Alcohol Use Disorder and Personality Disorders

Having a personality disorder means you’re at an increased risk for developing alcohol use disorder, regardless of what you’ve been diagnosed with. While many people use alcohol as a way to relieve the symptoms of their personality disorder, what they inadvertently end up doing is making matters much worse.

What You’ll Learn:

• The common thread for why alcohol use disorder is more common with a personality disorder

• What landmark study is a valuable reference for research into AUD and personality disorders

• The three clusters of personality disorders and their defining traits

• The traits connected to alcohol abuse and key research findings for:

• How people with personality disorders can get their drinking under control

If you're living with a personality disorder and you've noticed your drinking has become part of the problem, you're not imagining the connection, and you’re not alone.

The Choose Your Horizon team explored the connection between alcohol use disorder (AUD) and different personality disorders.

Our research made one thing very clear - having a personality disorder significantly increases the risk of alcohol dependence and abuse.

There was a common reason for the heightened risk across different personality disorders. The traits that are associated with personality disorders are difficult to deal with.

Social anxiety, low self-esteem, paranoia - no one wants to go through life feeling so unsure and uncomfortable.

The solution for a startling number of people with personality disorders is to self-medicate with alcohol.

Each personality disorder has unique alcohol addiction risk factors as well.

Some are less notable than others, but ultimately being diagnosed with a personality disorder means that you need to keep alcohol use under control or abstain completely so that substance abuse doesn’t make matters worse.

And if AUD or self-medicating is already an issue, steps need to be taken immediately to reduce alcohol use.

Studies That Prove the Connection Between Alcohol Use Disorder and Personality Disorders

Decades of research, most of it drawn from large national studies like the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), show the same pattern again and again.

Each of the personality disorders recognized in the DSM-5 carries a meaningfully elevated risk of alcohol use disorder compared to the general population. Every single one of them.

Consistent findings like those should never be ignored.

The NESARC studies that began in 2001 have sparked more than 25 years of follow-up research that delves deeper into the issue of problematic alcohol use among people with personality disorders.

They have examined not just the increased risk, but the reasons behind it.

The Personality Disorder Clusters

There are 10 types of personality disorders that are categorized in three clusters:

Cluster A: Identified as having odd or eccentric patterns of thinking and relating

Cluster B: Characterized by dramatic, emotional or erratic patterns

Cluster C: Notable for anxious or fearful patterns

Cluster A: Odd or Eccentric Patterns

Paranoid Personality Disorder

Paranoid Personality Disorder (PPD) is defined by a pervasive, unwarranted distrust of others. There’s a tendency to read hidden hostility into neutral remarks, doubt the loyalty of friends and partners and hold grudges.

PPD is the second most prevalent personality disorder in the general population, affecting roughly 4.4% of U.S. adults.

Traits Connected to Alcohol Misuse:

• Chronic hypervigilance

• Interpersonal tension

• Social isolation that comes from difficulty trusting others

• Accumulated stress of interpreting the world as consistently threatening

Key Research Takeaways: In NESARC data, 38.27% of people with paranoid PD had experienced lifetime alcohol dependence, compared to 12% of those without the disorder. Interestingly, this relationship can also run in reverse.

Heavy, chronic alcohol use can itself produce paranoid symptoms (a recognized phenomenon sometimes called alcoholic paranoia), which makes untangling cause from effect an important part of getting help.

Keep Reading: Paranoid Personality Disorder and Alcohol Use Disorder

Schizotypal Personality Disorder

Schizotypal Personality Disorder (STPD) involves social and interpersonal deficits alongside cognitive or perceptual distortions. People with STPD have odd beliefs, unusual perceptions, eccentric behavior and often intense social anxiety.

In terms of alcohol dependence, schizotypal personality disorder is extremely worrisome. Not only is there a heightened risk, but it’s often harder for people with STPD to break the dependence.

Overall psychiatric comorbidity burden is among the heaviest of any personality disorder

Traits Connected to Alcohol Misuse:

• Chronic social anxiety

• Isolation

• Unsettling perceptual or cognitive experiences

• Psychiatric comorbidity

Key Research Takeaways: NESARC data shows 42.38% of people with schizotypal PD had lifetime alcohol dependence.

More strikingly, a 3-year follow-up study found schizotypal PD is one of only three personality disorders that predicts a persistent, non-remitting course of alcohol dependence once it develops.

Keep Reading: Schizotypal Personality Disorder and Alcohol Use Disorder

Cluster B: Dramatic, Emotional or Erratic Patterns

Antisocial Personality Disorder

The name can be a little misleading since Antisocial Personality Disorder (ASPD) involves a pervasive disregard for the rights of others.

It’s connected to deceitfulness, impulsivity, aggression and a lack of remorse, with roots that trace back to conduct problems before the age of 15.

Traits Connected to Alcohol Misuse:

• Impulsivity

• Reward-driven behavior

• General pattern of behavioral undercontrol

that shows up across many areas of life, not just drinking

Key Research Takeaways: ASPD has the strongest documented personality-disorder-alcohol link in the research literature. NESARC data found 49–52% of people with ASPD had lifetime alcohol dependence. There is some genetic basis for this.

Antisocial behavior and alcohol dependence appear to share a common, highly heritable vulnerability toward disinhibition.

Keep Reading: Antisocial Personality Disorder and Alcohol Use Disorder

Borderline Personality Disorder

Borderline Personality Disorder (BPD) is marked by instability in relationships, self-image and emotions. People with BPD struggle with impulsivity and an intense fear of abandonment.

Traits Connected to Alcohol Misuse:

• Emotion dysregulation

• Low self-esteem

• Impulsivity that shows up across multiple risky behavior

Key Research Takeaways: Individuals with borderline personality disorder often use alcohol to blunt otherwise intolerable feelings. NESARC data found 47.41% lifetime alcohol dependence among people with BPD.

More recent meta-analyses put lifetime AUD prevalence as high as 55%.

The good news is Dialectical Behavior Therapy adapted for substance use (DBT-SUD) has real randomized-trial evidence behind it, making BPD one of the better-supported disorders when it comes to integrated treatment.

Keep Reading: Borderline Personality Disorder and Alcohol Use Disorder

Histrionic Personality Disorder

Histrionic Personality Disorder (HPD) centers on excessive emotionality and attention-seeking. People with HPD experience discomfort when they’re not the center of attention, rapidly shifting emotional displays that can be quite dramatic.

Traits Connected to Alcohol Misuse:

• Impulsivity

• Sensation- and novelty-seeking

• Pattern of using social and attention-driven situations

Key Research Takeaways: NESARC data found 49.79% lifetime alcohol dependence among people with HPD. This is a genuinely under-discussed finding because HPD's reputation is "dramatic," not "at-risk," but the epidemiological data says otherwise.

Keep Reading: Histrionic Personality Disorder and Alcohol Use Disorder

Narcissistic Personality Disorder

Narcissistic Personality Disorder (NPD) involves grandiosity, a persistent need for admiration, a lack of empathy and a sense of entitlement. But all this often masks a fragile underlying self-esteem.

Traits Connected to Alcohol Misuse:

• Difficulty tolerating criticism or failure

• Difficulty maintaining relationships

• Use of alcohol to sustain a sense of confidence

• Poor self-image

Key Research Takeaways: NESARC data found 39.03% lifetime alcohol dependence among people with NPD. The disorder also has high rates of overall psychiatric comorbidity.

However, NPD is less strongly associated with staying alcohol dependent long-term compared to antisocial or borderline PD.

Keep Reading: Narcissistic Personality Disorder and Alcohol Use Disorder

Cluster C: Anxious or Fearful Patterns

Avoidant Personality Disorder

Avoidant Personality Disorder (AVPD) involves pervasive social inhibition, feelings of inadequacy and hypersensitivity to criticism or rejection. It’s closely related to, but distinct from, social anxiety disorder.

Traits Connected to Alcohol Misuse:

• Extreme social anxiety

• Alcohol use to get through specific, unavoidable social situations

• Tension-reduction substance use patterns more so than a volume pattern

Key Research Takeaways: NESARC data found 34.91% lifetime alcohol dependence among people with AVPD. Research on the closely related social anxiety disorder shows a genuine paradox.

People high in social anxiety often report more alcohol-related problems despite drinking the same amount or less than their peers. It’s about when and why they drink, not how much.

Keep Reading: Avoidant Personality Disorder and Alcohol Use Disorder

Dependent Personality Disorder

Dependent Personality Disorder (DPD) is defined by an excessive need to be taken care of, submissive and clinging behavior and intense fear of separation.

It’s the rarest of the personality disorders, affecting roughly 0.5–0.6% of the general population.

Traits Connected to Alcohol Misuse:

• Difficulty being alone

• Urgent need for reassurance and connection

• Fear of abandonment

• Pattern of drinking that’s tied to maintaining relationships

Key Research Takeaways: NESARC data found 28.04% lifetime alcohol dependence among people with DPD. It has the lowest alcohol dependence of the personality disorders studied, but "lowest" is relative.

It still has nearly triple the general population's risk for alcohol dependence.

Keep Reading: Dependent Personality Disorder and Alcohol Use Disorder

Obsessive Compulsive Personality Disorder

Obsessive-Compulsive Personality Disorder (OCPD) is marked by a rigid preoccupation with orderliness, perfectionism and control. Someone with OCPD focuses on these things often at the cost of flexibility, relationships and even efficiency.

Traits Connected to Alcohol Misuse:

• Perfectionism-driven self-criticism

• Feelings of shame

• Exhaustion of maintaining rigid control

• Difficulty maintaining relationships

Key Research Takeaways: NESARC data found 31.85% lifetime alcohol dependence among people with OCPD.

In some clinical samples of people in treatment for alcohol dependence, OCPD has actually turned out to be the single most common personality disorder present.

Keep Reading: Obsessive Compulsive Personality Disorder and Alcohol Use Disorder

Getting the Support You Need to Control Alcohol Use Despite a Personality Disorder

Managing a personality disorder is hard enough on its own, but controlling alcohol use makes things more difficult because the two problems feed one another.

Heavy or frequent drinking can blunt the very emotions you're trying to learn to regulate in therapy, cloud the judgment you need to recognize your own patterns and interfere with medications or treatment plans aimed at the personality disorder itself.

Meanwhile, the personality disorder's core symptoms can make it harder to see the drinking problem clearly.

At Choose Your Horizon, we understand that this isn't a matter of willpower stacked on top of willpower. It's two overlapping conditions that require coordinated, realistic support. Addressing one and not the other often falls short.

One tool worth knowing about is naltrexone, an FDA-approved medication for alcohol use disorder. Naltrexone works by blocking opioid receptors in the brain, which blunts the rewarding, reinforcing effect that alcohol normally produces.

For many people, that translates into fewer and less intense alcohol cravings that make it easier to cut back.

Naltrexone isn't a treatment for the personality disorder itself. It’s part of a broader treatment plan that addresses AUD and the personality disorder.

When cravings aren't running the show, there's more room emotionally, cognitively and practically to show up consistently for the deeper work of understanding and managing the personality disorder in a healthy, sustainable way.

If you're wondering whether naltrexone could be part of your treatment plan, reach out to the Choose Your Horizon team.

We offer online naltrexone prescriptions that make it easy for someone with a personality disorder to get the help they need without triggering shame, social anxiety, fear of criticism and other personality disorder symptoms that perpetuate alcohol use.

Start by taking the Alcohol Use Assessment online or reach out to our team for more information.