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Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician

8.4 Major clinical issues with personality disorders and alcohol use

Table of contents

Personality disorders (in particular antisocial and borderline) and alcohol use disorders frequently co-exist.
Alcohol can exacerbate the sedative effects of some antidepressants such as tricyclics and mirtazepine.
Alcohol can exacerbate the sedative effects of carbamazepine, lithium, and sodium valproate.
Acamprosate or naltrexone can be considered for long-term abstinence with naltrexone showing effectiveness in moderating drinking in those with antisocial personality traits.

8.4.1 Effects of alcohol on personality disorders

Personality disorders (in particular antisocial and borderline) and alcohol use disorders frequently co-exist^{(16, 120, 317, 319-322)}.
Personality disorders are associated with an earlier age of onset of alcohol use disorders⁽³²³⁾.
Symptom severity of alcohol dependence continues to increase over time in those with personality disorders⁽³²⁰⁾.
Personality disorders (in particular anti-social characteristics) are associated with^{(320, 324, 325)}:
- More severe alcohol disorders.
- Poorer long-term drinking outcome.
- Poorer outcomes for treatment of alcoholism.
Personality disorders and alcohol use disorders are associated with:
- More criminal convictions⁽³²¹⁾.
- High levels of novelty-seeking behaviour and impulsivity^{(323, 326)}.
Alcohol use also significantly complicates personality disorders⁽¹²¹⁾.

Alcohol can exacerbate the sedative effects of carbamazepine, lithium, and sodium valproate^x.
Alcohol can exacerbate the sedative effects of some antidepressants such as tricyclics and mirtazepine. Alcohol toxicity and risk of overdose may occur through the inhibition of CYPs involved in the metabolism of alcohol^x(133).
Interactions between antidepressants and acamprosate used to treat alcohol dependence are minimal, as are interactions between antidepressants and disulfiram and naltrexone also used to treat alcohol dependence^xx(134).

Carbamazepine***⁽³²⁷⁾ and sodium valproate***^{(328, 329)} can be used in alcohol withdrawal to reduce the risk of seizures.
While studies are yet to confirm this, cabarmazepine has been discussed as being useful in the prevention of relapse to drinking^{(330, 331)}.
Acamprosate or naltrexone can be considered for long-term abstinence****^{(141, 144, 235, 236)}, with naltrexone showing effectiveness in moderating drinking in those with antisocial personality traits**⁽³³²⁾. However, medication adherence may be problematic.
As people with comorbid personality disorders and substance use are more prone to risk taking and subsequent injury, individuals prescribed with naltrexone need to be aware of its implications for emergency pain management.
Patients prescribed with naltrexone should be advised to carry a medical warning card or bracelet which states they will not respond to opioid analgesia (obtainable from Orphan Australia).
Disulfiram may be problematic as these patients may drink alcohol impulsively despite being warned of the risks.