclusion criteria

53.85% of the studies specified age, meeting DSM-IV diagnostic criteria for borderline personality disorder and substance dependence as inclusion criteria (Ball et al., 2005; Gregory et al., 2008; Kaltenegger et al., 2020, Philips et al., 2018a, Philips et al., 2018b; Santisteban et al., 2015; Van den Bosch et al., 2005). Three of the papers did not detail inclusion criteria (Ball et al., 2011; Flynn et al., 2019; Penzenstadler et al., 2018) and two did not specify exclusion criteria (Penzenstadler et al., 2018; Santisteban et al., 2015). Participants were generally excluded if they: a) had a psychotic disorder, an affective disorder with psychotic features, or bipolar disorder type 1; b) cognitive impairment; c) multiple suicide attempts; d) acute violence; and e) near imprisonment.

Main results of the psychological therapy

The articles focus on various psychological therapies that have achieved good results in most cases. First, in relation to Mentalization-Based Treatment (n=4), a reduction in substance use, suicidal behaviour and hospitalisations is observed, as well as an increase in mentalisation capacity (Kaltenegger et al., 2020; Lana et al., 2016; Philips et al., 2018a: Philips et al., 2018b). Meanwhile, the articles focusing on Dialectical Behaviour Therapy (n=2) find that it is useful in reducing substance use, BPD-associated symptomatology, suicide attempts, impulsive behaviours, and increasing participants' confidence and improving their outlook on life, with these changes being maintained over time (Flynn et al., 2019; Van den Bosch et al., 2005). Three articles focused on Dual-Focus Schema Therapy (Ball et al., 2011; Ball, 2007; Ball et al., 2005), and found low adherence to treatment (42% finished treatment). Symptom severity was observed to decline, but these changes were not maintained. However, the changes were maintained with Individual Drug Counselling (Ball et al., 2011). In a comparison between Dual-Focus Schema Therapy and 12 Step Facilitation Therapy, a decline in substance use was observed in the former, but a reduction in emotional symptoms was observed in the latter (Ball, 2007). In the study by Ball et al. (2005) the dropout of participants was so high (83.88%) that the results were inconclusive.

One of the studies (Santisteban et al., 2015) focused on Integrative Borderline Personality Disorder - Adolescent Family Therapy in adolescents, which improved the symptomatology associated with co-morbid BPD and SUD, and the participants who also had depression benefited to a much greater extent. Another study focused on Good/General Psychiatric Management, showing that BPD-associated symptoms were reduced, and a strong therapeutic alliance was achieved (Penzenstadler et al., 2018). Finally, one study focused on Dynamic Deconstructive Psychotherapy, obtaining improvements in depressive, dissociative and BPD-associated symptoms (Table 1).

Intervention format and therapists

Two of the studies combined individual and group therapy (Kaltenegger et al., 2020; Van den Bosch et al., 2005), three of the studies opted for the group format (Ball et al., 2005; Flynn et al., 2019; Lana et al., 2016) and three others for the individual format (Ball, 2007; Gregory et al.; 2008; Penzenstadler et al., 2018). Finally, two of the studies compared treatments in group versus individual format (Ball et al., 2011; Santisteban et al., 2015). In terms of the therapists involved in the interventions, we observed that the number of therapists in the studies ranged from two to 24. Their profession was not specified in a large proportion of them (66.67%) (Ball et al., 2005; Ball et al., 2011; Flynn et al., 2019; Kaltenegger et al., 2020; Van den Bosch et al., 2005). One study also did not specify who the therapists were (Van den Bosch et al., 2005), one study stated that they were psychologists, but did not specify how many there were (Lana et al., 2016). One study said that there were several therapists but did not specify their profession or the number of therapists (Ball et al., 2005). The studies that mentioned who the therapists were included psychologists, social workers, psychiatric nurses and assistants (Philips et al., 2018b), psychologists and nurses (Philips et al., 2018a), psychiatric residents (Gregory et al., 2008) and clinical psychologists (Ball, 2007). When therapists were combined, there was no analysis of differences in therapy outcomes between them, and this variable was not analysed as a possible confounder.

Difficulties in treatment and representativity

Despite financial rewards for treatment attendance and psychological assessment in some studies, most studies reported high dropout rates (Ball et al., 2005; Philips et al., 2018a; Philips et al., 2018b). Five of the studies did not report any dropout rates (Ball, 2007; Ball et al., 2011; Flynn et al., 2019; Kaltenegger et al., 2020; Penzenstadler et al., 2018). Only four of them reported acceptable or adequate adherence to treatment (Gregory et al., 2008; Lana et al., 2016; Santisteban et al., 2015; Van de Bosch et al., 2005).

Quality assessment

Table 2 shows the scores obtained by the articles analysed, following the assessment of the quality indicators therein. The quality scores range from 1 to 5, with 1 being the highest score (lowest probability of bias and highest quality) and 5 being the weakest score (highest probability of bias or lowest quality). The study quality assessment was conducted by one of the reviewers (LLT). The mean quality score was 2.26, i.e. a high-moderate overall score for most studies (Table 2).

Conclusion

The aim of the present study was to determine the effectiveness of psychological treatments applied to individuals with co-morbid BPD and SUD by means of a systematic review according to PRISMA standards (Shamseer et al., 2015). After an exhaustive search, few studies that met the specified inclusion and exclusion criteria were obtained, and 12 studies were finally analysed. These studies focused on assessing the effects of different psychological and psychiatric treatments in people with co-morbid BPD and SUD. Our results show that there is a wide variety of approaches to the treatment of people with co-morbid BPD and SUD, and that they generally share a common problem: low adherence to treatment. However, the treatment most frequently referred to in the literature is Mentalization-Based Treatment. This treatment is based on the fact that the symptoms of BPD occur when the person is unable to mentalise, makes decisions and performs behaviours without reflecting, and is detached from reality. This skill is developed in childhood when living in a stimulating and emotionally safe environment. Treatment combining individual and group sessions is therefore generally directed towards increasing reflective thinking, evaluation of one's own and others' emotional situations and flexibility (Bateman & Fonagy, 2004; Choi-Kain et al., 2017). The studies reviewed indicated that this treatment was effective for BPD symptoms, but not for SUD symptoms (Kaltenegger et al., 2020; Lana et al., 2016; Philips et al., 2018a; Philips et al., 2018b).

Dialectical Behaviour Therapy, an individual therapy that aims to improve social skills, emotional regulation, frustration tolerance and attention to the present (Linehan, 1993; May et al., 2016), proved useful over time in reducing BPD and SUD symptoms, suicidal behaviours and consumption, improving management of emotions, and increasing quality of life (Flynn et al., 2019; Van den Bosch et al., 2005).

In the studies in which it is used (Ball et al., 2011; Ball, 2007; Ball et al., 2005) Dual-Focus Schema Therapy reduces the severity of BPD and SUD symptoms, the results are not sustained over time and there is a high level of experimental mortality. In contrast, General Psychiatric Management achieves adequate therapeutic alliance and symptom reduction (Penzstadler et al., 2018), which helps to improve adherence. Integrative Borderline Adolescent Family Therapy was shown to be effective in reducing adolescent and family distress and adolescent substance use, especially among adolescents who also presented major depression (Santisteban et al., 2015). Finally, Dynamic Deconstructive Psychotherapy was shown to be effective in reducing suicidal behaviour, substance use, hospitalisation, healthcare attendance, and dissociative, depressive and BPD-associated symptoms (Gregory et al., 2008).

A summary of the results shows a wide variety of intervention proposals that generally lead to a reduction in the severity of the symptoms experienced and an improvement in the different variables evaluated, with the most common improvements being related to a reduction in suicide attempts and in hospitalisation and medical care. The results regarding substance use are not so conclusive, and it is difficult to ascertain the best intervention for reducing substance use in people with comorbid BPD.

Despite the contributions of our work, it should be noted that the studies that met the inclusion criteria have small samples, ranging from 17 to 41 participants with co-morbid BPD and SUD, with total samples ranging from 46 to 105 participants (if all the participants are taken into account, regardless of their condition). However, these samples are very heterogeneous, due to the fact that they include patients with different substance use issues, with different types of severity, and with other comorbid pathologies. In addition, the participants come from diverse institutional settings, ranging from institutionalised patients to homeless people to people subject to justice measures. This makes it difficult to compare treatments and conclusions. On the other hand, all the studies selected participants by convenience and there was a high dropout rate in some of them, although attendance was financially rewarded (Ball, 2007; Ball et al., 2005; Ball et al., 2011). We therefore believe that the sample characteristics and the sampling in these studies complicate the generalisability of the results to the general population. Furthermore, few studies report the drop-out rate of participants; and when they do, it is usually quite high. More studies are needed to continue investigating the situation of people with co-morbid BPD and SUD, using probability sampling that adequately represents the characteristics and needs of this population. Similarly, the sample size should be increased and randomised controlled trials should be conducted in order to draw higher quality conclusions. However, access to people with co-morbid BPD and SUD is complex, given the complexity of the situations they generally face, and the continuity of treatment is therefore also difficult.

In terms of the variables and instruments taken into account in the research studied, as well as the data analysis, all the studies use psychometrically appropriate instruments. However, few of them use robust statistics (Gregory et al., 2008; Lana et al. 2016, Santiesteban, et al. 2015) which enable a consistent analysis of the results obtained. Moreover, some of them do not take into account the analysis of masked variables, such as the severity of the disorders, traumatic experiences, family relationships or social support, or even the assessment of self-injurious behaviours or previous attempts at medical or psychological treatment, among other variables. Furthermore, some of them do not specify the number of dropouts (Flynn et al., 2019; Kaltenegger et al., 2020), or who the therapists were or their sociodemographic variables or profession (Ball et al., 2005; Ball et al., 2011; Flynn et al., 2019; Kaltenegger et al., 2020; Lana et al., 2016; Van den Bosch et al., 2005), despite the fact that all the studies considered in this review are published in impact journals. However, all of them use longitudinal designs, and most of them use randomised studies (Ball et al., 2005; Ball et al., 2011; Ball, 2007; Kaltenegger et al., 2020; Penzenstadler et al., 2018; Philips et al., 2018b; Van den Bosch et al., 2005). On the other hand, only one of the selected studies was conducted in the Spanish population (Lana et al., 2016), and as such we believe that research is still needed to clarify the effectiveness of these interventions in this group in our context.

Future research could also take into account important adjustment variables such as emotional bonds, resilience or emotional intelligence, as studies have generally focused on reducing risk factors, but have not addressed the increase in protective factors. In addition, future research should consider how to reach people in particularly vulnerable situations, such as homeless people, pregnant women and minors with co-morbid BPD and SUD. These at-risk groups often make it more difficult to provide them with treatment or fail to maintain the therapeutic alliance and adhere to therapy. Finally, other studies could apply Eye Movement Desensitisation Reprocessing in this group of patients, as it has been shown to be useful in people with BPD and in people with SUD (Carletto et al., 2018; Slotema et al., 2019).

Systematic reviews in co-morbid BPD and SUD are very scarce, and this applies particularly to those focused on effective interventions for their treatment. As a result of a systematic search of the literature based on precise and systematic inclusion criteria, this review extends knowledge beyond the conclusions of narrative reviews. In addition, our review included two blinded reviewers throughout the process, as well as the rate of agreement between them. Although some literature is available on the topic under investigation, it is not sufficient to draw any conclusions, and we propose that more studies be conducted, using larger samples. It is also essential to develop strategies to reduce experimental mortality, as this was the main problem or limitation in the research reviewed.

The main results of our study indicate that there is a diversity of treatment alternatives for people with co-morbid BPD and SUD, in individual, group or combined settings, carried out by different professionals including psychologists, psychiatrists, nurses and social workers, which have been shown to be particularly effective with the symptoms associated with BPD. We therefore believe that the present review provides professionals responsible for the health of individuals with a guide to the most extensively studied psychological interventions in the literature for co-morbid BPD and SUD. It facilitates decision-making regarding which therapy to apply for patients with these characteristics, as well as providing a summary of the main benefits of these interventions.

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