Diagnosis of Borderline Personality Disorder
Diagnostic Criteria
Borderline personality disorder is diagnosed based on a pervasive pattern of instability in self-image, interpersonal relationships, and affects, with onset in early adulthood, requiring assessment through structured clinical interviews rather than patient self-report. 1
Core Diagnostic Features
The diagnosis requires documentation of the following characteristic patterns 1, 2:
- Repeated suicide attempts and non-lethal self-injury - this is a defining feature with extremely high clinical significance 1
- Pervasive impulsivity strongly associated with suicidality 1
- Unstable mood and interpersonal relationships with sudden shifts 2, 3
- Varying self-concept and identity disturbance 1, 2
- Dissociative symptoms including experiences of unreality 1, 2
- Self-damaging behaviors beyond suicidality 1
- Intense anger and feelings of emptiness 2, 3
- Strong abandonment fears 2, 4
- Transient stress-related paranoid ideation 2, 3
Critical Assessment Approach
Use structured or semi-structured interviews conducted by mental health specialists, not self-report questionnaires, because lack of insight is a core feature of personality disorders. 1, 2
The assessment must include 1:
- Information from multiple sources using developmentally sensitive techniques
- Confirmation from multiple informants due to expected discrepancies in self-reporting
- Systematic evaluation of informant discrepancies - these do not invalidate the diagnosis but provide diagnostic information
A critical pitfall to avoid: Self-report psychiatric scales have minimal usefulness in BPD specifically due to patients' impaired insight 1. Behavioral observations of who initiated the consultation and whether the patient over- or under-emphasizes disability provide more reliable diagnostic information 1.
Severity Classification
The ICD-11 framework differentiates BPD by severity 1:
- Mild - problems in self-functioning and/or interpersonal dysfunction present but manageable
- Moderate - more pervasive impairments across domains
- Severe - extensive dysfunction requiring intensive intervention
Optional specification can include maladaptive personality traits across domains including negative affectivity, detachment, dissociality, disinhibition, anankastia, and borderline pattern 1.
Comorbidity Assessment
Expect and systematically document psychiatric comorbidities, as they are the rule rather than the exception in BPD. 2, 3
Common comorbid conditions include 2, 3:
- Mood disorders (major depression or bipolar disorder) - present in 83% of cases
- Anxiety disorders - present in 85% of cases
- Substance use disorders - present in 78% of cases
- Post-traumatic stress disorder - frequently comorbid
- Attention-deficit/hyperactivity disorder - commonly co-occurs
- Eating disorders (particularly bulimia nervosa) - share neurochemical pathways
Important consideration: When BPD presents with comorbid major depressive disorder, document whether the personality disorder onset preceded the mood disorder, as this affects treatment expectations - antidepressants are unlikely to be effective for depression symptoms when BPD is the primary diagnosis 5.
Treatment Options
First-Line Treatment: Evidence-Based Psychotherapy
Psychotherapy is the treatment of choice for BPD, with dialectical behavior therapy (DBT) being the only treatment proven in randomized controlled trials to reduce suicidality in adults with borderline personality disorder. 5, 6, 2, 3
Dialectical Behavior Therapy (DBT)
DBT involves four core modules delivered over 12-22 weekly sessions (longer for severe presentations) 6:
- Core Mindfulness Skills - to diminish identity confusion and enhance emotional control through meditation techniques 5
- Interpersonal Effectiveness Skills - assertiveness training and interpersonal problem-solving 5
- Distress Tolerance - acceptance of painful situations, self-soothing, distraction techniques, and generating balanced perspectives 5
- Emotion Regulation Skills - identifying emotions, reducing emotional vulnerability, increasing positive events 5
Treatment structure includes 5:
- Weekly individual therapy reviewing diary cards documenting suicidal/self-destructive behaviors
- Behavioral analysis of each problem behavior to understand function and triggers
- Skills training groups (for adolescents, family participation is required)
- Telephone consultations during first 12 weeks for crisis management
- Patient consultation groups in second 12 weeks for peer support
Use motivational interviewing techniques to enhance engagement, explaining that treatment aims to reduce distress and improve quality of life rather than focusing on personality "flaws." 6
Other Evidence-Based Psychotherapies
Alternative approaches with empirical support include 1, 2:
- Mentalization-Based Treatment - focuses on understanding mental states
- Transference-Focused Psychotherapy - addresses relationship patterns
- Schema Therapy - targets maladaptive schemas from early experiences
- Cognitive Behavioral Therapy - addresses dysfunctional thought patterns
No single psychotherapeutic approach has proven superior to others, with effect sizes between 0.50 and 0.65 for core BPD symptom severity compared to treatment as usual 2. However, approximately half of patients do not respond sufficiently to psychotherapy 2.
Pharmacological Treatment
No psychoactive medication consistently improves the core features of BPD - pharmacotherapy should target specific comorbid conditions rather than core personality disorder symptoms. 6, 2, 3
For Comorbid Depression and Anxiety
SSRIs (fluoxetine, sertraline, escitalopram) are the preferred choice for comorbid anxiety disorders or major depression due to their safety profile, but maintain realistic expectations regarding impact on core BPD symptoms. 6, 3
Critical caveat: When personality disorder onset is documented as antecedent to depression, antidepressants are unlikely to be effective and may mimic treatment non-response 5.
For Affective Dysregulation and Mood Instability
Mood stabilizers may be considered for anger, aggression, and affective lability 6:
- Valproate - for impulsive aggression
- Lamotrigine - for mood instability
- Topiramate - for anger and aggression
Note: Evidence is based on small single studies, limiting robustness of results 6.
Medications to Avoid
Do not use benzodiazepines for chronic anxiety management due to high risk of behavioral disinhibition and dependence in this population. 6, 3
Crisis Management
For acute crises (suicidal behavior/ideation, extreme anxiety, psychotic episodes), implement crisis response planning with clear warning signs and coping strategies. 6
Use low-potency antipsychotics (quetiapine) or off-label sedative antihistamines (promethazine) for short-term acute crisis management rather than benzodiazepines. 6, 3
Crisis interventions should include 6:
- Pre-established crisis response plan with patient
- Identification of specific warning signs
- Concrete coping strategies
- Brief Motivational Intervention if medication adherence is poor
Special Considerations for Adolescents
DBT for adolescents (DBT-A) has been modified to include family participation in skills training groups and reduced from one year to two 12-week stages with simpler language. 5
In non-randomized comparative studies, DBT-A showed acceptability to teenagers and reduced psychiatric hospitalization rates 5.
Prognostic Information
BPD is associated with high morbidity and mortality, including significant suicide risk - approximately half of young people with BPD report self-harm, making it a particularly high-risk psychiatric condition. 7
- Considerable functional impairment across social and vocational domains
- Intensive treatment utilization
- High societal costs
- Premature mortality risk 1
However, many patients report symptom relief with appropriate treatment, though lingering problems often persist, emphasizing the need for comprehensive long-term management. 4