Dialectical Behavior Therapy for Patients with Co-occurring Alcohol Dependence Syndrome and Borderline Personality Traits: A Scoping Review

Dialectical Behavior Therapy for Patients with Co-occurring Alcohol Dependence Syndrome and Borderline Personality Traits: A Scoping Review

Ms. Athira M *¹, Dr. Vandana Jain ²  

1. Research Scholar, Department of Psychology, Sri Dharmasthala Manjunatheshwara College (Autonomous) Research Centre affiliated to Mangalore University, Ujire.
2. Assistant Professor and Head, Department of Psychology, Sri Dharmasthala Manjunatheshwara College (Autonomous), Ujire.

*Correspondence to: Ms. Athira M, Research Scholar, Department of Psychology, Sri Dharmasthala Manjunatheshwara College (Autonomous) Research Centre affiliated to Mangalore University, Ujire.

Copyright

© 2026 Ms. Athira M, This is an open access article distributed under the Creative Commons Attribution                  License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 20 June 2026

Published: 01 July 2026

     DOI: https://doi.org/10.5281/zenodo.21068379

Abstract

Background: Increased emotional dysregulation, impulsivity, self-harm, treatment non-adherence, and relapse risk are all consequences of the common co-occurrence of Alcohol Dependency Syndrome (ADS) with borderline personality traits. Due to its emphasis on emotion regulation and adaptive coping mechanisms, dialectical behavior therapy (DBT), which was first created for people with borderline personality disorder (BPD), is increasingly being used to treat substance use disorders. However, there is still conflicting evidence about its use in people with borderline personality disorder and alcohol-related problems.

Objective: The purpose of this scoping review was to map and compile the available data about the efficacy of DBT therapies for people with co-occurring borderline personality traits, alcohol dependence syndrome, and substance use disorders.

Methods: Using the PRISMA-ScR framework, a scoping review was carried out. Eight of the eleven studies that were found after a thorough search of the literature satisfied the requirements for inclusion in the review. Descriptive data extraction and synthesis were done with an emphasis on treatment outcomes, intervention types, and study characteristics.

Results: The included research included pilot studies, open trials, feasibility studies, randomized controlled trials, and single-case experimental methods. The results showed that DBT was linked to improvements in emotional regulation, a decrease in self-harm and suicide behaviors, a decrease in alcohol and drug use and improved coping abilities. DBT shown to be feasible in a variety of delivery modes, such as internet-delivered treatments, outpatient, group-based, and intense treatment. However, methodological heterogeneity, small sample sizes, and a dearth of long-term follow-up research constrained the evidence base.

Conclusion: Based on the information that is now available, DBT appears to be a promising intervention for those with borderline personality traits and alcohol-related problems. DBT may help enhance psychosocial functioning and drug use outcomes by addressing emotional dysregulation. To determine its long-term efficacy, more thorough research is required.

Keywords: Dialectical Behavior Therapy, Alcohol Dependence Syndrome, Alcohol Use Disorder, Borderline Personality Disorder, Borderline Personality Traits, Substance Use Disorder, Emotion Regulation, Scoping Review.

Introduction

Alcohol Use Disorder

The World Health Organization (WHO) notes that harmful alcohol consumption is linked to more than three million deaths each year, and it is roughly 5% of the global burden of disease (World Health Organization [WHO], 2023). But the trouble with alcohol related harm is it doesn’t just stay with the person who drinks. It also lands on families, communities, and healthcare systems, partly through more accidents, violence, long term illnesses, and earlier than expected deaths. Because alcohol use is so common, and the fallout is so widespread, alcohol dependence has become a major public health worry in both high income countries and those that are still developing.

Alcohol Dependence Syndrome (ADS) usually involves trouble with control when it comes to alcohol, physiological dependence, craving, tolerance, withdrawal symptoms, plus continuing to drink even when negative consequences are clearly present (American Psychiatric Association [APA], 2022). Individuals diagnosed with alcohol dependence syndrome is reportedly shown major concerns in their social-occupational and psychological functioning. Long term alcohol use has also been tied to a range of medical complications, like liver damage, cardiovascular disorders, neurological difficulties, and a higher chance of mental health issues such as depression and anxiety. When you put all these pieces together, you can see why the overall impact can be huge, including heavier healthcare costs and bigger social costs related to alcohol misuse. On the epidemiology side, alcohol use disorders seem to affect millions of people worldwide, and they create real consequences for physical health, mental well-being, job performance, and close relationships (Grant et al., 2015). A lot of individuals can’t keep abstinence going for the long run, mostly because cravings continue, emotions spike, environments keep triggering them, and coping skills are often not strong enough. Despite of the pharmacological and psychological approaches, relapse rate stays high.

 So, there is more and more emphasis on treatment approaches that don’t only target alcohol intake, but also the inner psychological processes that help set up and then maintain dependence.

Borderline Personality Traits and Alcohol Dependence 

Borderline Personality Disorder (BPD) is described by a long lasting instability in emotional regulation, interpersonal dynamics, self image, and impulse control (APA, 2022). Individuals with the traits of Borderline personality can have sudden changes in emotion, a continued empty feel, concerns about abandonment and being consistent in the relationship maintenance and also have increased chances of following maladaptive coping strategies such as self harm and substance usage. Study after study points to higher substance use disorder rates in people with BPD, and alcohol use disorder is among the more frequent co-occurring problems (Trull et al., 2018). Alcohol is reported to have worked as a easily doable method for managing emotional distress or handling interpersonal tensions. Still, leaning on alcohol as a “reliever” tends to make emotional volatility worse, and it can help lock people into a loop of dependence plus ongoing psychological dysfunction.

Some estimates put it that about 40% to 70% of individuals diagnosed with BPD also end up with a lifetime substance use disorder (Grant et al., 2008). That overlap is important, because when alcohol dependence and borderline personality traits co-occur, treatment tends to get worse overall. Outcomes can include more psychiatric hospitalization, higher risk for suicidal behaviour, and more relapses. Individuals with cooccurring conditions find it difficult to adhere and stay consistent to the treatment. Taken together, these hurdles really point to the need for more integrated interventions that can address both substance use and personality-based difficulties, at the same time, rather than one after the other.

Emotional Dysregulation as a Shared Mechanism 

Emotional dysregulation is a key process between the alcohol dependence and borderline traits. In general terms, emotional dysregulation means difficulties in understanding, managing, and responding in a flexible way to emotional experiences (Gratz & Roemer, 2004). When an individual is emotionally dysregulated, he finds difficulty in tolerating distress for long, find difficulty with managing intense emotions and they face trouble with the usage of coping strategies that can help in stressful times. Thus, they may then reach for maladaptive strategies to handle distress. Alcohol use can become a route for escaping, or at least muting, negative emotional states, and in that sense, it reinforces dependence via negative reinforcement mechanisms (Khantzian, 1997). The evidence also suggests that problems with emotional regulation play a major role in craving, relapse, impulsive actions, and interpersonal difficulties for those who have both alcohol dependence and borderline personality traits (Axelrod et al., 2011). Since emotional dysregulation is found to be a major concern in both conditions, it becomes relevant that it must be considered as a target which is central to change.

Dialectical Behaviour Therapy

Marsha Linehan introduced dialectical behavior therapy (DBT), which is considered as a thorough treatment for people with significant self-harming tendencies, suicidality, and emotional dysregulation (Linehan, 1993a). DBT was first created for people with Borderline Personality Disorder (BPD) in response to the shortcomings of conventional cognitive-behavioral therapies in treating the emotional instability and recurrent suicidal tendencies that are frequently seen in this population.

The foundation of DBT is the biosocial hypothesis of emotional dysregulation, which holds that biological vulnerabilities and persistently invalidating contextual experiences interact to produce widespread issues with emotion regulation (Linehan, 1993a). DBT has four major domains of fundamental skills to address issues like emotional regulation, interpersonal effectiveness, distress tolerance and mindfulness. When taken as a whole, these elements seek to decrease maladaptive coping strategies, increase interpersonal functioning, and strengthen emotional control (Linehan, 1993b). DBT successfully lowers suicide thoughts, self-harming actions, emotional instability, and psychiatric hospitalizations in people with BPD and related disorders, according to empirical research (Linehan et al.,1991; Linehan et al., 2006). When Borderline personality characteristics co-occur with Alcohol Dependency Syndrome, the clinical condition becomes particularly difficult as they exhibit suicide and self-harm tendencies, emotional instability, impulsivity, difficulties in interpersonal relationships, higher risk for relapse and poor treatment adherence (Links et al. 1995). Interventions focusing on emotion regulation may be especially helpful for this population since emotional dysregulation has been found to be a key mechanism underlying both drug use disorders and borderline pathology. Linehan and colleagues designed DBT modifications especially for people with co-occurring drug use disorders and emotional regulation issues after realizing the critical role emotional dysregulation plays in substance abuse.

 DBT for Substance Abusers combines therapy modalities like dialectical abstinence, attachment-based therapies, relapse prevention strategies and active outreach protocols to increase treatment engagement and retention; (Dimeff & Linehan, 2008). These changes come in both the forms of substance use behaviors as well as the emotional vulnerabilities responsible for relapse and perpetuation of sustained substance dependence. Studies of DBT-based treatments for SUDs have also shown promise. In randomized controlled trials comparing DBT with TAU or otherwise standard treatment interventions, DBT participants have been more likely to be accepted into and retained in both individual and group therapy settings, reported less substance use between these therapies, and demonstrated lasting improvement across multiple measures of psychosocial functioning.

Moreover, DBT has therapeutic value on salient features of alcohol dependency, such as impulsivity (Dimeff & Linehan, 2008), emotional dysregulation (Eckhardt et al., 2013), maladaptive coping skills (Trainor & Mullins) and interpersonal dysfunction. OBJECTIVE: The application of DBT to individuals suffering adult co-occurring Alcohol Dependency Syndrome and Borderline Personality characteristics (or pathology) is increasingly gaining acceptance; however, the evidence currently available is still diffused across research utilizing differing methodologies, treatment modalities, or outcome measures. Hence, there is a need to thoroughly review this research in order to determine the effectiveness of DBT-based therapies for those with SUDs. The review seeks to evaluate outcomes related to treatment participation, affect regulation, reduction in alcohol usage and psychosocial well being.

Thus, the goal of the current systematic review is to critically analyze and compile empirical data about the efficacy of DBT-based therapies for people who have both borderline personality features and alcohol dependence syndrome.

Existing Evidence and Rationale for Conducting a Scoping Review

Since past few years, there has been an increased discussions on adapting DBT for treating substance use disorders.  At the same time, researchers have noticed that a lot of these individuals show marked emotional disruption, high impulsivity, and interpersonal trouble, stuff that traditional addiction treatment by itself often doesn’t really reach. So DBT has been added more and more into programs aimed at substance misuse, especially when people also show co-occurring psychiatric issues.  Researches have found results showing reduction in self-harm behavior, better emotional regulation, and reduced substance usage (Linehan et al., 1999; Linehan et al., 2002; Dimeff & Linehan, 2008). The results also hint that DBT might be especially helpful when substance use is tightly connected to emotional distress as well as impulsive patterns. And beyond lowering alcohol and drug use, DBT interventions have been linked with improvements in psychosocial functioning, quality of life, and general psychological well-being. Overall, these findings give support to DBT as a kind of blended, more integrated treatment option for people with complicated dual-diagnosis profiles. 

Even though, the studies are diverse in design, sample recruitment, duration of the intervention, outcomes measured and the different adaptation methods used in practice. And the number of reviews that covers the population with cooccurring ADS and BPD traits are relatively few. Instead, evidence is spread across studies that look at different substances, different clinical environments, and different diagnostic backgrounds, which makes it hard to settle on clear conclusions for this particular group. Because of that, a thorough synthesis is needed, to check how effective DBT-based interventions are for individuals who have both alcohol dependence and borderline personality traits, and also to map out possible directions for future research as well as clinical practice, maybe not only one or two, but multiple next steps.

Method

Study Design

The effectiveness of Dialectical Behavior Therapy (DBT) for people with Alcohol Dependence Syndrome (ADS), Alcohol Use Disorder (AUD), and co-occurring Borderline Personality Disorder (BPD) or borderline personality traits were mapped and synthesized using the scoping review methodology.

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) and the methodological framework developed by Arksey and O'Malley (2005) and subsequently improved by Levac et al. (2010).

Search Strategy

To find pertinent research on DBT therapies for alcohol dependency, substance use disorders, and borderline personality pathology, a thorough literature search was carried out across electronic databases. Terms including "Dialectical Behavior Therapy," "DBT," "Alcohol Dependence Syndrome," "Alcohol Use Disorder," "Substance Use Disorder," "Borderline Personality Disorder," "Borderline Personality Traits," and "Emotion Regulation" were used as keywords and combinations. To find more research, the reference lists of pertinent articles were also examined.

Eligibility Criteria

Studies that (a) focused on Dialectical Behavior Therapy or DBT-based interventions; (b) included individuals with Alcohol Dependency Syndrome, Alcohol Use Disorder, Substance Use Disorder, Borderline Personality Disorder, or borderline personality traits; (c) reported treatment-related outcomes; and (d) were published in English-language peer-reviewed journals were included. Inclusion criteria were pilot studies, feasibility studies, open trials, randomized controlled trials, experimental studies, and single-case experimental studies.

Studies that did not include a DBT-based intervention, concentrated only on theoretical discussions without empirical data, did not describe pertinent treatment outcomes, or were conference abstracts, dissertations, editorials, or publications written in languages other than English were also omitted.

Study Selection

Titles and abstracts were used to screen all identified records. After that, full texts of research that might qualify were examined for inclusion. The final review contained studies that satisfied the predetermined eligibility requirements. A PRISMA-ScR flow diagram was used to describe the study selection procedure.

Data Extraction

A standardized graphing form created for the evaluation was used to extract data. Study title, authors, year of publication, country, study design, sample characteristics, diagnosis of alcoholism or substance abuse, assessment of borderline personality, type of DBT intervention, length of therapy, outcome measures, and important findings were among the data gathered.

Data Synthesis

Thematic synthesis was used for analysis and descriptive synthesis of the extracted data. The results were categorized into major topics pertaining to DBT's efficacy in lowering alcohol and drug use, promoting psychological functioning, minimizing self-harm and suicidal behaviors, improving emotional regulation, and treating co-occurring borderline personality illness. Within the current body of information, common themes, gaps, and future study directions were found using thematic analysis.