Borderline Personality Disorder: DSM-5-TR Diagnostic Criteria
To diagnose borderline personality disorder (BPD), you must identify a pervasive pattern of instability in interpersonal relationships, self-image, and affects, plus marked impulsivity beginning by early adulthood, with at least 5 of 9 specific DSM criteria present. 1, 2
Core Diagnostic Criteria
The diagnosis requires at least 5 of the following 9 criteria to be present 2, 3:
- Frantic efforts to avoid real or imagined abandonment (excluding suicidal or self-mutilating behavior covered in criterion 5) 2
- Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 2, 3
- Identity disturbance: markedly and persistently unstable self-image or sense of self 2, 3
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) 1, 2
- Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior 1, 2, 3
- Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and rarely more than a few days) 2, 3
- Chronic feelings of emptiness 2, 3
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 1, 2
- Transient, stress-related paranoid ideation or severe dissociative symptoms 2, 3
Essential Clinical Assessment Approach
Begin by applying DSM-5 criteria rigorously through structured clinical interview, as recommended for psychiatric assessment 1. The most validated structured interviews specifically designed for BPD are the Revised Diagnostic Interview for Borderlines and the Structured Clinical Interview for DSM-5 Alternative Model for Personality Disorders 2.
Key Differentiating Features to Document
Assess the temporal pattern of symptoms: BPD features must represent a pervasive pattern beginning by early adulthood and present across multiple contexts 2. This distinguishes BPD from episodic mood disorders where symptoms cluster during discrete episodes 1.
Evaluate the degree of emotional distress and insight: Unlike neurocognitive disorders where emotional blunting and lack of insight predominate, BPD patients typically demonstrate intense emotional distress and some degree of concern about their difficulties 1. This is a critical differentiator from conditions like frontotemporal dementia 1.
Document impulsivity patterns: After controlling for lifetime history of depression and substance abuse, impulsivity remains strongly associated with suicidality in BPD 1. Characterize whether impulsive behaviors are reactive (response to identifiable triggers) versus proactive/predatory (planned, goal-directed) 4.
Critical Differential Diagnoses to Exclude
Bipolar Disorder vs BPD
The key distinction is episode duration and pattern: Bipolar disorder presents with discrete episodes of mania/hypomania lasting days to weeks, whereas BPD shows rapid mood shifts lasting hours (rarely more than a few days) 1, 3. Many adolescents with rapid mood shifts, brief periods of depression, anxiety, and rage alternating with euthymia and/or mania, plus transient psychotic symptoms including paranoid ideas and hallucinations, receive various diagnoses including major depressive disorder with psychotic features, bipolar disorder, schizoaffective disorder, and borderline personality disorder 1.
Recurring suicidal behavior has been associated with hypomanic personality traits and cluster B personality disorders, making this distinction particularly challenging 1. However, the question of whether borderline personality disorder is a form of bipolar or other mood disorder remains open 1.
Major Depressive Disorder
BPD commonly co-occurs with mood disorders (83% have comorbid mood disorders including major depression or bipolar disorder) 3. To differentiate, assess whether depressive symptoms are pervasive and sustained (suggesting MDD) versus reactive and brief (more consistent with BPD affective instability) 1.
Substance Use Disorders
78% of BPD patients have comorbid substance use disorders 3. Exclude active severe substance use as the primary cause of behavioral dysregulation before attributing symptoms to BPD 5.
Assessment of Suicide Risk
BPD has an established correlation with increased suicide risk 2. When assessing suicidal behavior in BPD patients, document 1:
- Previous suicide attempts and their characteristics (method, steps taken to avoid detection)
- Current mental state abnormalities (irritability, agitation, delusions, threatening behavior, persistent wish to die)
- Presence of rapid mood shifts with transient psychotic symptoms
- History of nonlethal self-injury distinct from suicide attempts
Structured Assessment Strategy
Use a two-tier diagnostic approach 6:
Tier 1: Categorical DSM-5-TR diagnosis - Determine whether the patient meets criteria for BPD based on the 5 of 9 criteria threshold 6
Tier 2: Dimensional/functional assessment - Depict the psychological dysfunctions and symptom severity dimensionally to guide treatment planning 6
Gather collateral information from multiple sources using varied developmentally sensitive techniques including interviews, behavioral observation, and standard rating scales 1. The reliability of patient self-report may be affected by cognitive development, emotional intensity, and psychological distress at time of interview 1.
Common Diagnostic Pitfalls to Avoid
Do not rely solely on self-report screening questionnaires for diagnosis - While self-report instruments can serve as cost-effective screening tests, definitive diagnosis requires structured clinical interview 7. Self-report scales have limited usefulness when insight is impaired 1.
Do not diagnose BPD during acute crisis states - Longitudinal observation is essential to distinguish pervasive personality patterns from episodic psychiatric syndromes 7. Symptoms must represent a stable pattern over time, not just acute decompensation 2.
Carefully distinguish BPD from comorbid Axis I syndromes - Complete assessment of the full range of Axis I and Axis II disorders is essential, as BPD rarely occurs in isolation 7. Most patients have additional psychiatric conditions including anxiety disorders (85%), mood disorders (83%), and substance use disorders (78%) 3.
Do not overlook trauma history - The etiology of BPD is related to both genetic factors and adverse childhood experiences, particularly sexual and physical abuse 3. Implementing interventions before trauma-informed assessment is a critical pitfall 4.
Clinical Presentation in Primary Care
BPD may be present in up to 6.4% of adult primary care visits, fourfold higher than in the general population 2. Clinical presentations that should prompt BPD assessment include 2:
- High healthcare utilization patterns
- Health-sabotaging behaviors
- Chronic or vague somatic concerns
- Aggressive outbursts
- High-risk sexual behaviors
- Obesity and binge-eating disorders (common comorbidities)