What are the diagnostic criteria for Borderline Personality Disorder?

Diagnostic Criteria for Borderline Personality Disorder

Borderline Personality Disorder (BPD) requires at least five of nine specific DSM-5 criteria to be met, including unstable relationships, identity disturbance, impulsivity in self-damaging areas, recurrent suicidal behavior or self-harm, affective instability, chronic emptiness, inappropriate intense anger, frantic efforts to avoid abandonment, and transient stress-related paranoid ideation or dissociative symptoms. 1

Core Diagnostic Framework

BPD is fundamentally characterized by pervasive instability across three main domains that begin by early adulthood 2, 1:

• Interpersonal relationships: Unstable and intense relationships that alternate between extremes of idealization and devaluation, with frantic efforts to avoid real or imagined abandonment 1, 3
• Self-image: Identity disturbance with markedly unstable self-concept that oscillates between grandiosity and worthlessness 1, 3
• Affects: Rapid mood swings, intense irritability, difficulty controlling anger, and chronic feelings of emptiness 2, 3

The Nine DSM-5 Diagnostic Criteria

To diagnose BPD, document at least five of the following patterns 1:

1. Frantic efforts to avoid real or imagined abandonment 1
2. Unstable and intense interpersonal relationships alternating between idealization and devaluation 1
3. Identity disturbance with markedly unstable self-image or sense of self 1
4. Impulsivity in at least two self-damaging areas (e.g., excessive spending, impulsive sexual activity, reckless driving, substance abuse, binge eating) 2, 1
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior 1, 3
6. 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) 1
7. Chronic feelings of emptiness 1, 3
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 1
9. Transient, stress-related paranoid ideation or severe dissociative symptoms 1

Assessment Methodology

Use structured or semi-structured interviews conducted by mental health specialists rather than self-report questionnaires, as lack of insight is a core feature of personality disorders 1, 3. Self-report measures are unreliable due to the characteristic impaired insight in BPD 2.

The assessment must include 1, 3:

• Information from multiple sources using developmentally sensitive techniques
• Confirmation from multiple informants due to impaired patient insight
• Systematic evaluation of informant discrepancies to reconcile conflicting reports
• Detailed timeline of symptom development to establish pattern onset in early adulthood

Distinguishing BPD from Normal Concerns and Other Disorders

BPD differs from normative emotional instability by three key factors 4:

• Extreme time consumption: Preoccupations and behaviors take up several hours per day 4
• Time-consuming repetitive behaviors: Not just concerns, but compulsive checking, comparing, or avoidance behaviors 4
• Significant distress and impairment: Must cause dysfunction across multiple domains including school, work, home, and relationships 4

Key Differential Diagnoses

• Bipolar disorder: Distinguished by episodic nature of mood instability in bipolar versus the more chaotic and reactive mood instability in BPD 2, 1
• Psychotic disorders: BPD has transient stress-related paranoid ideation, not persistent hallucinations or disorganized thinking 2, 1
• Depression or social anxiety: May be presenting complaints that mask underlying BPD 1

ICD-11 Severity Classification

The ICD-11 framework provides dimensional severity grading 1, 3:

• Mild, moderate, or severe personality disorder based on functional impairment
• Optional specification of maladaptive personality traits: negative affectivity, detachment, dissociality, disinhibition, anankastia, and borderline pattern

Critical Risk Assessment

Approximately 75-80% of BPD patients attempt suicide, with 10% completing suicide, making BPD one of the highest-risk psychiatric disorders 1. Key areas requiring ongoing assessment include 1, 3:

• Self-harm behavior patterns
• Suicidal ideation and attempts
• History of sexual or physical abuse

Common Comorbidities

Systematically evaluate for co-occurring disorders 1:

• Mood disorders (83% prevalence) 5
• Anxiety disorders (85% prevalence) 5
• Substance use disorders (78% prevalence) 5
• Post-traumatic stress disorder
• Attention-deficit/hyperactivity disorder
• Bulimia nervosa
• Other personality disorders

Common Pitfalls to Avoid

• Do not rely on self-report questionnaires alone: The characteristic lack of insight in BPD makes these unreliable 2, 1
• Do not confuse reactive mood instability with bipolar disorder: BPD mood shifts are more chaotic and triggered by interpersonal stressors 2, 1
• Do not overlook the need for multiple informants: Single-source information is insufficient due to impaired patient insight 1, 3
• Do not miss the temporal pattern: Symptoms must represent a pervasive pattern beginning by early adulthood, not isolated episodes 1